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BayCare Alliant Hospital Medical Staff Bylaws Approved 02/19/2014

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Medical Executive Committee Reviewed/Approved: 01/21/2014

Board of Directors Reviewed/Approved: 02/19/2014


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TABLE OF CONTENTS PART 1: Interpreting These Bylaws

1.A. DEFINITIONS ...................................................................................................................7

1.B. PEER REVIEW PROTECTION .......................................................................................9

1.C. CAPTIONS .......................................................................................................................10

1.D. DELEGATION OF FUNCTIONS .................................................................................10

1.E. TIME LIMITS .................................................................................................................10

1.F. MEDICAL STAFF FUNDS ............................................................................................10

1.G. AMENDMENT OF THE BYLAWS ................................................................................10

PART 2: Medical Staff Structure & Functions

2.A. CATEGORIES OF THE MEDICAL STAFF ...............................................................10

2.A.1. Active Staff ............................................................................................................10

2.A.2. Consulting Staff ......................................................................................................12

2.A.3. Contracted Services Staff…………………………………………………………12 2.A.4. Provisional Staff.....................................................................................................12

2.A.5. Courtesy Staff .........................................................................................................13

2.B. MEDICAL STAFF OFFICERS .....................................................................................14

2.B.1. Officers of the Medical Staff .................................................................................14

2.B.2. Qualifications of Officers ......................................................................................14

2.B.3. President of Staff Duties ........................................................................................15

2.B.4. Vice President of Staff Duties ................................................................................16

2.B.5. Nominations and Elections ....................................................................................16

2.B.6. Term of Office .......................................................................................................17

2.B.7. Vacancies in Office ................................................................................................17

2.B.8. Removal from Office .............................................................................................17

2.B.9. Chief Medical Officer ............................................................................................18

2.C. MEDICAL STAFF COMMITTEES..............................................................................19

2.C.1. Functions of Committees .......................................................................................19


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2.C.2. Medical Executive Committee ...............................................................................21

2.D. MEDICAL STAFF ACTIVITIES ..................................................................................24

2.D.1. Medical Staff Year .................................................................................................24

2.D.2. Notice of Meetings .................................................................................................24

2.D.3. Notice of Special Meetings ....................................................................................24

2.D.4. Quorum ..................................................................................................................24

2.D.5. Agenda ...................................................................................................................24

2.D.6. Rules of Order ........................................................................................................25

2.D.7. Meetings .................................................................................................................25

2.D.8. Minutes ..................................................................................................................25

2.D.9. Conflicts of Interest ................................................................................................25

PART 3: Credentialing

3.A. QUALIFICATIONS FOR APPOINTMENT ................................................................26

3.A.1. Threshold Criteria ..................................................................................................26

3.A.2. Waiver of Criteria ..................................................................................................27

3.A.3. Factors for Consideration .......................................................................................27

3.A.4. No Entitlement to Appointment .............................................................................28

3.A.5. Nondiscrimination Policy ......................................................................................28

3.B. CONDITIONS OF APPOINTMENT AND REAPPOINTMENT ..............................29

3.B.1. Provisional Status & Focused Professional Practice Review Defines the .............31

3.B.2. Grant of Immunity and Authorization to Obtain/Release Information ..................32

3.C. INITIAL REAPPOINTMENT PROCESS ....................................................................33

3.C.1. Application Forms ..................................................................................................33

3.C.2. Burden of Providing Information ...........................................................................33

3.C.3. Application Review Process ...................................................................................34

3.C.4. Initial Review of Application .................................................................................34

3.C.5. Chief Medical Officer Procedure ...........................................................................35

3.C.6. Credentials Committee Procedure ..........................................................................35

3.C.7. Medical Executive Committee Procedure ..............................................................36

3.C.8. Action by the Board ...............................................................................................36

3.C.9. Time Periods for Processing ..................................................................................37


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3.D. CLINICAL PRIVILEGES ..............................................................................................37

3.D.1. Qualifications for Clinical Privileges .....................................................................37

3.D.2. Application for Clinical Privileges ........................................................................38

3.D.3. General Rules for Clinical Privileges .....................................................................39

3.D.4. Voluntary Relinquishment of Privileges ................................................................39

3.D.5. Clinical Privileges for New Procedures .................................................................40

3.D.6. Clinical Privileges for Dentists and Oral and Maxillofacial Surgeons ..................40

3.D.7. Clinical Privileges for Podiatrists…………………………………….…………..41

3.D.8 Clinical Privileges for Psychologists……………………….……………………..41

3.D.9. Clinical Privileges for Allied Health Professionals ...............................................42

3.D.10. Temporary Privileges ...........................................................................................43

3.D.11. Emergency/Disaster Clinical Privileges ................................................................44

3.E. CONTRACTS FOR CLINICAL SERVICES ...............................................................45

3.F. QUALIFICATIONS FOR REAPPOINTMENT ..........................................................46

3.F.1. Terms of Initial Appointment Continue .................................................................46

3.F.2. Threshold Criteria ...................................................................................................46

3.F.3. Factors for Evaluation.............................................................................................47

3.G. REAPPOINTMENT PROCESS.....................................................................................47

3.G.1. Applications for Reappointment ............................................................................47

3.G.2. Processing Applications for Membership Renewal ...............................................49

PART 4: Peer Review

4.A. INFORMAL PROCEEDINGS .......................................................................................51

4.B. INVESTIGATION PROCESS .......................................................................................51

4.C. CONDUCT .......................................................................................................................54

4.C.1. Actionable Conduct ................................................................................................54

4.C.2. Corrective Actions for Conduct .............................................................................55

4.C.3 Medical Staff Actionable Complaint Process .........................................................55

4.C.4. Conduct Complaints not Handled by Medical Staff Complaint Process ...............57

4.C.5. Abuse of Process ....................................................................................................57

4.C.6. Conduct Awareness Efforts ....................................................................................57


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4.D. SUMMARY SUSPENSION OF CLINICAL PRIVILEGES .......................................57

4.D.1. Grounds for Summary Suspension ........................................................................57

4.D.2. Procedure ...............................................................................................................58

4.D.3. Care of Patients ......................................................................................................58

4.E. OTHER ACTIONS ..........................................................................................................59

4.E.1. Automatic Relinquishment .....................................................................................59

4.E.2. Failure to Complete Medical Records ....................................................................59

4.E.3. Request for Reinstatement ......................................................................................60

4.D.4. Failure to Attend Special Conference ....................................................................60

4.F. LEAVE OF ABSENCE ...................................................................................................60

PART 5: Hearings & Appeals

5.A. INITIATION OF HEARING .........................................................................................62

5.A.1. Grounds for Hearing ..............................................................................................62

5.A.2. Actions Not Grounds for Hearing ..........................................................................62

5.B. THE HEARING ...............................................................................................................63

5.B.1. General Rules .........................................................................................................63

5.B.2. Notice of Recommendations ..................................................................................63

5.B.3. Request for Hearing ...............................................................................................63

5.B.4. Notice of Hearing and Statement of Reasons .........................................................64

5.B.5. Witness List ............................................................................................................64

5.B.6. Hearing Panel, Presiding Officer, and Hearing Officer .........................................65

5.C. PRE-HEARING AND HEARING PROCEDURE .......................................................67

5.C.1. Discovery ...............................................................................................................67

5.C.2. Pre-Hearing Conference .........................................................................................68

5.C.3. Resolution of Disputes ...........................................................................................68

5.C.4. Procedural Disputes................................................................................................69

5.C.5. Failure to Appear ....................................................................................................69

5.C.6. Record of Hearing ..................................................................................................69

5.C.7. Rights of Both Sides at Hearing .............................................................................69

5.C.8. Admissibility of Evidence ......................................................................................70

5.C.9. Postponements and Extensions ..............................................................................70


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5.D. HEARING CONCLUSION, DELIBERATIONS,

AND RECOMMENDATIONS .......................................................................................70

5.D.1. Order of Presentation .............................................................................................70

5.D.2. Basis of Decision ...................................................................................................71

5.D.3. Adjournment and Conclusion ................................................................................71

5.D.4. Deliberations and Recommendation of the Hearing Panel ....................................71

5.D.5. Disposition of Hearing Panel Recommendation ....................................................71

5.E. APPEAL PROCEDURE.....................................................................................................72

5.E.1. Time for Appeal .....................................................................................................72

5.E.2. Grounds for Appeal ................................................................................................72

5.E.3. Time, Place, and Notice ..........................................................................................72

5.E.4. Nature of Appellate Review ...................................................................................73

5.E.5. Final Decision of the Board ....................................................................................73

5.E.6. Exceptions to Hearing Rights .................................................................................74

5.E.7. Documentation and Reporting ................................................................................75

PART 6: Rules and Regulations and Policies

6.A. OVERVIEW .........................................................................................................................76

6.B. MEDICAL STAFF RULES.................................................................................................76

6.C. MEDICAL STAFF POLICIES...........................................................................................77

6.D. CONFLICTS BETWEEN THE MEDICAL STAFF AND MEDICAL EXECUTIVE

COMMITTEE .....................................................................................................................78

6.E. CONFIDENTIALITY AND PEER REVIEW PROTECTION .......................................78

6.F. HISTORIES AND PHYSICAL EXAMINATIONS .........................................................78

6.G. OTHER RULES AND REGULATIONS .........................................................................79

Part 7: Bylaw Amendments

Part 8: Adoption


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PART 1: Interpreting the Bylaws 1.A. DEFINITIONS

(1) “ALLIED HEALTH PROFESSIONALS” mean individuals other than Medical Staff members who are authorized by law and by the Hospital to provide patient care services

(2) “BOARD” means (3) the Board of Trustees of the hospital which has the overall responsibility for the

Hospital, or its designated committee; (4) “BOARD CERTIFICATION” is the designation conferred by one of the affiliated

specialties of the American Board of Medical Specialties (“ABMS”), the American Osteopathic Association (“AOA”), or the American Board of Podiatric Surgery, as applicable, upon a physician, dentist or podiatrist who has successfully completed an approved educational training program and an evaluation process, including passing an examination, in the applicant’s area of clinical practice.

(5) “BYLAWS” means the Medical Staff Bylaws of the Hospital. (6) “CHIEF EXECUTIVE OFFICER (CEO)” means the individual appointed by the

board to act on its behalf in the overall management of the hospital; (7) “CHIEF MEDICAL OFFICER (CMO)” means the individual appointed by the

Board consistent with these Bylaws to act as the chief medical officer of the Hospital; the CMO can serve as the President of the Medical Staff.

(8) “CLINICAL PRIVILEGES” means the authorization granted by the Board to

render specific patient care services and includes access to hospital resources, equipment and personnel necessary to exercise the clinical privileges granted;

(9) “DAYS” means calendar days; (10) “DENTIST” means a doctor of dental surgery (“D.D.S.) or doctor of dental

medicine (“D.M.D.); (11) “EX OFFICIO” means service as a member of a body by virtue of an office or

position held and, unless otherwise expressly provided, means without voting rights.

(12) “HOSPITAL” means BayCare Alliant Hospital;


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(13) “IN GOOD STANDING” means, at the time of the assessment of standing, his/her membership and/or privileges are not involuntarily limited, restricted, suspended, (excluding leaves of absence) or otherwise encumbered for disciplinary reasons;

(14) “INVESTIGATION” means a process specifically instigated by the Medical

Executive Committee to determine the validity, if any, and extent of a concern or complaint raised against a Medical Staff Member or individual holding clinical privileges. An investigation has begun when the Medical Executive Committee formally resolves to begin an investigation.

(15) “MEDICAL RECORDS” means documentation of patient care containing all

information required in a suitable electronic or paper format as designated by the Hospital and the Rules and Regulation and Policies of the Medical Staff.

(16) “MEDICAL EXECUTIVE COMMITTEE” means the Executive Committee of

the Medical Staff which is delegated the primary authority over activities related to the functions of self-governance of the Medical Staff;

(17) “MEDICAL STAFF” means all Physicians, Dentists, Podiatrists, and

Psychologists who are members of the medical staff, pursuant to these Bylaws; (18) “MEMBER(S)” means any physician, dentist, podiatrist, or psychologist who has

been granted Medical Staff membership and clinical privileges by the Board to practice at the Hospital;

(19) “NOTICE” means written communication by regular U.S. mail, e-mail, facsimile,

Hospital mail, or hand delivery. “SPECIAL NOTICE” means notice delivered by hand delivery or by certified mail, return receipt requested. “DATE OF RECEIPT” means the date that any Notice, Special Notice, or other communication was delivered personally by facsimile, electronic mail (e-mail), hospital mail, hand delivery or U.S. mail;

(20) “PATIENT CONTACTS” includes any admission, consultation, procedure,

response to emergency call, evaluation, treatment or service performed at BayCare Alliant Hospital;

(21) “PEER” means one of who is of equal professional standing with another,

belonging to the same profession or licensure category, and in some instances, the same specialty;

(22) “PHYSICIANS” includes both doctors of medicine (M.D.s” and doctors of

osteopathy (D.O.s).

(23) “PODIATRIST’ means a doctor of podiatric medicine (“D.P.M.”).


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(24) “PRACTITIONER” means unless otherwise expressly limited, any appropriately licensed physician or dentist or podiatrist or psychologist applying for or exercising clinical privileges in the Hospital;

(25) “PRESIDENT” means the President of the Medical Staff; Chairman of the

Medical Executive Committee. (26) “PROGRAM DIRECTOR” means the physician assigned by leadership to

oversee a department, program, unit or any specific area; (27) “PSYCHOLOGIST” means an individual with a Ph.D. in clinical psychology; (28) “RULES” means the Medical Rules and Regulations adopted in accordance with

these Bylaws; (29) “SEXUAL HARASSMENT” means unwelcome sexual advances, requests for

sexual favors, or verbal, visual or physical activity through which submission to sexual advances is made an explicit or implicit condition of employment or future employment-related decisions, unwelcome conduct of a sexual nature which has the purpose or effect of unreasonably interfering with a person’s work performance or which creates an offensive, intimidating or otherwise hostile work environment.

(30) “UNASSIGNED PATIENT” means any individual who comes to the Hospital for

care and treatment who does not have a Primary Physician or applicable specialist or whose attending physician or designated alternate is unavailable to attend the patient; or who does not want the prior attending physician to provide him/her care while a patient at the Hospital.

1.B. PEER REVIEW PROTECTION

(1) All minutes, reports, recommendations, communications, and actions made or taken pursuant to these Bylaws are deemed to be covered by the provisions of the Florida peer review statute or the corresponding provisions of any subsequent federal or state statute providing protection to peer review or related activities.

(2) The individuals, committees and/or panels charged with preparing reports,

findings, recommendations, or participating in investigations pursuant to these Bylaws shall be considered to be acting on behalf of the Hospital when engaged in such professional review activities and thus shall be deemed to be “professional review bodies” as that term is defined in the Health Care Quality Improvement Act of 1986.


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1.C. CAPTIONS

The captions or headings are for convenience only and are not intended to limit or define the scope or effect of any provision of these Bylaws.

1.D. DELEGATION OF FUNCTIONS

When a function is to be carried out by a Member of Hospital management, by a Medical Staff member, or by a Medical Staff Committee, the individual, or the committee through its chairman, may delegate performance of the function to one or more qualified designees.

1.E. TIME LIMITS

Time limits referred to in these Bylaws are advisory only and are not mandatory, unless it is expressly stated that a particular right is waived by failing to take action within a specified period.

1.F. MEDICAL STAFF FUNDS

Fines and assessments shall be set by the Medical Executive Committee and shall be payable to BayCare Alliant Hospital and will be deposited to the appropriate medical staff fund.

Signatories to the Hospital’s Medical Staff account shall be the President of the Medical Staff, or the designee. 1.G. AMMENDMENT OF THE BYLAWS Neither the organized medical staff nor the governing body may unilaterally amend

the medical staff bylaws or rules and regulations.


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PART 2: Medical Staff Structure and Functions 2.A. CATEGORIES OF THE MEDICAL STAFF

The categories of the Medical Staff are Active, Consulting, Contracted Services, Provisional and Courtesy. Members in all categories continuously must meet all of the requirements for Medical Staff membership contained in Section 3.A of these Bylaws. Members will be assigned to Medical Staff categories based on the criteria identified below. The Medical Staff expects each Member to make a commitment to the Hospital, and to assume Medical Staff responsibilities that are commensurate with his/her general level of activity at the Hospital. Therefore, action may be taken to transfer a Member to another Medical Staff category as the MEC deems appropriate based on the Member’s activity. A change in the Medical Staff category will not give rise to hearing and appeal rights unless the Member’s Privileges are affected in such a way that the individual would be entitled to request a hearing in accordance with these Bylaws. Total lack of patient activity in the Hospital during a Member’s term of appointment may render the individual ineligible to apply for reappointment. A Member of any Medical Staff category other than Provisional Staff who wishes to be transferred to a different Medical Staff Category shall submit a written request for transfer to the President of the Medical Staff stating the reasons for the request and providing any relevant documentation. The request shall be considered and acted upon by the MEC as soon as reasonably practicable, subject to approval of the MEC’s decision by the Board of Directors. 2.A.1. Active Medical Staff

Active Medical Staff shall consist of those Physicians, Dentists, Podiatrists and Psychologists who:

a. satisfy the criteria set forth in Section 3.A of these Bylaws;

b. have an active practice at the Hospital with more than ten (10) patient contacts annually;

c. have been granted Clinical Privileges at the Hospital and

d. have satisfied payment of all fines and assessments.

Each appointee to the Active Staff shall agree to assume all the functions and responsibilities of appointment to this staff category, including consultation, care for unassigned patients, and participation in performance improvement, peer review and monitoring activities including evaluation of members during their provisional period.

Active Staff appointees shall be eligible to vote and to serve as officers of the Medical Staff. Active Staff appointees are encouraged to attend all Medical Staff meetings.


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2.A.2. Consulting Medical Staff

a. The Consulting Medical Staff shall consist of those Physicians, Dentists, and Podiatrists who: satisfy the criteria set forth in Section 3.A of these Bylaws;

b. are specialists who provide a service that is not otherwise available at the Hospital and who admit and/or treat patients only upon the request of and/or in conjunction with, another physician on the active staff

c. are appointed for the specific purpose of providing consultation in the diagnosis and treatment of Hospital patients; and

d. have satisfied payment of all fines and assessments.

Appointment to the Consulting Medical Staff does not entitle the appointee to admit patients, to vote or to serve as an officer of the Medical Staff. Consulting Medical Staff appointees may attend staff meetings.

2.A.3. Contracted Services Medical Staff The Contracted Services Medical Staff shall consist of Physicians, Dentists, and Allied Health Professionals who are currently credentialed by Mease Dunedin Hospital (“Host”), and who through the Purchased Services Agreement (“Agreement”) between the Hospital and Host also furnish services on behalf of the Hospital under the terms and conditions of the Agreement. In this limited circumstance, the Hospital will accept the credentials and privilege delineations as determined by the Host for Contracted Services Medical Staff.

Contracted Services Medical Staff may furnish only those purchased services

identified in the Agreement to Hospital patients. The furnishing of any services other than those identified in the Agreement, or the furnishing of any services on the Hospital’s premises requires membership in the Hospital’s Active or Consulting Staff.

2.A.4. Provisional Medical Staff All initial appointees to the Medical Staff will be assigned to the Provisional Staff category, and must satisfy the criteria set forth in Section 3.A of these Bylaws. All Provisional Staff Members may be subject to a period of proctoring, or may be required to provide evidence of satisfactory completion of proctoring at other local institutions. Each Provisional Staff Member will be designated as Provisional Active, Provisional Courtesy, or Provisional Consulting, based on the Medical Staff category to which the Member has applied. (a) All Provisional Staff memberships at BayCare Alliant Hospital (regardless of the

category) and all initial clinical privileges will be provisional for a period of 12 months or longer, up to a maximum of 24 months.


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(b) All grants of increased clinical privileges are also provisional. The duration and/or terms of this provisional period will be recommended after consulting with the Chief Medical Officer and approved by the MEC and Board.

(c) During the provisional period, the individual will be evaluated by the Chief Medical Officer of the Hospital and by the relevant committees as to the individual’s clinical competence and general conduct within BayCare Alliant hospital

(d) Provisional Staff are encouraged to attend staff meetings and participate in various committees, but during their provisional period cannot chair a committee or participate as a voting member of the medical Staff and

(e) shall pay fines and assessments in order for renewal of membership and clinical privileges.

2.A.5. Courtesy Medical Staff

Qualifications a. The Courtesy Medical Staff shall consist of practitioners qualified for staff

membership who have satisfied the criteria set forth in Section 3.A of these Bylaws and have been granted privileges to admit and/or treat, as specified in subsection (b) and (c), an occasional patient in the hospital or to provide relief coverage for an Active or Courtesy staff member. Courtesy Medical Staff members shall not be required to attend Medical Executive Committee meetings but are encouraged to attend. Courtesy Medical Staff cannot chair a committee or participate as voting member of the medical staff. They may be assigned to committees but may not serve as committee chairs. Courtesy Medical Staff shall cooperate in peer review and performance improvement process.

b. They may admit or consult only 12 patients per year to the hospital; relief coverage will be limited to no more than 30 consecutive days. The number of patients admitted by this category shall also be restricted by patient load and by availability. Any practitioner who seeks to admit in excess of 12 patients per year shall be required to apply for Active Staff membership.

c. Courtesy Medical Staff practitioner who seeks to provide relief coverage for

longer than 30 consecutive days will be required to apply for active status or approval from the Medical Executive Committee for special circumstances that require an extension of this 30 day period.

d. Members of the Courtesy Medical Staff must be members of other Medical Staff, so information on current competencies will be available at the time of reappointment. At the time of reappointment, Courtesy Medical Staff Members may be required to provide evidence of recent clinical performance at other facilities where they practice more actively, to evaluate their current competence and ability to exercise requested clinical Privileges.


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e. Members of the Courtesy Medical Staff shall pay application fees, fines and assessments.

2.B. MEDICAL STAFF OFFICERS

2.B.1. Officers of the Medical Staff:

President of Medical Executive Committee

Vice President of Medical Executive Committee Chief Medical Officer 2.B.2. Qualifications of Officers:

Except as otherwise provided, in order to be eligible to serve as an officer of the Medical Staff, an individual must satisfy the following criteria:

(1) must be a physician;

(2) be appointed in good standing to the Active Staff and continue to be in good

standing during the term of office;

(3) have no pending adverse recommendations concerning Medical Staff appointment or Clinical Privileges;

(4) have actively and constructively participated in Medical Staff affairs;

(5) be willing to faithfully discharge the duties and responsibilities of the position to

which he or she is elected or appointed; officers must also demonstrate ability and willingness to exercise leadership and work cooperatively with Hospital Administration and others to carry out the duties of their offices – including enforcing these Bylaws, the Rules, and other applicable policies and procedures – and to assure that patient welfare takes precedence over other concerns;

(6) possess and have demonstrated ability for harmonious interpersonal relationships; (7) Medical Staff Officers may not have any personal, professional, or financial

relationships or affiliations that foreseeable could result in significant conflicts of interest with their responsibilities on behalf of the Medical Staff;

(8) attend continuing education relating to Medical Staff leadership and/or

credentialing functions approved by the Medical Executive Committee prior to or during the term of the office;


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(9) not presently be serving as Medical Staff officers, Board Members or department chairmen at any other hospital and shall not so serve during their terms of office;

2.B.3. President of Staff Duties:

The President of Staff shall perform the following functions:

(1) act in coordination and cooperation with the Chief Executive Officer in matters

involving the Hospital;

(2) serve as chairperson of the MEC, will call and preside at Medical Staff and MEC meetings;

(3) in consultation with the Chief Executive Officer, make appointments to any

special committees of the Medical Staff;

(4) represent the views, policies, needs, and grievances of the Medical Staff and report on the same to the Chief Executive Officer and the Board;

(5) serve as a liaison on medical matters to the Chief Executive Officer and to the

Board;

(6) receive and interpret the policies of the Board to the Medical Staff;

(7) oversee all clinical and administrative activities within the Hospital;

(8) serve as the Medical Staff representative on the Board, report regularly to the Board and CEO on the performance of Medical Staff functions, and maintain ongoing, constructive communication with the Board and Hospital’s CEO on all matters of mutual concern to the Hospital and Medical Staff;

(9) monitor and evaluate the quality and appropriateness of patient care provided

within the Hospital;

(10) recommend criteria for Clinical Privileges for individuals practicing in the Hospital;

(11) prepare a report concerning the appointment, reappointment, and delineation of

Clinical Privileges for all individuals seeking to practice at the Hospital;

(12) monitor the professional performance of all individuals who have delineated Clinical Privileges in the Hospital;

(13) recommend a sufficient number of qualified and competent persons to provide

care or service in the Hospital;


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(14) determine the qualifications and competence of Hospital personnel who are not licensed independent practitioners and who provide patient care services;

(15) assist the Chief Executive Officer in the preparation of annual reports and such

budget planning pertaining to clinical services as may be required;

(16) recommend space and other resources needed by the Medical Staff;

(17) assess and recommend to the Hospital off-site sources for needed patient care services not provided within the facility; and,

(18) be the Physician present in the Hospital (or appoint a designee) during a disaster.

(19) serve as an ex-officio member of all other Medical Staff committees (except as

otherwise provided in these Bylaws); (20) enforce the Medical Staff Bylaws and Rules and other policies and procedures

applicable to the Medical Staff;

(21) implement corrective action as determined to be appropriate in accordance with these Bylaws, and promote compliance with all procedural requirements in connection with corrective action;

(22) perform such other functions as may be assigned to him/her by these Bylaws, the MEC, or the Board; and

(23) chair the Medical Executive committee (with vote, as necessary) and be a member

of all other Medical Staff committees. 2.B.4. Vice President of Staff Duties:

The Vice President of the Medical Staff, in the absence of the President, will assume all of the President’s duties and have all his/her authority. The Vice President also will be expected to perform such duties as may be assigned to him/her by the President of the Staff or the MEC. The Vice President of the Medical Staff automatically will succeed the President of the Medical Staff and complete his/her term if the President of the Medical Staff becomes unable to serve for any reason.

2.B.5. Nominations and Elections

(1) The President of Medical Staff may appoint a Nominating Committee for all

general and special elections for officers and for at-large members of the Medical Executive Committee. The Nominating Committee may consist of at least three members of the Active Medical Staff.

(2) The Nominating Committee shall contact all potential nominees for a Medical

Staff office and an at-large position on the Medical Executive Committee and


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advise them of the obligations of the office, or the position for which they are being considered, and inquire about their willingness to serve. In order to be included on the ballot, individuals must satisfy the qualifications set forth in Section 3.A.3 of these Bylaws.

(3) The Nominating Committee shall prepare a slate of nominees for each available

office and position. The Medical Staff shall be notified of the nominees at least four weeks prior to the election.

(4) No later than two weeks prior to the election, any five members of the Active

Staff may submit to the Nominating Committee the name of a qualified Member of the Medical Staff for inclusion as a candidate on the ballot. The Nominating Committee shall review the qualifications of the proposed candidate and, if the candidate satisfies the qualifications for office, the individual shall be added to the slate of nominees.

(5) No later than one week prior to the election, a final slate of nominees shall be distributed to the members of the Active Staff. The candidates who receive a majority of the votes shall be elected.

(6) In any election, if there are three or more candidates for an office and no

candidate receives a majority vote, there shall then be successive balloting such that the name of the candidate receiving the fewest votes is omitted from

each successive slate until a majority is obtained by one candidate. 2.B.6. Term of Office:

Elected officers of the Medical Staff shall serve for a term of two years or until a successor is elected.

2.B.7. Vacancies in Office:

(1) If there is a vacancy in the office of President of Staff, that vacancy will be filled

by the Vice President who shall serve until the end of the President’s unexpired term.

(3) In the event there is a vacancy in another office, the Medical Executive

Committee shall appoint an individual to fill the office for the remainder of the term or until a special election can be held, at the discretion of the Medical Executive Committee.

2.B.8. Removal from Office:

(1) Removal of an elected officer or an at-large member of the Medical Executive Committee may be effectuated by a two-thirds vote of the Medical Executive Committee or by a majority vote of the Board for:


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(a) failure to comply with the policies, bylaws, or rules and regulations of the Hospital or the Medical Staff;

(b) failure to perform the duties of the position held;

(c) exhibiting conduct detrimental to the interests of the Hospital and/or the

Medical Staff; or

(d) suffering from an infirmity that renders the individual incapable of fulfilling the duties of that office.

(e) failure to abide by, support, and promote adherence to BAH Compliance

Program;

(3) Prior to the initiation of any removal action, the individual in question must be provided with notice of the date of the meeting at which such action shall be undertaken. The written notice will be issued by the President of Staff or it’s

designee and must be given at least 10 days prior to the date of the meeting. The individual shall be afforded an opportunity to speak to the Medical Executive

Committee or the Board prior to a vote on such removal being taken. (4) Removal proceedings undertaken by the Medical Executive Committee shall be

effective when approved by the Board. 2.B.9 Chief Medical Officer The Chief Medical Officer shall be appointed by the Board upon recommendation of the CEO and shall be responsible to the CEO as the CMO of the Hospital. The CMO shall perform such duties and functions as may be delegated from time to time by the CEO which may include, but are not limited to, the following: (1) Assisting the CEO in the implementation of the Hospital’s performance improvement

program;

(2) serving as an advisor to the Medical Staff and the President of the medical Staff for proper staff organization and compliance with the medical staff Bylaws;

(3) assisting Program Medical Directors in the performance of their duties; (4) acting as the Hospital’s medical liaison, after consultation with the CEO, to local,

state and federal agencies; (5) assisting the CEO in the supervision and direction of all Hospital-based physicians; (6) endeavoring to maintain accreditation status;


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(7) coordinating all of the medical education activities within the Hospital; (8) serving as liaison to all academic affiliations of the Hospital; and (9) assisting the medical staff with problem-solving and more efficient medical practice.

All leaders, including the CMO, will preserve the confidentiality of peer review, credentialing and other data shared with him/her, in accordance with state confidentiality and immunity statutes and the medical staff Bylaws, Rules and Regulations or policy.

2.C. MEDICAL STAFF COMMITTEES

2.C.1. Functions of Committees

(1) Provision shall be made for the effective performance of medical staff functions through the Medical Executive Committee and other special committees. Such committees shall confine their activities to the purpose for which they were appointed and shall report to the Medical Executive Committee.

(2) Committee/Subcommittee Composition and Term of Membership

The President of the Medical Staff or Chief Medical Officer, in consultation with the CEO, may appoint Medical Staff Members to serve on Medical Staff committees and subcommittees, as needed. The Hospital CEO, in consultation with the President of the Medical Staff or Chief Medical Officer, may appoint individuals who are not Medical Staff Members (such as nurses or administrative personnel) to serve on Medical Staff committees and subcommittees as appropriate, in addition to those non-Medical Staff members who serve on the MEC ex-officio. The President of the Medical Staff or Chief Medical Officer and the Hospital CEO may be ex-officio members of all Medical Staff subcommittees. Each committee/subcommittee member will be appointed initially for a term of two (2) years, and will serve until his/her successor is appointed, unless he/she earlier resigns or is removed. A committee/subcommittee member may be reappointed for additional terms on the same committee/subcommittee at the discretion of the President of the Medical Staff or Chief Medical Officer and the MEC. Where continuity of committee/subcommittee participation is beneficial, consecutive terms should be encouraged. A committee or subcommittee member (other than an ex-officio member) may be removed by a majority vote of the MEC. An ex-officio member may be removed only in accordance with the Bylaws’ provisions for removing him/her from his/her office.


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(3) Qualifications and Responsibilities of Committee/Subcommittee Chairs and Individuals Appointed to Perform Particular Medical Staff Functions

Each Medical Staff committee or subcommittee chair and individual appointed to

perform particular Medical Staff functions shall meet the following criteria and fulfill the following responsibilities:

a. he/she is a Physician who possesses interest and/or expertise in an area due to

specialized skills, training, years of experience, demonstrate competence, and judgment, and who is physically and mentally capable of carrying out the duties of his/her position;

b. he/she is appointed by the President of the Medical Staff or chief Medical

Officer to be responsible for the Medical Staff monitoring and evaluation of his/her appointed function, and accepts that responsibility;

c. he/she is responsible for the development and maintenance of the Performance

Improvement Program within his/her assigned area of responsibility and for recommending means for improving the quality of care provided;

d. he/she is responsible for upholding the standards of care and policies of the

Hospital;

e. he/she involves and works cooperatively with appropriate Hospital staff in performing his/her function, including quality review and improvement of patient care;

f. he/she reports to the MEC; and

g. he/she effectively communicates decisions/actions of MEC to other Medical

Staff Members as necessary.

(4) Performance Improvement and Measurement Functions

Performance improvement functions are the way the Medical Staff works to improve the clinical and non-clinical processes that require Medical Staff leadership or participation. To further its commitment to performance improvement, the Medical Staff will, through its committees, be actively involved in the measurement, assessment, and improvement of the following:

(a) medical assessment and treatment of patients;

(b) use of medications;

(c) use of blood and blood components;


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(d) use of operative and other procedures;

(e) appropriateness of clinical practice patterns; (f) significant departures from established patterns of clinical practice;

(h) accurate, timely, and legible completion of patients' medical records; (j) compliance with all regulatory agency and applicable accrediting body

requirements;

(k) Sentinel Event & Adverse Incident Reporting/Patient Safety Director

(l) personnel, equipment, and supplies

(m) autopsies

The Medical Staff will also participate in the measurement, assessment, and improvement of other patient care processes, including education of patients and families and coordination of care with other practitioners and Hospital personnel, as relevant to the care of an individual patient.

2.C.2. Medical Executive Committee

(1) Composition:

(a) The Medical Executive Committee shall be comprised of the officers and

at least three at-large Members of the Medical Staff to a maximum of seven voting members.

(b) The Chief Executive Officer or authorized designee shall be an ex officio

member of the Medical Executive Committee. (c) The President of Staff shall serve as Chairperson of the Medical Executive

Committee. (d) The CEO/DPCS/Quality Manager may attend meetings of the Medical

Executive Committee without a vote. (2) Duties:

The Medical Executive Committee is delegated the primary authority over activities related to the functions of the Medical Staff and performance improvement activities regarding the professional services provided by individuals with Clinical Privileges. The Medical Executive Committee is responsible for the following:


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(a) acting on behalf of the Medical Staff in the intervals between Medical

Staff meetings (the officers are empowered to act in urgent situations between Medical Executive Committee meetings);

(b) recommending directly to the Board on at least the following:

(i) the Medical Staff's structure;

(ii) the mechanism used to review credentials and to delineate

individual Clinical Privileges;

(iii) individuals for Medical Staff appointment/reappointment; (iv) delineated Clinical Privileges for each eligible individual taking

into consideration participation of the Medical Staff in Hospital performance improvement activities;

(v) the mechanism by which Medical Staff appointment may be

terminated; and

(vi) hearing procedures;

(c) consulting with administration on quality related aspects of contracts for patient care services;

(d) receiving and acting on reports and recommendations from Medical Staff

committees and other groups as appropriate;

(e) making appropriate recommendations for improvement when there are significant departures from established or expected clinical practice patterns;

(f) reviewing, at least every year, the Bylaws, Policies, Rules and

Regulations, and associated documents of the Medical Staff and recommending such changes as may be necessary or desirable;

(g) reviewing and approving policies directly related to medical care;

(h) reviewing and facilitating further evaluation and treatment regarding any

practitioner impairment concerns that are brought to the Medical Executive Committee's attention;

(i) identifying educational materials that address practitioner health and

emphasize prevention, diagnosis and treatment of physical, psychiatric and emotional illness;


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(j) handling impairment matters in a confidential fashion, keeping the Chief

Executive Officer apprised of the matters under review;

(k) reviewing quality indicators to promote uniformity regarding patient care services;

(l) providing leadership in activities related to patient safety;

(m) providing oversight in the process of analyzing and improving patient

satisfaction;

(n) prioritizing continuing medical education activities; (o) overseeing focused and ongoing practice reviews of all Medical Staff;

(p) performing such other functions as are assigned to it by these Bylaws or

other applicable policies; and (q) the MEC is accountable to the medical Staff, and, except for

recommendations regarding individual membership, privileges and corrective actions, subject to reversal of its decisions by a majority vote of the Active Staff

(3) Meetings:

(a) The MEC shall meet not less than least ten (10) times a year.

(b) Copies of all minutes and reports of the Medical Executive Committee

shall be transmitted to the Chief Executive Officer routinely, as prepared. (4) Removal of Duties Delegated to Medical Executive Committee

The authority delegated to the Medical Executive Committee pursuant to these Bylaws may be removed by amendment of these Bylaws, or by Resolution of the Medical Staff approved by a 2/3 vote of the Medical Staff who vote at a general or special meeting noticed to include the specific purpose of removing specifically-described authority of the Medical Executive Committee.

(5) Hospital’s Duty to the Medical Executive Committee

In order to fulfill its duties, the Medical Executive Committee shall be kept informed of any hospital decisions that may affect the medical staff organization and its functions. Consequently, any business decisions that affect or may affect the medical staff shall be presented at a meeting of the MEC, as soon as possible


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but in all cases in advance of their implementation, by hospital management or board members.

2.D. MEDICAL STAFF ACTIVITIES

2.D.1. Medical Staff Year:

For the purpose of these Bylaws, the medical staff year commences on the first day of January and ends on the 31st day of December each year. 2.D.2. Notice of Meetings:

(a) Notice of all routine meetings shall be posted by mail, e-mail or hand-delivery no

less than one week in advance of the meeting. The notice shall state the date, time, and place of the meeting. For all meetings, such posting shall be deemed to constitute actual notice.

(b) The attendance of any individual at any meeting shall constitute a waiver of that

individual’s notice of the meeting. (c) Minutes of these meetings will be delivered to the office of each Member of the

Medical Staff by mail, e-mail or hand-delivery.

2.D.3. Notice of Special Meetings:

(a) Special meetings of the Medical Staff may be called at any time by the President of Staff or a petition signed by at least five Members of the Active Staff.

(b) In the event that it is necessary for the staff to act on a question without being able

to meet, Members of the Active Staff may be presented with the question by mail or electronically and their votes returned to the President of Staff or the Chief Executive Officer.

2.D.4. Quorum:

(a) Except as provided below, for any regular or special meeting of the Medical Staff,

those present shall constitute a quorum.

(b) Once a quorum is established, the business of the meeting may continue and all actions taken by a majority of the Members present shall be binding, unless these Bylaws state otherwise.

2.D.5. Agenda:

The President of Staff shall set the agenda for regular and special meetings of the Medical Staff.


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2.D.6. Rules of Order:

Wherever they do not conflict with these Bylaws, the currently revised Robert’s Rules of Order shall govern all meetings and elections.

2.D.7. Meetings:

The Medical Staff shall meet at least once annually in person. 2.D.8. Minutes:

(1) Minutes of all meetings of the Medical Staff shall be prepared and shall include a

record of the attendance of Members and the recommendations made and the votes taken on each matter. The minutes shall be authenticated by the President of Staff.

(2) Copies of all minutes and reports of the Medical Staff shall be transmitted to the

Chief Executive Officer routinely as prepared. The Board shall be kept apprised of the recommendations of the Medical Staff.

(3) A permanent file of the minutes of all Medical Staff meetings shall be maintained

by the Hospital. 2.D.9. Conflicts of Interest:

(1) In any instance in which a Member of the Medical Staff has or reasonably could

be perceived as having a conflict of interest, or a bias, in any matter involving another Member of the Medical Staff that comes before the individual, such individual shall first declare the conflict and shall not vote on the matter. However, the individual may be asked, and may answer, any questions concerning the matter.

(2) The existence of a potential conflict of interest or bias on the part of any Member

of the Medical Staff may be called to the attention of the President of Staff by any other Member with knowledge of such.


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PART 3: Credentialing 3.A. QUALIFICATIONS FOR INITIAL APPOINTMENT

3.A.1. Threshold Criteria

Only Physicians, Dentists, Podiatrists, and Psychologists who satisfy the following conditions shall be eligible to apply for appointment to the Medical Staff:

(1) have a current unrestricted license to practice in the State of Florida;

(2) where applicable to their practice, have a current, unrestricted DEA certificate;

(3) are located (office or residence) close enough to the Hospital to fulfill their medical

staff responsibilities and to provide a reasonable response time to their hospitalized patients;

(4) possess current, valid professional liability insurance coverage in such form and in

amounts satisfactory to the Board;

(5) have successfully completed an approved residency training program in the specialty in which they seek Clinical Privileges;

(6) are certified by the American Board of Medical Specialties or American

Osteopathic Association approved Board in his/her clinical specialty or are board-eligible in his/her clinical specialty. A Psychologist shall be certified by the American Board of Professional Psychology in Clinical Psychology. A Podiatrist shall be certified by the American Board of Podiatric Surgery. Board certification is not required for Dentists. Those applicants who are not board certified at the time of application shall be eligible for Medical Staff appointment. However, in order to remain eligible, those applicants must achieve board certification in their primary area of practice within three years from the date of completion of residency or fellowship training. A member who does not attain subspecialty certification may remain a member of the Medical Staff, provided he or she is certified in the primary area of practice. Eligibility to request privileges shall be limited to the area in which certification has been achieved;

(7) demonstrate active clinical practice at least two of the last four years;

(8) have not been and are not currently excluded or precluded from participation in

Medicare, Medicaid, or any other federal health care program;

(9) have not pled guilty to or been convicted of any felony; and (10) have not pled guilty to or been convicted of any misdemeanor relating to the

practice of their profession, other health care-related matters, third-party reimbursement, or controlled substances violations;


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(11) have or agree to make coverage arrangements with other members of the Medical Staff for those times when the individual will be unavailable;

(12) have never had Medical Staff appointment, clinical privileges or permission to

practice denied, revoked, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct, and have never resigned appointment or permission to practice or relinquished privileges during a Medical Staff investigation or in exchange for not conducting such an investigation.

3.A.2 Waiver of Criteria: (1) Any individual who does not satisfy one or more of the criteria out lined above may

request that it be waived. The individual requesting the waiver bears the burden of demonstrating exceptional circumstances, and that his or her qualifications are equivalent to, or exceed, the criterion in question.

(2) A request for a waiver will be submitted to the Hospital MEC for consideration. In reviewing the request for a waiver, the Hospital MEC may consider the specific qualifications of the individual in question. Additionally, the Hospital MEC may, in its discretion, consider the application form and other information supplied by the applicant. The Hospital MEC’s recommendation will be forwarded to the Hospital Board. Any recommendation to grant a waiver must include the basis for such.

(3) The Hospital Board will review the recommendation of the Hospital MEC and determine whether to grant a waiver.

(4) No individual is entitled to a waiver or to a hearing solely because the Hospital Board determines not to grant a waiver. A determination that an individual is not entitled to a waiver is not a “denial” of membership or clinical privileges.

(5) The granting of a waiver in a particular case is not intended to set a precedent for any other individual or group of individuals.

(6) An application for membership that does not satisfy an eligibility criterion will not be processed until the Hospital Board has determined that a wavier should be granted following this procedure.

3.A.3. Factors for Consideration

Only those individuals who can document that they are highly qualified in all regards will be appointed to the Medical Staff. The following factors will be evaluated as part of the appointment and reappointment processes:

(1) relevant training, experience, demonstrated current competence, including

medical/clinical knowledge, technical and clinical skills, clinical judgment, and an understanding of the contexts and systems within which care is provided;


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(2) adherence to the ethics of their profession, continuous professional development, an understanding of and sensitivity to diversity, and responsible attitude toward patients and their profession;

(3) good reputation and character;

(4) ability to work harmoniously with others, including, but not limited to,

interpersonal and communication skills sufficient to enable them to maintain professional relationships with patients, families and other members of health care teams;

(5) ability to safely and competently perform the Clinical Privileges requested; and

(6) recognition of the importance of, and willingness to support, the Hospital's

commitment to quality care and recognition that interpersonal skills and collegiality are essential to the provision of quality patient care.

3.A.4. No Entitlement to Appointment

No individual shall be entitled to appointment or reappointment to the Medical Staff or to the grant or renewal of Clinical Privileges merely by virtue of the fact that such individual:

(1) is licensed to practice a profession in this or any other state;

(2) is a member of any particular professional organization;

(3) resides in the geographic service area of the Hospital; or

(4) is affiliated with, or under contract to, any managed care plan, insurance plan,

HMO, PPO, or other entity. (5) Has had in the past, or currently has, Medical Staff membership or privileges at

any hospital or health care facility

3.A.5. Nondiscrimination Policy

No individual shall be denied membership on the basis of sex, sexual orientation, gender or gender orientation, race, creed, age, religion, color or national origin or member’s legitimate professional or business interests.


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3.B. CONDITIONS OF APPOINTMENT AND REAPPOINTMENT

Responsibilities and Requirements for Applicants and Appointees: As a condition for consideration of initial appointment or reappointment, every applicant and appointee shall specifically agree to the following:

(1) provide appropriate continuous care and supervision to all patients being treated at the Hospital for whom the individual has responsibility including arranging alternate coverage for his/her patients in the event of his/her absence;

(2) abide by all bylaws, rules and regulations, and policies of the Hospital and the Medical Staff, in force during the term of the appointment to the Medical Staff, and abide by all applicable laws and regulations of governmental bodies and agencies, and comply with applicable standards of the Joint Commission;

(3) accept reasonable medical staff duties and responsibilities, including committee assignments, professional peer review activities, performance improvement activities, utilization review, service call, and patient call rotations, as assigned and such other reasonable duties and responsibilities as assigned by the medical staff;

(4) to constructively participate in the development, review, and revision of clinical protocols and pathways pertinent to his or her medical specialty, including those related to national patient safety initiatives and core measures;

(5) to comply with medical staff adopted protocols and pathways or document reasons for variance;

(6) provide, with or without request, new or updated information to the Chief Executive Officer as it occurs, that is pertinent to any question on the application form;

(7) attest that he or she has had an opportunity to read a copy of these Bylaws and the

Medical Staff Rules and Regulations, and agrees to be bound by them;

(8) appear, if requested, for personal interviews in regard to an application for initial appointment or reappointment;

(9) that any misrepresentation or misstatement in, or omission from, an application for appointment or reappointment, whether intentional or not, is cause for rejection of the application without right to a hearing or appeal. In the event that appointment or reappointment has been granted prior to the discovery of the misrepresentation, misstatement or omission, the discovery of such may be grounds for automatic relinquishment of Clinical Privileges and Medical Staff appointment without the right to a hearing or appeal;

(10) use the Hospital facilities sufficiently to allow for appropriate evaluation of

continuing current competence;


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(11) refrain from illegal fee splitting or other illegal inducements relating to patient referral;

(12) refrain from delegating responsibility for diagnoses or care of patients to any

individual who is not qualified to undertake this responsibility or who is not adequately supervised;

(13) refrain from deceiving patients as to the identity of any individual providing

treatment or services;

(14) seek consultation whenever necessary;

(15) abide by generally recognized ethical principles applicable to the individual’s profession;

(16) work cooperatively and professionally with other Members of the Medical Staff,

Hospital management, Allied Health Professionals, and Hospital employees;

(17) satisfy continuing medical education requirements; (18) prepare and complete timely, legible, and accurate medical and other required

records for all patients for whom the Practitioner in any way provides services in the Hospital; conduct a physical examination and complete a medical history up to thirty (30) days prior to admission and no later than twenty-four (24) hours after admission but prior to surgery or any procedure requiring anesthesia services. When the medical history and physical examination are complete within thirty (30) days prior to admission, an updated medical record entry documenting an examination for any changes must be completed within twenty-four (24) hours after admission; to provide continuity of care all history and physicals 30 days prior or upon admission must be in the chart within 24 hours all medical record entries must be legible, dated and timed;

(19) refrain from disruptive behavior, harassment, and discrimination against any person based upon the person’s age, sex, sexual orientation, religion, race, color, creed, national origin, health status, marital status, pregnancy, veteran status, ability to pay, or source of payment

(20) provide upon request information from his/her office records or other outside sources within his/her custody or control as needed to facilitate the care or review of the care of specific patients upon provision of valid consent or in accordance with applicable laws;

(21) communicate with appropriate Medical Staff leaders whenever he/she has credible information indicating that another Medical Staff Member may have engaged in substandard, unprofessional, or unethical conduct, or may have a mental or physical condition that could pose a threat to patient care, and then to cooperate as reasonable necessary to help resolve any such matter;


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(22) cooperate in implementing Hospital policies and procedures relating to disaster preparedness and response;

(23) provide uncompensated care to indigent patients in accordance with requirements or policies as the MEC and the Board may establish;

(24) cooperate with the Medical Staff and the Hospital to meet any obligations of the Hospital concerning care of unassigned patients;

(25) continuously meet all of the qualifications and requirements for membership and Privileges set forth in these Bylaws and the Rules. A member may be required to demonstrate continuing satisfaction of any such qualifications and requirements upon reasonable request of the MEC or the Board.

(26) To comply with hospital policy regarding patient privacy; and

(27) To promptly pay any applicable assessments and/or fines imposed by the medical staff;

3.B.1. Provisional Status and Focused Professional Practice Review

(1) Initial appointment to the Medical Staff (regardless of the staff category) and all initial grants of clinical privileges, whether at the time of appointment, reappointment, or during the term of an appointment, will be provisional.

(2) During the provisional period, the practitioner’s exercise of the relevant clinical privileges will be subject to focused professional practice evaluation by the Chief Medical Officer of the hospital or designated physician. The evaluation may include chart review, monitoring of the individual’s practice patterns, proctoring, external review, and information obtained from other physicians and Hospital employees. The numbers and types of cases to be reviewed shall be determined by the Chief Medical Officer or designated physician.

(3) In addition to the FPPE conducted during the provisional period, all Medical Staff members, including those in the provisional period, will have their practice evaluated through the OPPE and FPPE/peer review processes.

(4) If a current member of the Medical staff who has been granted additional clinical privileges fails, during the provisional period, to participate in the required number of cases or cooperate with the FPPE process, including monitoring and review conditions, the additional clinical privileges shall be automatically relinquished at the end of the provisional period. The individual may not reapply for the privileges in question for two years.

3.B.2. Grant of Immunity and Authorization to Obtain/Release Information:


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By applying for appointment, reappointment, or Clinical Privileges, the applicant expressly accepts the following conditions during the processing and consideration of the application, whether or not appointment or Clinical Privileges are granted, and throughout the term of any appointment or reappointment.

(1) Immunity:

To the fullest extent permitted by law, the individual releases from any and all liability, extends absolute immunity to, and agrees not to sue the Hospital, the Medical Staff, their authorized representatives, and appropriate third parties for any matter relating to appointment, reappointment, Clinical Privileges, or the individual’s qualifications for the same. This includes any actions, recommendations, reports, statements, communications, or disclosures involving the individual which are made, taken, or received by the Hospital, its authorized agents, or appropriate third parties, who provided the information relating to the individual or were in any way involved in the matters discussed in this Section.

(2) Authorization to Obtain Information from Third Parties:

The individual specifically authorizes the Hospital, Medical Staff leaders, and their authorized representatives (1) to consult with any third party who may have information bearing on the individual’s professional qualifications, credentials, clinical competence, character, ability to perform safely and competently, ethics, behavior, or any other matter reasonably having a bearing on his or her qualifications for initial and continued appointment to the Medical Staff, and (2) to obtain any and all communications, reports, records, statements, documents, recommendations or disclosures of third parties that may be relevant to such questions. The individual also specifically authorizes third parties to release this information to the Hospital and its authorized representatives upon request and agrees to sign necessary consent forms to permit a consumer reporting agency to conduct a criminal background check on the individual and report the results to the hospital.

(3) Authorization to Release Information to Third Parties:

The individual also authorizes Hospital representatives to release information to other hospitals, health care facilities, managed care organizations, government regulatory and licensure boards or agencies and their agents when information is requested in order to evaluate his or her professional qualifications for appointment, reappointment Privileges, and/or participation at the requesting organization/facility, and any licensure or regulatory matter.

(4) Hearing and Appeal Procedures:


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Medical Staff applicants and members agree that when corrective action is initiated or taken against them pursuant to these Bylaws or when an adverse recommendation or decision as defined in these Bylaws is made, they will exhaust the remedies provided in these Bylaws as a prerequisite to resorting to any other action, and any failure to fully exhaust the remedies provided herein shall operate as a waiver of any and all cases of action against the hospital, the medical staff, and any representative thereof, relating to the subject professional practice evaluation or collegial intervention.

(5) Authorization to Share Information among Components of the System:

The individual specifically authorizes the Hospital and its components to share credentialing and peer review information within the system pertaining to the individual’s clinical competence and/or professional conduct. This information may be shared at initial appointment or reappointment and at any other time during the individual’s appointment.

3.C. INITIAL APPOINTMENT PROCESS

3.C.1. Application Forms:

Applications for initial appointment and reappointment shall contain a request for specific Clinical Privileges desired by the individual and shall require detailed information concerning the individual’s professional qualifications. The applications for initial appointment and reappointment, existing now and as may be revised, are incorporated by reference and made a part of these Bylaws.

3.C.2. Burden of Providing Information:

(1) Individuals seeking appointment or reappointment shall have the burden of

producing information deemed adequate by the Hospital for a proper evaluation of competence, character, ethics, and other qualifications, and of resolving any doubts about such qualifications.

(2) Individuals seeking appointment or reappointment shall have the burden of

providing evidence that all the statements made and information given on their applications are true and correct.

(3) An application shall be deemed to be complete when all questions on the

application form have been answered, all supporting documentation has been supplied, and all information has been verified from primary sources. If at any time during the evaluation, the need arises for additional information, the application shall be considered incomplete. Any application that continues to be incomplete 30 days after the individual has been notified of the need for additional information shall be deemed to be withdrawn.


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(4) It is the responsibility of the individual seeking appointment or reappointment to provide a complete application, including adequate responses from references. An incomplete application will not be processed.

3.C.3. Application Review Process: (1) Membership for appointment will be on forms approved by the Credentialing

Verification Organization(CVO) identified by the Hospital

(2) Any individual requesting an application for initial membership shall be sent by the CVO (1) a letter that outlines the threshold eligibility criteria for membership and clinical privileges as set forth in Section 3.A.1, and (2) a Request for Application form which requests proof that the individual meets the threshold eligibility criteria for membership and clinical privileges. A completed Request for Application form with copies of all required documents must be returned to the CVO within 30 days after receipt, if the individual desires further consideration the CVO will review the application and determine that all questions have been answered, all references and other information or materials deemed pertinent have been received, and all pertinent information provided on the application has been verified by the primary sources Individuals who fail to meet these criteria shall not be given an application and shall be notified that they are ineligible to apply There is no right to a hearing on a determination of ineligibility.

3.C.4. Initial Review of Application

(1) A completed application form with copies of all required documents must be returned to the Credentialing Verification Office (CVO) within 30 days after receipt. The application may be accompanied by the application fee and a photograph of the applicant.

(2) As a preliminary step, the application will be reviewed by the CVO to determine that all questions have been answered and the individual satisfies all threshold criteria. Incomplete applications will not be processed. The Medical Staff Office or Chief Medical Officer (CMO) of BayCare Alliant Hospital will assist with this task. Individuals who fail to return completed applications or fail to meet the threshold criteria will be notified that their applications will not be processed.

(3) The CVO with the assistance of the MSO will oversee the process of gathering and verifying relevant information, and confirming that all references and other information or materials deemed pertinent have been received.


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3.C.5. Chief Medical Officer Procedure:

(1) The Chief Medical Officer shall evaluate the applicant’s education, training, experience, current clinical competence, and ability to work with others. This evaluation shall include inquiries directed to the applicant’s past or current department chairperson(s), residency training director, and others who may have knowledge about the applicant. The Chief Medical Officer may delegate this primary verification to the CVO.

(2) As part of the process of performing the evaluation, the Chief Medical Officer

may meet with the applicant.

(3) The Chief Medical Officer may require the applicant to undergo a physical and/or mental examination by a physician(s) satisfactory to the Chief Medical Officer if there is any question about the applicant’s ability to fulfill the responsibilities of appointment or to safely and competently exercise the Privileges requested. The results of this examination shall be made available to the Chief Medical Officer. Failure of an applicant to undergo an examination, within a reasonable time after being requested, shall constitute a withdrawal of the application and all processing of the application shall cease.

(4) The Chief Medical Officer may prepare a written report as needed, including a

recommendation concerning the applicant’s qualifications for appointment and for the requested Clinical Privileges. This report may address whether the applicant satisfies the current criteria for the Clinical Privileges requested. The report may be prepared within a reasonable time frame, but not later than 30 days from the time the completed application is received.

3.C.6.Credentials Committee Procedure (MEC serves as Credentials Committee): (1) The MEC will review and consider the recommendations from the Chief Medical

Officer and make a recommendation.

(2) The MEC may use the expertise of any member of the Medical Staff or an outside consultant, if additional information is required regarding the applicant’s qualifications.

(3) After determining that an applicant is otherwise qualified for membership and privileges, the MEC will review confirmation of the applicant’s Confirmation of Ability to Perform Privileges Requested to determine if there is any question about the applicant’s ability to perform the privileges requested and the responsibilities of membership. If so, the committee may require the applicant to undergo a physical and/or mental examination by a physician(s) satisfactory to the committee. The results of this examination will be made available to the committee for its consideration. Failure of an applicant to undergo an examination within a reasonable time after being requested to do so in writing by the MEC will be


36

considered a voluntary withdrawal of the application and all processing of the application will cease.

(4) The MEC may recommend the imposition of specific conditions. These conditions may relate to behavior (e.g., code of conduct) or clinical issues. The MEC may also recommend that membership be granted for a period of less than two years in order to permit closer monitoring of an individual’s compliance with any conditions.

(5) If the recommendation of the MEC is delayed longer than 60 days, a letter will be sent to the applicant, with a copy to the CEO/CMO explaining the reasons for the delay.

3.C.7. Medical Executive Committee Procedure:

(1) At its next regular meeting, after receipt of the written findings and recommendation of the Medical Executive Committee shall:

a. Review and adopt the findings and recommendation of the reviews as its own; or

(2) The Medical Executive Committee may, in its discretion, recommend that certain

limitations, conditions or restrictions be imposed on the initial grant of appointment and/or Clinical Privileges.

(3) If the recommendation of the Medical Executive Committee is favorable to the

applicant, it shall include Clinical Privileges to be granted and any limitations, conditions or restrictions on those Privileges and shall be transmitted to the Board.

(4) Any recommendation by the Medical Executive Committee that would entitle the

affected individual to a hearing and appeal shall be forwarded to the Chief Medical Officer, with a copy to the CEO. The Chief Executive Officer shall promptly notify the affected individual by Special Notice. The Executive Officer shall hold the recommendation until after the individual has exercised or has waived the right to a hearing.

3.C.8. Action by the Board:

(1) Upon receipt of the recommendation from the Medical Executive Committee, the

Board shall: Appoint the applicant and grant Clinical Privileges as recommended; or

Refer the matter back to the Medical Executive Committee, or another source inside or outside the Hospital for additional research or information; or

Reject or modify the recommendation.


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(2) If the Board determines to reject a favorable recommendation, it should first

discuss the matter with the President of the MEC. If the Board’s determination remains unfavorable to the applicant, that determination and the reasons in support thereof shall be sent to the Chief Executive Officer and the MSO, who shall promptly notify the applicant by Special Notice. The Board shall make no final decision until after the individual has exercised or has waived the right to a hearing.

(3) If the Board’s action is favorable, it shall send notice to the applicant by mail.

(4) Any final decision by the Board to grant, deny, revise or revoke appointment and/or Clinical Privileges is disseminated to appropriate individuals and, as required, reported to appropriate entities.

3.C.9.Time Periods for Processing

Once an application is deemed complete, it is expected to be processed within 120 days, unless it becomes incomplete. This time period is intended to be a guideline only and will not create any right for the applicant to have the application processed within this precise time period.

3.D. CLINICAL PRIVILEGES Every Practitioner who practices in the Hospital must request and be granted specific delineated Privileges by the Board of Directors, and each Practitioner may exercise only those Privileges that have been expressly granted. A current list of Privileges granted will be maintained in each Practitioner’s Medical Staff file at all times. Except

in an emergency as defined in Section 3.D.10, any Practitioner who performs professional services in the Hospital that are outside the scope of his/her delineated Privileges will be subject to corrective action.

3.D.1. Qualifications for Clinical Privileges:

The Clinical Privileges recommended to the Board shall be based upon consideration of the following:

(1) education, relevant training, experience, demonstrated current competence,

including medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal and communication skills, and professionalism with patients, families and other members of the health care team and peer evaluations relating to the same;

(2) utilization patterns;

(3) ability to perform the Privileges requested competently and safely;


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(4) information resulting from ongoing and focused professional practice evaluation, performance improvement and other peer review activities, if applicable;

(5) availability of qualified staff Members to provide coverage in case of the

applicant's illness or unavailability;

(6) adequate professional liability insurance coverage for the Clinical Privileges requested;

(7) the Hospital's available resources and personnel;

(8) any previously successful or currently pending challenges to any licensure or

registration, or the voluntary or involuntary relinquishment of such licensure or registration;

(9) any information concerning professional review actions or voluntary or

involuntary termination, limitation, reduction, or loss of appointment or Clinical Privileges at another hospital or other licensed entity;

(10) practitioner-specific data as compared to aggregate data, when available;

(11) morbidity and mortality data, when available; and

(12) professional liability actions, especially any such actions that reflect an unusual

pattern or excessive number of actions.

3.D.2. Application for Clinical Privileges

(1) Applications for Clinical Privileges will be processed in the same manner as applications for appointment to the Medical Staff.

(2) In order for a request for Privileges to be processed, the applicant must satisfy any

applicable threshold eligibility criteria.

(3) Requests for Clinical Privileges that are subject to an exclusive contract will not be processed except as consistent with applicable contracts.

(4) An individual requesting Clinical Privileges shall have the burden of establishing

that he or she satisfies the basic qualifications for, and is otherwise competent to exercise, the Clinical Privileges requested.

(5) During the term of appointment, a Member may request increased Privileges by

applying in writing. The request shall state the specific additional Clinical Privileges requested and information sufficient to establish eligibility, as specified in applicable criteria. If the individual is eligible and the application is complete,


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it shall be processed in the same manner as an application for initial Clinical Privileges.

(6) Periodic redetermination of Privileges, including either the increase or curtailment

of Privileges, shall be based upon the factors set forth in 3.D.1. as well as direct observation of care provided, a review of the records of patients treated in this and/or other hospitals, Medical Staff leadership evaluation of the Member’s participation in the delivery of medical care, the results of performance improvement measurements and monitoring, results of OPPE and FPPE, results of utilization review, and any other factors that may affect the ability to provide safe, quality care.

3.D.3. General Rules of Clinical Privileges

(1) Medical staff appointment shall not confer on any individual Clinical Privileges

or the right to practice at the Hospital.

(2) Each individual who has been appointed to the Medical Staff shall be entitled to exercise only those Clinical Privileges specifically granted by the Board.

(3) The granting of Clinical Privileges shall carry with it acceptance of the

obligations of such Privileges. (5) A qualified Practitioner may elect to extend or restrict his/her practice to a

particular specialty or sub-specialty. The Practitioner shall document his/her qualifications to specialize in this way sufficiently to allow a proper appraisal of this request by the Credentials Committee, and/or the MEC and the Board of Directors.

3.D.4. Voluntary Relinquishment of Privileges

(1) A Medical Staff member may voluntary relinquish clinical privileges by submitting a written request to the MEC specifying the clinical privilege(s) to be relinquished and the desired effective date of relinquishment.

(2) The MEC may request a meeting with the member involved. The MEC will make

a recommendation to the Hospital Board. (3) The Board will make a final decision on the request, based upon, among other

factors, how the request will affect the Hospital's ability to comply with applicable regulatory requirements, including the Emergency Medical Treatment and Active Labor Act. The Hospital Board's decision will be reported in writing by the President of the Medical Staff to the member, the MEC, and the CMO. If the Board permits the relinquishment of privileges, it will specify the effective date of the relinquishment.


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(4) Members must maintain competency for the core privileges in their specialty. Members who have voluntarily limited their practice to include less than core privileges typically associated with their specialty may be required either to arrange for appropriate coverage OR to participate in a general on-call schedule and to maintain sufficient competence to fulfill this responsibility.

3.D.5. Clinical Privileges for New Procedures: (1) Requests for Clinical Privileges to perform either a significant procedure not currently being performed at the Hospital or a significant new technique to perform an existing procedure ("new procedure") will not be processed until: (1) a determination has been made that the procedure will be offered by the Hospital; and (2) criteria to be eligible to request those Clinical Privileges have been established. (2) The MEC shall make a preliminary recommendation as to

whether the new procedure should be offered to the community. Factors to be considered by the Credentials Committee include, but are not limited to, whether

there is empirical evidence of improved patient outcomes and/or other clinical benefits to patients, whether the new procedure is being performed at other similar hospitals and the experiences of those institutions, and whether the Hospital has the resources, including space, equipment, personnel, and other support services, to safely and effectively perform the new procedure.

(3) If it is recommended that the new procedure be offered, the MEC or designee

shall conduct research and consult with experts, including those on the Medical Staff and those outside the Hospital, and develop recommendations regarding (1) the minimum education, training, and experience necessary to perform the new procedure, and (2) the extent of monitoring and supervision that should occur if the Privileges are granted. The MEC may also develop criteria and/or indications for when the new procedure is appropriate.

(4) The Chief Medical Officer shall forward a recommendation to the Medical

Executive Committee, which shall review the matter and forward its recommendations to the Board for final action.

(6) Upon reaching age 75, all Members of the Medical Staff who desire to exercise

Clinical Privileges will, on an annual basis, have five consecutive operative procedures, consultations, and/or admissions (as appropriate) observed and/or monitored by the Chief Medical Officer.

3.D.6. Clinical Privileges for Dentists and Oral and Maxillofacial Surgeons:

(1) The scope and extent of Clinical Privileges that a Dentist or oral and maxillofacial surgeon may exercise in the Hospital will be delineated and recommended in the same manner as other Clinical Privileges.

(2) A medical history and physical examination of the patient will be made and


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recorded by a physician who is a Member of the Medical Staff and that designated physician will be responsible for the medical care of the patient throughout the period of hospitalization. Except that, oral and maxillofacial surgeons who admit patients without underlying health problems may perform a complete admission history and physical examination and assess the medical risks of the procedure on the patient if they are deemed qualified to do so by the Medical Executive Committee and Board.

(3) The dentist or oral and maxillofacial surgeon will be responsible for the dental

care of the patient, including the dental history and dental physical examination, as well as all appropriate elements of the patient's record. Dentists and oral and maxillofacial surgeons may write orders within the scope of their license and consistent with the Medical Staff Rules and Regulations and in compliance with the Hospital bylaws and these Bylaws.

3.D.7. Clinical Privileges for Podiatrists:

(1) The scope of Clinical Privileges that a Podiatrist may exercise in the Hospital will be delineated and recommended in the same manner as other Clinical Privileges.

(2) A medical history and physical examination of each patient will be made and

recorded by a physician who is a Member of the Medical Staff and a designated physician will be responsible for the medical care of the patient throughout the period of hospitalization.

(3) The Podiatrist will be responsible for the podiatric care of the patient, including

the podiatric history and the podiatric physical examination, as well as all appropriate elements of the patient's record. Podiatrists may write orders which are within the scope of their license and consistent with the Medical Staff Rules and Regulations and in compliance with the Hospital bylaws and these Bylaws.

3.D.8. Clinical Privileges for Psychologists:

(1) The scope of Clinical Privileges that a Psychologist may exercise in the Hospital will be delineated and recommended in the same manner as other Clinical Privileges.

(2) Psychologists may write orders which are within the scope of their license and

consistent with the Medical Staff Rules and Regulations and in compliance with the Hospital and Medical Staff Bylaws.

3.D.9. Clinical Privileges for Allied Health Professionals


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(1) Determination of Need

Whenever an Allied Health Professional requests to practice at the Hospital, and the Board has not already approved the class of practitioner for practice at the Hospital, the Chief Medical Officer will evaluate the need for that class of Allied Health Professional based on the factors set forth in Section 3.D.4. (2), among others, and report to the Medical Executive Committee, which will make a recommendation to the Board for final action. If the Board has previously determined that there is not a need for the class in question, then the matter need not be re-investigated.

(2) Qualifications for Categories of Practitioners

If the Board determines that there is a need for the particular class of Allied Health Professionals at the Hospital, the Chief Medical Officer will recommend:

(a) any specific qualifications and/or training that Allied Health Professionals

must demonstrate beyond those set forth for Medical Staff appointment and Clinical Privileges;

(b) a detailed description of Clinical Privileges within the practitioners' scope

of practice;

(c) any specific conditions that apply to practice within the Hospital; and

(d) any supervision requirements, if applicable.

(3) Qualifications Applicable to All Allied Health Professionals

(a) To be eligible to apply for initial and continued Clinical Privileges within their scope of practice, Allied Health Professionals must meet the same criteria required for appointment to the Medical Staff, except a current, unrestricted certification/registration/ license, as determined by state law or regulation and residency programs and certification, will not be required, unless applicable.

(b) Allied Health Professionals must also satisfy all additional eligibility

qualifications relating to their specific area of practice that may be established by the Hospital.

(c) If seeking to practice as a dependent practitioner, an Allied Health

Professional must have a written agreement with a Member of the Medical Staff to provide the requisite supervision, which agreement must meet all applicable requirements of state law and Hospital policy. A copy must be submitted with the application.


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(d) The Allied Health Professional must show evidence of insurance, separate

from any insurance coverage or limits covering the supervising Physician, subject to Hospital policy. The Allied Health Professional cannot share limits with the supervising Physician.

(4) Application Process

(a) Applications by Allied Health Professionals will not be processed until the

Board has determined that there is a need for the particular category of Allied Health Professional and qualifications have been adopted, in accordance with these Bylaws.

(b) Applications by Allied Health Professionals shall be processed in the same

manner as applications for appointment and reappointment to the Medical Staff.

(5) No Medical Staff Appointment

(a) Allied Health Professionals will not be appointed to the Medical Staff.

(b) Allied Health Professionals must abide by the conditions of Medical Staff

appointment and the grant of Clinical Privileges. (c) Allied Health Professionals shall be entitled to the same hearing and

appeal rights offered to Members of the Medical Staff, as set forth in these Bylaws.

3.D.10. Temporary Privileges

(a) Temporary privileges may be granted by the CEO or his or her designee, upon

recommendation of the President of the Medical Staff or his or her designee to:

(1) applicants for initial appointment whose complete application is pending review by the Executive Committee and Board, following a favorable recommendation of the Credentials Committee. In order to be eligible for temporary privileges, an applicant must have demonstrated ability to perform the privileges requested and have had no (i) current or previously successful challenges to licensure or registration or (ii) involuntary restriction, reduction, denial or termination of medical staff membership or clinical privileges at another health care facility.

(2) non-applicants’, when there is an important patient care, treatment, or

service need, including the following:

(i) the care of a specific patient;


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(ii) when necessary to prevent a lack of services in a needed specialty area;

(iii) proctoring; or

(iv) when serving as a locum tenens for a member of the medical staff.

(b) The following verified information will be considered prior to the granting of any temporary privileges: current licensure, relevant training, experience, current competence, current professional liability coverage acceptable to the Hospital, and results of a query to the National Practitioner Data Bank.

(c) The grant of temporary clinical privileges will not exceed 120 days. For

non-applicants’ the days need not be consecutive and may be renewed. (d) Prior to any temporary privileges being granted, the individual must agree in

writing to be bound by the Bylaws, Rules and Regulations, policies, procedures and protocols of the medical staff and the Hospital.

(e) The granting of temporary privileges is a courtesy. Temporary privileges may be

withdrawn for any reason by the CEO at any time, after consulting with the President of the Medical Staff. The individual may be afforded an opportunity to refrain from exercising privileges. The withdrawal of the courtesy of exercising temporary privileges does not entitle the individual to request a hearing or appeal pursuant to these Bylaws.

(f) The President of the Medical Staff will assign to another member of the medical

staff responsibility for the care of patients until they are discharged. Whenever possible, consideration will be given to the wishes of the patient in the selection of a substitute physician.

3.D.11. Emergency/Disaster Clinical Privileges In the event of an emergency and when the emergency operations plan has been activated, any Medical Staff Member, regardless of staff status or Clinical Privileges, shall be permitted to do everything possible to save the life of a patient or to save a patient from serious harm. For the purpose of this section, an “emergency” is defined as the condition which could result in serious or permanent harm to a patient(s) and in which any delay in administering treatment would add to that harm or danger. In the event of an emergency/disaster, the disaster staff may be conjoined with the Host hospital’s disaster staff to assure the highest quality care possible in that situation. In order to safeguard against inadequate care in an emergency situation, the organizations may also assign disaster responsibilities to volunteer practitioners who are not licensed independent practitioners, but who are required by law and regulation to have a license, certification or registration. The Chief Executive Officer or designee or Chief Medical Officer or designee will assign disaster privileges. The Chief Medical Officer or


45

designee that is present during the disaster will oversee the volunteer disaster licensed independent practitioners. The disaster privileges expire after 72 hours, but can be extended if needed. Before a volunteer practitioner is considered eligible to practice at the Hospital, the following will be presented: (1) government-issued identification photo identification (for example, a driver’s

license or passport) and at least one of the following: (a) identification card from a healthcare organization, (b) current license to practice, (c) identification indicating that the individual is a member of a Disaster Medical

Assistance Team (DMAT), the Medical Reserve Corps (MRC). (d) Confirmation by a licensed independent practitioner currently privileged by

the Hospital or staff member with personal knowledge of the volunteer practitioner’s ability to act as a licensed independent practitioner during a disaster.

(2) Primary source verification should be completed within 72 hours from the time

service begins for an emergency/disaster.

(3) In extraordinary circumstances when primary source verification cannot be completed within 72 hours, it should be completed as soon as possible. In these situations, there must be documentation of the following: (a) the reason primary source verification could not be performed in the required time frame; (b) evidence of the volunteer's demonstrated ability to continue to provide adequate care; and (c) an attempt to obtain primary source verification as soon as possible. If a volunteer has not provided care, then primary source verification is not required.

3.E. CONTRACTS FOR CLINICAL SERVICES

(1) From time to time the Board may enter into contracts or employment relationships with individuals, partnerships or corporations for the performance of certain health care services, including medical-administrative services. All individuals functioning pursuant to such contracts or employment relationships, who would be subject to the provisions of these Bylaws, shall obtain and maintain staff appointment and/or Clinical Privileges, in accordance with these Bylaws.

(2) If a question arises concerning clinical competence that may affect such

individual’s staff appointment or Clinical Privileges during the term of the contract, that question shall be processed in the same manner as would pertain to


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any other Medical Staff appointee. If a modification of Privileges or appointment occurs that is sufficient to prevent the individual from performing his/her contractual duties, the contract shall automatically terminate.

(3) Clinical Privileges or Medical Staff appointment that are necessary to carry out

the obligations of the contract or employment shall be valid only during the term of the contract. In the event that the contract or employment expires or is terminated, the Clinical Privileges and any Medical Staff appointment resulting from the contract or employment shall automatically expire at the time the contract or employment expires or terminates. This expiration of Clinical Privileges and Medical Staff appointment, or the termination or expiration of the contract itself, shall not entitle the individual to any hearing or appeal, unless there is a specific provision to the contrary in the contract. In the event that only a portion of the individual’s Clinical Privileges are covered by the contract or employment, only that portion shall be affected by the expiration or termination of the contract or employment.

(4) Specific contractual or employment terms shall, in all cases, be controlling in the

event that they conflict with provisions of these Bylaws. 3.F. QUALIFICATIONS FOR REAPPOINTMENT

3.F.1. Terms of Initial Appointment Continue to Apply

All terms, conditions, requirements, and procedures relating to initial appointment shall apply to continued appointment and Clinical Privileges and to reappointment.

3.F.2. Threshold Criteria

To be eligible to apply for reappointment and renewal of Clinical Privileges, an individual must have, during the previous appointment term: (1) completed all medical records;

(2) completed all continuing education requirements;

(3) satisfied all Medical Staff responsibilities, including payment of dues, fines, and

assessments;

(4) continued to meet all qualifications and criteria for appointment and the Clinical Privileges requested; and

(5) had sufficient patient contacts to enable the assessment of current clinical judgment and competence for the Privileges requested. Any individual seeking reappointment who has minimal activity at the Hospital must submit such information as may be requested (such as a copy of his/her confidential


47

quality profile from his/her primary hospital, clinical information from the individual's private office practice, and/or a quality profile from a managed care organization) before the application will be considered complete and processed further;

3.F.3. Factors for Evaluation In considering an individual's application for reappointment, the factors listed in Sections 3.A. of these Bylaws will be considered. Additionally, the following factors will be evaluated as part of the reappointment process: (1) compliance with the bylaws, rules and regulations, and policies of the Medical

Staff and the Hospital;

(3) participation in Medical Staff duties, including committee assignments and emergency call;

(4) Current ability to safely and competently exercise the clinical privileges

requested and perform responsibilities of staff membership;

(4) the results of the Hospital's performance improvement, ongoing professional practice evaluations, and other peer review activities, taking into consideration practitioner-specific information compared to aggregate information concerning other individuals in the same or similar specialty (provided that, other practitioners shall not be identified);

(5) data from the ongoing professional practice evaluations (OPPE) and focus

professional practice evaluations (FPPE) processes;

(6) verified complaints received from patients and/or staff; and/or other Members of the Medical Staff.

(7) other reasonable indicators of continuing qualifications.

3.G. REAPPOINTMENT PROCESS

3.G.1. Applications for Reappointment (BayCare Health System Credentials Verification Office (CVO) Policy 1104)

(1) The CVO will follow these procedures to help remind members to submit

completed applications in a timely fashion. However, it is the ultimate responsibility of each member to ensure that his or her application is completed on time: (a) The CVO will maintain a list of all Medical Staff members and the dates

upon which they are due for membership renewal.


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(b) An application for membership renewal will be furnished to members at

least four months prior to the expiration of their current membership term, with a request that the completed membership renewal application be returned to the CVO within the specified time frame.

(c) The CVO will e-mail each member to notify him or her regarding

reappointment notification. (d) If the CVO has not received a member’s notification membership renewal

application 21 days after initial e-mail, the CVO shall call the member to provide a reminder. The CVO may leave a message for the member, via voice mail, with office staff, etc., if the member is not personally available to speak.

(e) If the CVO has not received a member's membership renewal application

32 days after initial e-mail, the CVO shall notify the member by special notice that his or her membership and privileges will automatically expire at the end of the practitioner's current term.

(f) If the CVO has not received a member's complete membership renewal

application by the end of the member's current term, the individual's membership and privileges will expire, and the individual will be required to apply as an initial applicant.

(2) Membership Renewal will be for a period of not more than two years. (3) Except as provided below, if an application for membership renewal is submitted

timely, but the Hospital Board has not acted on it prior to the end of the current term, the individual's membership and clinical privileges will expire at the end of the then current term of membership. Subsequent Board action may be to grant membership renewal and renewal of clinical privileges.

(4) In those situations where the Board has not acted on a pending application for

membership renewal and there is an important patient care need that mandates an immediate authorization to practice, including but not limited to an inability to meet on-call coverage requirements, or denying the community access to needed medical services, temporary privileges may be granted pursuant to the provisions of these Bylaws regarding temporary privileges for an important patient care need.

(5) In the event the application for membership renewal is the subject of an

investigation or hearing at the time membership renewal is being considered, a conditional membership renewal for a period of less than two years may be granted pending the completion of that process.


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(6) The Medical Staff Office (MSO) will be provided a monthly a report of all those physicians/allied health professionals who are in the reappointment process and the progress of the reappointment.

(7) The CVO will oversee the process of gathering and verifying relevant

information. The MSO will also be responsible for confirming that all relevant information has been received.

3.G.2. Processing Applications for Membership Renewal

(1) When an application is received from a practitioner, the CVO staff will review the application to determine if it is completed appropriately and begin processing. (2) The application is considered complete if all questions are answered and

additional information or explanation is attached or noted. Each applicant must also sign and ate the consent and release of liability form.

(3) If any of the questions were left unanswered, an attachment not included in the

packet, or there is information that varies substantially from the information provided to the organization, the practitioner will be contacted and asked to complete the application or forward any attachment/explanation needed to the CVO.

(5) The CVO will perform primary source verification per Primary Verification Policy

1103, current hospital affiliations, continuous query to the NPDB, licensure verification

(5) Upon completion of verification of credentials the application is then available electronically via the credentialing software to the requesting MSO. (6) The MSO obtains two professional references on the applicant and sends applicant the “BAH Medical Staff Agreement” and appropriate clinical privilege forms for signature and return.

(7) Completed applications are reviewed by Chief Medical Officer prior to presentation to Hospital MEC Committee.

(8) If it becomes apparent to the Hospital MEC is considering a recommendation to

deny membership renewal or a requested change in staff category, or to reduce clinical privileges, the chairman of the committee may notify the individual of the general tenor of the possible recommendation and invite the individual to meet prior to any final recommendation being made. At the meeting, the individual should be informed of the general nature of the information supporting the recommendation contemplated and will be invited to discuss, explain or refute it. This meeting is not a hearing, and none of the procedural rules for hearings will


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apply. The committee will indicate as part of its report whether such a meeting occurred and will include a summary of the meeting with its minutes.


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PART 4: Peer Review 4.A. INFORMAL PROCEEDINGS

(1) To the extent possible, routine questions or concerns that are raised about a Member of the Medical Staff shall be addressed initially by the Chief Medical Officer.

(2) Nothing in these Bylaws shall preclude collegial, educational, and/or informal

efforts to address questions or concerns relating to an individual’s practice and conduct at the Hospital. Collegial efforts may include, but are not limited to, counseling, sharing of comparative data, monitoring, and additional training or education. These Bylaws specifically encourage the voluntary structuring of Clinical Privileges to achieve a clinical practice mutually acceptable to the individual and to the Board. All efforts of the Hospital in this regard are intended to be and are part of performance improvement and professional and focused professional practice evaluation activities.

(3) Serious questions or concerns, or those that have arisen on a recurring basis, may

be reported to the Medical Executive Committee as set forth below. 4.B. INVESTIGATION PROCESS

(1) The Chairperson of the Board, the Chief Executive Officer, the President of the Medical Staff or the Chief Medical Officer may, upon receipt and verification of a complaint about a Member of the Medical Staff or another individual who has been granted clinical privileges, which regards the clinical competence or clinical practice of the practitioner, including the practitioner’s care, treatment or management of patients, the known or suspected violation of the applicable ethical standards of the practitioner’s profession, the known or suspected violation of the Bylaws, policies, Rules and Regulations of the Medical Staff or Hospital, or the professional conduct of the practitioner, make a written request that the Medical Executive Committee investigate the complaint.

(2) The Medical Executive Committee shall meet as soon as possible after receiving a

request for an investigation. The Medical Executive Committee shall review the request and any supporting documentation and determine whether there is a need to conduct an investigation. An investigation shall begin only after the Medical Executive Committee has passed a resolution to that effect.

(3) The MEC will inform the individual that an investigation has begun. Notification may be delayed if, in the MEC's judgment, informing the individual immediately would compromise the investigation or disrupt the operation of the applicable Hospital or Medical Staff.


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(4) Upon the adoption of a resolution, the Medical Executive Committee shall immediately begin to investigate the matter. The Medical Executive Committee shall have the discretion to conduct the investigation itself, request that the Credentials Committee conduct the investigation, or appoint an ad hoc committee to do so.

(5) In the event the Medical Executive Committee appoints an ad hoc committee, that

committee shall consist of at least three persons, who may or may not be Members of the Medical Staff. This committee shall not include partners, associates or relatives of the individual being investigated.

(6) Whenever the questions raised concern the clinical competence of the individual under review, the ad hoc committee will include a peer of the individual (e.g., physician, dentist, podiatrist or psychologist). (7) The President of the Medical Staff will keep the CEO and the Chief Medical

Officer informed of all action taken in connection with an investigation. (8) The committee conducting the investigation shall:

(a) have the authority to review documents and interview individuals with

relevant information;

(b) have available to it the full resources of the Medical Staff, as well as the authority to use outside consultants, if needed;

(c) An outside consultant or agency may be used whenever a determination is made by the Hospital and investigating committee that:

(1) the clinical expertise needed to conduct the review is not available on the Medical Staff; or (2) the individual under review is likely to raise, or has raised,

questions about the objectivity of other practitioners on the Medical Staff; or (3) the individuals with the necessary clinical expertise on the Medical Staff would not be able to conduct a review without risk of allegations of bias, even if such allegations are unfounded.

(d) have the authority to require a physical and mental examination, including

diagnostic testing and testing of blood and/or urine for the purpose of evaluating a concern about substance abuse, of the individual being investigated. The individual being investigated will execute a release allowing (i) the investigating committee (or its representative) to discuss


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with the health care professional(s) conducting the examination the reasons for the examination; and (ii) the health care professional(s) conducting the examination to discuss and provide documentation of the results of such examination directly to the investigating committee. The examination shall be made by a physician(s) satisfactory to the committee.

(9) The individual being investigated shall have an opportunity to meet with the

investigating committee before it makes its report. At this meeting (but not, as a matter of right, in advance of it), the individual shall be informed of the general nature of the information supporting the question being investigated and shall be invited to discuss, explain, or refute it.

(10) The interview with the affected individual shall not constitute a hearing, and none

of the procedural rules provided in these Bylaws with respect to hearings shall apply. A summary of such interview shall be made by the investigating committee and included with its report.

(11) The investigating committee will make a reasonable effort to complete the investigation and issue its report within 30 days of the commencement of the

investigation, provided that an outside review is not necessary. When an outside review is necessary, the investigating committee will make a reasonable effort to complete the investigation and issue its report within 30 days of receiving the results of the outside review. These time frames are intended to serve as guidelines and, as such, will not be deemed to create any right for an individual

to have an investigation completed within such time periods. In the event the investigating committee is unable to complete the investigation and issue its report within these time frames, it will inform the individual of the reasons for the delay and the approximate date on which it expects to complete the investigation.

(12) Following the investigation, a report and recommendation shall be submitted to

the Medical Executive Committee.

(13) The Medical Executive Committee may accept, modify or reject any recommendation it receives from the investigating committee, including doing any of the following:

(a) recommend that no action is needed;

(b) issue a letter of guidance or a letter of counsel;

(c) issue a written warning; (d) issue a letter of reprimand;

(e) impose conditions for continued appointment;


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(f) impose a requirement for monitoring;

(g) impose a requirement for consultation;

(h) recommend reduction of Clinical Privileges;

(i) recommend suspension of Clinical Privileges for a term;

(j) recommend revocation of Medical Staff appointment and/or Clinical Privileges;

(k) recommend additional training or education; or

(l) make such other recommendations as it deems necessary or appropriate.

(14) A recommendation by the Hospital MEC that would entitle the individual to

request a hearing will be forwarded to the CEO and MSO, who will promptly inform the individual by special notice. The CEO/MSO will hold the recommendation until after the individual has completed or waived a hearing and appeal.

(15) If the Hospital MEC makes a recommendation that does not entitle the individual

to request a hearing, it will take effect immediately and will remain in effect unless modified by the Hospital Board.

(16) In the event the Hospital Board considers a modification to the recommendation

of the MEC that would entitle the individual to request a hearing, the CEO will inform the individual by special notice. No final action will occur until the

individual has completed or waived a hearing and appeal (17) When applicable, any recommendations or actions that are the result of an investigation or hearing and appeal will be monitored by Medical Staff leaders on an ongoing basis through the medical staff’s peer review; or performance improvement processes, as appropriate. 4.C. CONDUCT 4.C.1. Actionable Conduct Sexual harassment, harassment and other inappropriate personal conduct with the

potential to adversely affect patient care are not acceptable to the medical staff and will be corrected, or if correction fails or the conduct warrants, discipline. Harassment, sexual harassment or other forms of inappropriate personal conduct by a medical staff member or privileges holder, in which conduct jeopardizes or could jeopardize quality patient care or the ability of others to provide quality patient care at the hospital, or threatens, or constitutes, harassment against patients, other health care


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professionals, hospital staff, or individuals on hospital premises will be grounds for corrective action. Verbal, visual or physical abuse directed against patients, other health care professionals, hospital staff, or individuals on hospital premises on the basis of race, religion, color, national origin, ancestry, physical disability, mental disability, medical disability, age, marital status, sex or sexual orientation will be considered harassment. Failure or refusal of members to cooperate with these conduct procedures, even if the underlying accusation is found to be untrue, will be acted upon as inappropriate conduct. Members are not restricted in advancing medical staff interests and fulfilling duties in good faith or in engaging in competition or pursuit of business interests. Business activities and patient or medical staff advocacy are specifically not to be deemed “disruptive” to the hospital, the system its operations, or mission, and are not actionable under these bylaws. Actionable conduct by medical staff members or privileges holders, which conduct generates a complaint will be responded to according to these bylaws. Conduct that is actionable but that indicates that the medical staff member suffers from a physical, mental or emotional condition will also be referred to the Health Committee or otherwise evaluated to promote assisting the medical staff member or privileges holder while protecting others. 4.C.2. Corrective Actions for Conduct Disruptive and/or unprofessional conduct may be managed collegially or may be evaluated for corrective action. Any Corrective action will be commensurate with the nature and severity of the unacceptable conduct. Repeated instances of unacceptable conduct will be considered cumulatively and action shall be taken accordingly. 4.C.3. Medical Staff Actionable Conduct Complaint Process Complaints about a medical staff member’s or privileges holder’s conduct must be in writing, signed and directed to the President of the Medical Staff. The President or designee must review the complaint immediately, and provide the complainant with a written acknowledgement of the complaint and the bylaws or those sections of the bylaws addressing conduct. The President or designee shall make an initial determination of authenticity and severity, and act accordingly. In all cases, the member/privileges holder involved shall be provided with a copy of these bylaws and a description of the general nature of the complaint. Requests by a complainant that "nothing should be done" about an event and that the report is "for information only" cannot be granted. A record of each complaint shall be retained, even if the complainant “withdraws” his or her support for the complaint. Withdrawal of a complaint will not affect the Medical Executive Committee’s ability to proceed with an investigation or other action pursuant to these bylaws. At the discretion of the President or at the discretion of the Medical Executive Committee, the duties here assigned to the President can be delegated to a


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different officer of the Medical Staff, on a case-by-case basis or for the President’s term of office. Complaints will be categorized according to the following severity index:

Type I Physical violence, physical abuse, or threats of physical violence; sexual harassment or harassment involving physical contact; or carrying a gun or other weapon. In these cases, the President shall interview the complainant and, if possible, any witnesses within 24 hours of receiving the complaint. The President and another member of the medical executive committee shall interview the medical staff member within 24 hours. Type II Verbal abuse such as unwarranted yelling, swearing or cursing; threatening, humiliating, sexual or otherwise inappropriate comments directed at a person or persons verbally; visual abuse such as threatening, humiliating, sexual or otherwise inappropriate writing or picture(s) directed at a person or person, or violence or abuse directed at an inanimate object. The President shall interview the complainant and, if possible, any witnesses within 5 working days of receiving the complaint. The President and another member of the medical executive committee shall interview the medical staff member within 5 working days. Type III Abuse or conduct which is directed at-large rather than at any one individual or group of individuals, but has been reasonably perceived by a witness to be inappropriate conduct, as described above; imposing burdensome, idiosyncratic requirements on nursing staff, residents or others, which cannot be reasonably expected to improve patient care. The President of the Medical Staff shall interview the complainant and, if possible, any witnesses within 10 days of receiving the complaint. In each case, the President shall provide the member the opportunity to respond in writing. The President shall do one or more of the following: i. determine that no formal action is warranted.

ii. issue a warning and/or otherwise work with the individual collegially to improve upon the areas of concern. iii. require a written apology to the complainant. iv. refer member to the Medical Staff Health Committee within the BayCare Health System (BCHS).

v. refer the matter to the Medical Executive Committee for further action in accordance with these Bylaws.


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4.C.4. Conduct Complaints Not Handled By Medical Staff Complaint Process Inappropriate conduct that violates hospital, but not Medical Staff, policy (e.g. violating the hospital’s no-smoking policy) shall be handled in accordance with the relevant policy. 4.C.5. Abuse of Process Threats or actions directed against the complainant by the subject of the complaint will not be tolerated under any circumstance. Retaliation or attempted retaliation by members against complainants will give rise to corrective action pursuant to the medical staff bylaws. Individuals who submit a complaint or complaints which are determined to be false shall be subject to corrective action under the medical staff bylaws or hospital employment policies, whichever applies to the individual. 4.C.6. Conduct Awareness Efforts The medical staff shall promote continuing awareness of inappropriate conduct issues among the medical staff and the hospital community, including the following efforts:

sponsoring or supporting educational programs on inappropriate conduct to be offered to medical staff members and hospital employees;

disseminating this Bylaws section to all current members and privileges holders upon its adoption and to all new privileges holders and members of the medical staff upon joining the staff;

facilitating assistance by a Medical Staff Health Committee within the BCHS for members of the medical staff and other privileges holders exhibiting inappropriate conduct to obtain education, behavior modification, or other treatment to prevent further violations.

4.D. SUMMARY SUSPENSION OF CLINICAL PRIVILEGES

4.D.1. Grounds for Summary Suspension: (1) The Chairperson of the Board, the Chief Executive Officer, President of the

Medical Staff and/or the Chief Medical Officer shall each have the authority to suspend all or any portion of the Clinical Privileges of any individual whenever failure to take action may result in imminent danger to the health and/or safety of any individual. A summary suspension can be imposed at any time including after a specific event, a pattern of events, or a recommendation by the Medical Executive Committee that would entitle the individual to request a hearing. When


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possible, prior to the imposition of a summary suspension, the person(s) considering the suspension will meet with the individual and review the concerns that support the suspension and afford the individual an opportunity to respond.

(2) Such summary suspension shall be deemed an interim precautionary step in the

medical review activity related to the ultimate medical review action that may be taken with respect to the suspended individual, but is not a complete medical review action in and of itself. A summary suspension shall not imply any final finding of responsibility for the situation that caused the suspension.

(3) Unless otherwise stated, such summary suspension shall become effective

immediately upon imposition, and the person responsible shall promptly give verbal, followed by Special Notice and shall remain in effect unless or until modified by the Chief Executive Officer or the Board.

(4) Within three calendar days of the imposition of a suspension or restriction, the

individual will be provided with a brief written description of the reason(s) for the action, including the names and medical record numbers of the patients involved, if any.

4.D.2. Procedure: (1) Any individual who imposes a summary suspension shall immediately report such

to the Chief Executive Officer, President of the Medical Staff and/or the Chief Medical Officer. The Medical Executive Committee shall immediately take further action in the manner specified in Section 4.B of these Bylaws.

(2) A review of the matter resulting in precautionary suspension shall be completed

within a reasonable time period, not to exceed 30 days, or reasons for the delay shall be transmitted to the Chief Executive Officer so that the Chief Executive Officer and the Board may consider whether the suspension should be lifted.

4.D.3 Care of Patients (1) Immediately upon the imposition of a summary suspension or restriction, the

President of the Medical Staff will assign to another individual with appropriate clinical privileges responsibility for care of the suspended individual’s hospitalized patients, or to aid in implementing the summary restriction, as appropriate. The assignment will be effective until the patients are discharged. The wishes of the patient will be considered in the selection of a covering physician.

(2) All members of the Medical Staff have a duty to cooperate with the President of

the Medical Staff, the MEC, the Chief Medical Officer and the Chief Executive Officer in enforcing summary suspensions or restrictions.


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4.E. OTHER ACTIONS

4.E.1. Automatic Relinquishment:

(1) The occurrence of any of the following events shall result in automatic relinquishment of appointment as of the date such action occurs, without any right to a hearing or appeal pursuant to these Bylaws:

(a) revocation, expiration or suspension of professional license;

(b) revocation or suspension of a DEA certificate or state controlled substance

certificate;

(c) termination or expiration of required insurance coverage;

(d) exclusion or preclusion from participation in any federal health care program; or

(e) indictment, conviction, or a plea of guilty or no contest pertaining to any felony, or to any misdemeanor involving

i) controlled substances;

ii) illegal drugs

iii) Medicare, Medicaid, or insurance or health care fraud or abuse

iv) Violence against another (f) failure to provide, within a reasonable period of time, information

requested by the Chief Medical Officer or the Chief Executive Officer, including a request for a physical and/or mental examination.

(2) Appointees are required to immediately inform the Chief Executive Officer if any

of these events occur.

4.E.2. Failure to Complete Medical Records:

The clinical privileges of any individual recommended by the MEC may be automatically relinquished for failure to complete medical records in accordance with applicable regulations governing the same, hospital, policy, and after notification by the hospital of such delinquency. This relinquishment shall continue until all of the records of the individual’s patients are no longer delinquent.


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4.E.3. Request for Reinstatement Requests for reinstatement or removal or restrictions will be reviewed by the Chief Medical Officer, the Medical Staff President and the CEO. If all these individuals make

a favorable recommendation on reinstatement, the Medical Staff member may immediately resume clinical practice at BAH. This determination will then be forwarded to the Hospital MEC, and the Hospital Board for ratification. If, however, any of the individuals reviewing the request have any questions or concerns, those questions will be noted and the reinstatement request will be forwarded to the Hospital MEC, and the Hospital Board for review and recommendations.

4.E.4 Failure to Attend Special Conference: (1) Whenever there is an apparent or suspected deviation from standard clinical practice involving any individual, the Chief Medical Officer or the President of the Medical Staff may require the individual to attend a special conference with a standing or ad hoc committee of the Medical Staff. (2) The notice to the individual regarding this conference will be given by special notice at least three days prior to the conference and will inform the individual that attendance at the conference is mandatory. (3) Failure of the individual to attend the conference will be reported to the applicable Hospital MEC. Unless excused by the MEC upon a showing of good cause, such failure will result in automatic relinquishment of all or such portion of the individual’s clinical privileges as the MEC may direct. Such relinquishment will remain in effect until the matter is resolved. 4.F. LEAVE OF ABSENCE

(1) Individuals appointed to the Medical Staff may, for good cause, be granted leaves of absence by the Board for a definitely stated period of time not to exceed one year. Absence for longer than one year shall constitute voluntary resignation from the Medical Staff, unless an exception is made by the Board upon recommendation of the Chief Medical Officer and/or President of the Medical Staff.

(2) Requests for leaves of absence shall be made to the Chief Medical Officer and/or

President of the Medical Staff and shall state the beginning and ending dates of, and the reasons for, the leave. The Chief Medical Officer and/or President of the Medical Staff shall report favorably or unfavorably on the request and forward the same to the Chief Executive Officer for final action.

(3) Members of the Medical Staff must report to the MEC any time they are away

from medical staff and/or patient care responsibilities for longer than 30 days and the reason for such absence is related to their physical and mental health or


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otherwise to their ability to care for patients safely and competently. Under such circumstances, the Chief Medical Officer and/or President of the Medical Staff may trigger and automatic leave of absence.

(4) To the extent feasible, given the reason for the leave, no leave of absence shall

begin until the individual completes all medical records. (5) No later than 45 days prior to the conclusion of the leave of absence, the

individual must request, in writing, to be reinstated. The request shall summarize the professional activities undertaken during the leave. The individual shall also provide such other information as may be requested by the Hospital at that time. Requests for reinstatement will then be reviewed by the Chief Medical Officer, the Medical Staff President, and the CEO. If all these individuals make a favorable recommendation on reinstatement, the Medical Staff member may immediately resume clinical practice at BAH. This determination will then be forwarded to the MEC, and the Board for ratification. If, however, any of the individuals reviewing the request have any questions or concerns, those questions will be noted and the reinstatement request will be forwarded to the MEC, and the Board for review and recommendation. If a request for reinstatement is not granted, for reasons related to clinical competence or professional conduct, the individual will be entitled to request a hearing and appeal.

(6) If the leave of absence was for medical reasons, a report must be submitted by the

individual’s attending physician indicating that he or she is physically and/or mentally capable of resuming a hospital practice and exercising the Clinical Privileges requested.

(7) After considering all relevant information, the Chief Medical Officer shall make a

recommendation regarding reinstatement and forward the same to the Medical Executive Committee. The recommendation of the Medical Executive Committee shall be sent to the Chief Executive Officer, acting on behalf of the Board, for final action.

(8) If an individual's current membership is due to expire during the leave, the

individual must apply for membership renewal, or membership and clinical privileges will lapse at the end of the membership period.

(10) Individuals wishing to resign from the Medical Staff, including relinquishment

of all clinical privileges, must provide 30 days’ notice to the MSO. This information is reported to the MEC and Board and the CVO.


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PART 5: Hearings & Appeals 5.A. INITIATION OF HEARING

5.A.1. Grounds for Hearing:

(a) An individual is entitled to request a hearing whenever the Executive Committee makes one of the following recommendations:

(1) denial of initial appointment, reappointment or requested clinical

privileges; (2) revocation of appointment to the medical staff or clinical privileges; (3) suspension of clinical privileges for more than 30 days (other than

precautionary suspension); (4) restriction of clinical privileges, meaning a mandatory concurring

consultation requirement, in which the consultant must approve the course of treatment in advance; or

(5) denial of reinstatement from a leave of absence if the reasons relate to

professional competence or conduct.

(b) No other recommendations will entitle the individual to a hearing. (c) If the Board makes any of these recommendations without an adverse

recommendation by the Medical Executive Committee, an individual is entitled to request a hearing. For ease of use, this Article refers to adverse recommendations of the Medical Executive Committee. When a hearing is triggered by an adverse recommendation of the Board, any reference in this Article to the “Medical Executive Committee” will be interpreted as a reference to the “Board.”

5.A.2. Actions Not Grounds for Hearing:

None of the following actions constitute grounds for a hearing. These actions take effect without hearing or appeal. The individual is entitled to submit a written statement regarding these actions for inclusion in his or her file: (a) a letter of guidance, counsel, warning, or reprimand;

(b) conditions, monitoring, proctoring, or a general consultation requirement; (c) a lapse or decision not to grant or not to renew temporary privileges; (d) automatic relinquishment of appointment or privileges;


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(e) a requirement for additional training or continuing education; (f) precautionary suspension; (g) denial of a request for leave of absence, for an extension of a leave or for

reinstatement from a leave if the reasons do not relate to professional competence or conduct;

(h) determination that an application is incomplete; (i) determination that an application will not be processed due to a misstatement or

omission; or (j) determination of ineligibility based on a failure to meet threshold eligibility

criteria, a lack of need or resources, or because of an exclusive contract.

5.B. THE HEARING 5.B.1. General Rules: The hearing shall be conducted in as informal a manner as possible, subject to the rules and procedures set forth in these Bylaws.

5.B.2. Notice of Recommendation:

When a recommendation is made which entitles an individual to a hearing, the affected individual shall promptly be advised by the Chief Executive Officer by Special Notice. This notice shall contain the following:

(1) a statement of the recommendation made and the general reasons for it; (2) notice that the individual has the right to request a hearing on the recommendation

within 30 days of receipt of the notice; and

(3) a copy of this Part 5.

5.B.3. Request for Hearing:

An individual shall have 30 days from receipt of the notice within which to request a hearing. The request shall be in writing to the Chief Executive Officer and will include the name, address, and telephone number of the individual’s counsel, if any. In the event the individual does not request a hearing in a timely fashion, the individual shall be deemed to have waived the right to the hearing and to have accepted the recommendation. Such recommendation shall become effective immediately upon final action by the Board.


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The Practitioner shall state, in writing, his or her intentions with respect to attorney representation in the hearing proceeding itself at the time he or she submits the request for a hearing. However, regardless of whether the Practitioner elects to have attorney representation at the hearing, the parties shall have the right to consult with legal counsel to prepare for any hearing or appellate review. If the hearing is based upon an adverse action by the Board of Directors, the chairperson of the Board of Directors or his/her designee shall fulfill the functions assigned in this Section to the President of the Medical Staff.

5.B.4. Notice of Hearing and Statement of Reasons: (1) The Chief Executive Officer will schedule the hearing and provide, by special

notice, the following: (a) the time, place, and date of the hearing; (b) a proposed list of witnesses who will give testimony at the hearing and a

brief summary of the anticipated testimony; (c) the names of the Hearing Panel members and Presiding Officer (or

Hearing Officer) if known; and (d) a statement of the specific reasons for the recommendation, including a

list of patient records (if applicable), and information supporting the recommendation. This statement may be revised or amended at any time, even during the hearing, so long as the additional material is relevant to the recommendation or the individual's qualifications and the individual has had a sufficient opportunity, up to 30 days, to review and rebut the additional information.

(2) The hearing will begin as soon as practicable, but no sooner than 30 days after the

notice of the hearing, unless an earlier hearing date has been specifically agreed to in writing by the parties.

5.B.5. Witness List:

(1) At least 15 days before the pre-hearing conference, the individual requesting the

hearing will provide a written list of the names of witnesses expected to offer testimony on his or her behalf.

(2) The witness list will include a brief summary of the anticipated testimony. (3) Witness lists shall be finalized at the time of the pre-hearing conference.

However, the witness list of either party may, in the discretion of the Presiding


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Officer, be supplemented or amended at any time during the course of the hearing, provided that notice of the change is given to the other party.

5.B.6. Hearing Panel, Presiding Officer, and Hearing Officer:

(1) Hearing Panel:

(a) When a hearing is requested, the Chief Executive Officer, in consultation

with the Chief Medical Officer and/or President of the Medical Staff (or the Chairperson of the Board, if the hearing is occasioned by a Board determination) shall appoint a Hearing Panel consisting of not less than 3 members, at least one of whom should, whenever practical, be a peer of the individual who is the subject of the hearing (i.e. physician, dentist, podiatrist, psychologist). The members of the Hearing Panel may be Members of the Medical Staff, other physicians, or laypersons.

(b) The Hearing Panel shall be selected from members of the Medical Staff,

provided the member has not actively participated in the matter at any previous level, and

(c) Knowledge of the underlying peer review matter, in and of itself, shall

not preclude the individual from serving on the Panel; (d) Employment by, or other contractual arrangement with, Morton Plant

Mease, the Hospital, or an affiliate shall not preclude an individual from serving on the Panel;

(e) The Hearing Panel shall not include any individual who would gain direct

financial benefit from the outcome, who is in direct economic competition with the subject of the hearing, or who is professionally associated (including in a referral relationship) with or related to the subject of the hearing. None of the Hearing Panel members may have acted as an accuser, investigator, fact-finder or initial decision-maker, or otherwise actively participated in the consideration of the matter leading up to the recommendation or action. Hearing Panel members also should not have participated in the care of the patient(s) whose care forms the subject of the hearing. The Panel shall not include any individual who is demonstrated to have an actual bias, prejudice, or conflict of interest that would prevent the individual from fairly and impartially considering the matter.

(f) The Chief Executive Officer in consultation with the Chief Medical

Officer and/or President of the Medical Staff shall also appoint a Presiding Officer or a Hearing Panel Chairperson.


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(2) Presiding Officer:

(a) The Presiding Officer may be an attorney and should be familiar with Medical Staff hearings. The Presiding Officer, Hearing Officer, and counsel for either party may be an attorney at law who is licensed to practice, in good standing, in any state.

(b) The Presiding Officer must not act as a prosecuting officer, or as an

advocate for either side at the hearing. The Presiding Officer may participate in the private deliberations of the Hearing Panel and be a legal advisor to it, but shall not be entitled to vote on its recommendations.

(c) If a chairperson of the Hearing Panel is appointed in lieu of a Presiding

Officer, such chairperson shall exercise all the authority otherwise vested in the Presiding Officer and shall also be entitled to vote.

(d) The Presiding Officer shall perform the following functions:

(i) act to insure that all participants in the hearing have a reasonable

opportunity to be heard and to present evidence, subject to reasonable limits on the number of witnesses and duration of direct and cross examination;

(ii) prohibit conduct or the presentation of evidence that is cumulative, excessive, irrelevant, abusive, or that causes undue delay;

(iii) maintain decorum throughout the hearing;

(iv) determine the order of procedure throughout the hearing;

(v) have the authority and discretion to make rulings on all questions

which pertain to matters of procedure and to the admissibility of evidence, including the discretion to refuse to allow a witness to testify if the other party was not provided with adequate notice;

(vi) act in such a way that all information relevant to the continued appointment or Clinical Privileges of the individual requesting the hearing is considered by the Hearing Panel; and

(vii) conduct argument by counsel on procedural points outside the

presence of the Hearing Panel unless the Panel wishes to be present.

(e) The Presiding Officer may be advised by legal counsel to the Hospital.


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(3) Objections:

Any objection to any member of the Hearing Pane or the Presiding Officer, will be made in writing, within 10 days of receipt of notice, to the CEO. A copy of such written objection must be provided to the President of the Medical Staff and Chief Medical Officer and must include the basis for the objection. The President of the Medical Staff, the CEO along with the Chief Medical Officer will be given a reasonable opportunity to comment. The CEO will rule on the objection and give notice to the parties. The Chief Executive Officer may request that the Presiding Officer make a recommendation as to the validity of the objection.

5.C. PRE-HEARING AND HEARING PROCEDURE

5.C.1. Discovery:

(1) There is no right to discovery in connection with the hearing. However, the individual requesting the hearing shall be entitled, upon specific request, to the documents listed below. These documents shall be provided only after both

parties have signed a stipulation stating that the documents will be maintained in a confidential fashion and will not be disclosed or used for any purpose outside of the hearing and that production of the documents shall not constitute a waiver of the protection afforded by the state peer review statute. The individual must also provide a written representation that his/her counsel and any expert(s) have executed Business Associate Agreements in connection with any patient Protected Health Information contained in any documents provided. Upon receipt of the above Agreement and representation, the individual requesting the hearing will be provided with a copy of the following:

(a) copies (at the individual’s expense) of, or reasonable access to, all patient

medical records relevant to the adverse recommendation;

(b) reports of experts relied upon by the Chief Medical Officer, the Medical Executive Committee, or the Board in reaching the recommendation;

(c) redacted copies of relevant committee minutes; and

(d) copies of any other documents relied upon by the Medical Executive

Committee.

The affected individual shall not be provided with copies of confidential documents, including peer review, performance improvement, and/or quality assessment documents, relating to any other member of the Medical Staff.

Neither the individual, nor any other person acting on behalf of the individual,

may contact Hospital employees or medical staff members whose names appear on the Executive Committee’s witness list or in documents provided pursuant to


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this section concerning the subject matter of the hearing, until the Hospital has been notified and has contacted the individuals about their willingness to be interviewed. The Hospital will advise the individual who requested the hearing once it has contacted such employees or medical staff members and confirmed their willingness to meet. Any employee or medical staff member may agree or decline to be interviewed by or on behalf of the individual who requested a hearing.

5.C.2. Pre-Hearing Conference:

The Presiding Officer shall require a representative of the affected individual and a representative of the Medical Executive Committee to participate in a pre-hearing conference for the purpose of resolving all procedural questions in advance of the hearing. The Presiding Officer shall specifically require that:

(1) all documentary evidence to be submitted at the hearing be exchanged ten (10)

days prior to the pre-hearing conference by the parties and that any objections regarding the documents be made at the pre-hearing conference. Failure to comply with this requirement is good cause for a continuance. Repeated failures to comply shall be good cause for the Presiding Officer to limit the introduction of any documents not provided to the other side in a timely manner. In addition, the body whose decision prompted the hearing may object to the introduction of evidence that the Practitioner did not provide during the application or corrective action process despite requests from the peer review body for such information. The information will be excluded by the Presiding Officer unless the Practitioner can prove he/she acted diligently and could not have submitted the information earlier.

(2) evidence unrelated to the reasons for the unfavorable recommendation or

unrelated to the individual’s qualifications for appointment or the relevant Clinical Privileges be excluded;

(3) any objections regarding witnesses be made at this conference;

(4) the time granted for each party to present its case be generally agreed upon or

determined by the Presiding Officer; and

(4) witnesses and documentation not provided and agreed upon in advance of the hearing may be excluded from the hearing.

5.C.3. Resolution of Disputes

The Presiding Officer shall rule on disputes regarding information exchange that the parties cannot resolve. The Presiding Officer may deny access to information as appropriate to protect peer review or in the interest of fairness. Further, the right to inspect and copy by either party does not include confidential information that refers to


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identifiable Practitioners other than the Practitioner under review, nor does it create any obligations to modify or create documents. 5.C.4 Procedural Disputes The parties shall exercise reasonable diligence in notifying the Presiding Officer of any pending or anticipated procedural disputes as far in advance of the scheduled hearing as possible, so that the Presiding Officer may make rulings concerning such matters in advance of the hearing. Objections to any pre-hearing decisions may be preserved for the record at the beginning of the hearing, but will not otherwise be discussed, argued, or ruled upon at the hearing. All procedural matters shall be resolved by the Presiding Officer outside the presence of the Hearing Panel. The Presiding Officer may permit the parties to make oral arguments and/or to submit motions in support or defense of procedural objections, except for objections related to matters to be resolved at the pre-hearing conference (which shall not be revisited during the course of the hearing). The party raising an objection shall argue and/or submit a motion in support of that objection. The opposing party shall then be given a reasonable opportunity to respond. The Presiding Officer shall rule on all objections. All motions, responses, and rulings shall be entered into the record by the Presiding Officer.

5.C.5. Failure to Appear:

Failure, without good cause, of the individual requesting the hearing to appear and proceed on the designated date shall be deemed to constitute acceptance of the pending recommendation, which shall then be forwarded to the Board for final action. 5.C.6. Record of Hearing:

A record of the hearing shall be maintained by a stenographic reporter or by a recording of the proceedings. The cost of such reporter shall be borne by the Hospital, but copies of the transcript shall be provided to the individual requesting the hearing at that individual’s expense. Unless otherwise agreed to by the parties, oral evidence shall be taken only on oath or affirmation administered by any person designated by such body and entitled to notarize documents in Florida.

5.C.7. Rights of Both Sides at the Hearing:

(1) At a hearing both sides shall have the following rights, subject to reasonable

limits determined by the Presiding Officer:

(a) to call and examine witnesses to the extent available;

(b) to introduce exhibits;


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(c) to cross-examine any witness on any matter relevant to the issues;

(d) to rebut any evidence;

(e) to representation by a physician who may call, examine, and cross-examine witnesses and present the case;

(f) to representation by counsel who may advise the party but who shall not,

unless otherwise provided by the Hospital, present the case; and (g) to submit proposed findings, conclusions and recommendations to the

Hearing Panel. (2) Any individual requesting a hearing who does not testify in his or her own behalf

may be called and examined as if under cross-examination. If the individual fails to testify when questioned by the Presiding Officer, Hearing Officer, Hearing Panel, or the individuals representing the MEC or Board at the Hearing, as applicable, the hearing shall immediately stop and the individual shall be deemed to have waived his or her right to a hearing and appeal and to have accepted the recommendation of the MEC and any final action of the Board.

(3) The Hearing Panel may question the witnesses, call additional witnesses, and/or

request documentary evidence.

5.C.8. Admissibility of Evidence:

The hearing shall not be conducted according to rules of evidence. Any relevant evidence shall be admitted if it is the sort of evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of such evidence in a court of law.

5.C.9. Postponements and Extensions:

Postponements and extensions of time beyond any time limit set forth in these Bylaws may be requested by anyone but shall be permitted only by the Presiding Officer or the Chief Executive Officer on a showing of good cause.

5.D. HEARING CONCLUSION, DELIBERATIONS, AND RECOMMENDATIONS

5.D.1. Order of Presentation:

The Medical Executive Committee or the Board, depending on whose recommendation prompted the hearing initially, shall first present evidence in support of its recommendation. Thereafter, the individual who requested the hearing shall present evidence.


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5.D.2. Basis of Decision:

(1) The Hearing Panel shall recommend in favor of the Medical Executive Committee (or the Board), unless it finds that the individual who requested the hearing has proven that the recommendation that prompted the hearing was arbitrary, capricious, or not supported by substantial evidence.

(2) The decision of the Hearing Panel shall be based on the evidence produced at the

hearing. This evidence may consist of the following:

(a) oral testimony of witnesses;

(b) any information regarding the individual who requested the hearing so long as that information was admitted into evidence at the hearing and the person who requested the hearing had the opportunity to comment on and, by other evidence, refute it;

(c) any and all applications, references, and accompanying documents;

(d) other documented evidence, including medical records; and

(e) any other evidence that has been admitted.

5.D.3. Adjournment and Conclusion:

The Presiding Officer may, without Special Notice, adjourn the hearing and reconvene the same at the convenience and with the agreement of the participants. Upon conclusion of the presentation of evidence by the parties and/or questions by the Hearing Panel, the hearing shall be closed.

5.D.4. Deliberations and Recommendation of the Hearing Panel:

Within 20 days after final adjournment of the hearing (which shall be designated as the time the Hearing Panel receives the post-hearing memoranda), the Hearing Panel shall conduct its deliberations outside the presence of any other person except the Presiding Officer. The Hearing Panel shall prepare a written statement of its recommendation and the reasons for it. The report shall contain the Hearing Panel’s findings of fact and a conclusion articulating the connection between the evidence presented at the hearing and the decision reached.

5.D.5. Disposition of Hearing Panel Recommendation:

The Hearing Panel shall forward its recommendation to the Chief Executive Officer. The Chief Executive Officer shall send a copy of the recommendation, by Special Notice, to


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the individual who requested the hearing. A copy of the recommendation shall also be given to the Chief Medical Officer and President of the Medical Staff.

5.E. APPEAL PROCEDURE

5.E.1. Time for Appeal:

(1) Within 10 days after notice of the Hearing Panel’s recommendation, either party may request an appellate review. The request shall be in writing and shall be delivered to the Chief Executive Officer either in person or by certified mail, return receipt requested. If such appellate review is not requested within 10 days, both parties shall be deemed to have waived appellate review, and the Hearing Panel’s recommendation shall be forwarded to the Board for final action.

(2) A request for an appeal shall include a statement of the reasons for appeal and the

specific facts or circumstances which justify further review.

5.E.2. Grounds for Appeal:

The grounds for appeal shall be limited to the following:

(1) there was substantial failure to comply with these Bylaws during or prior to the hearing, so as to deny a fair hearing; or

(2) the recommendations of the Hearing Panel were made arbitrarily, capriciously, or

with prejudice; or

(3) the recommendations of the Hearing Panel were not supported by substantial evidence.

5.E.3. Time, Place and Notice:

(1) Whenever an appeal is requested, and the individual requesting the appeal has

shown with substantial evidence that one or more grounds for appeal exist, the Chief Executive Officer shall, within 15 days after receipt of such request, schedule and arrange for an appellate review.

(2) The date of appellate review shall be not less than 10 days, nor more than 30 days,

from the date of receipt of the request for appellate review, provided, however, that when a request for appellate review is from an individual who has been suspended on a precautionary basis, the appellate review shall be held as soon as the arrangements may reasonably be made. The time for appellate review may be extended by the Chairperson of the Board for good cause.


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5.E.4. Nature of Appellate Review:

(1) The Chairperson of the Board shall appoint a Review Panel composed of not less than three persons, either members of the Board or others, including but not limited to reputable persons outside the Hospital. In the discretion of the Board Chairperson, the Board, as a whole, may hear the appeal.

(2) Each party shall have the right to present a written statement in support of its

position on appeal. The party requesting the appeal will submit a statement first and the other party will then have ten days to respond.

5.E.5. Final Decision of the Board:

(1) The Review Panel shall consider the record before it in making a final

recommendation to the Board. The basis for the Review Panel’s recommendation shall be clearly stated in its report.

(2) Upon receipt of the Review Panel’s report and recommendation, the Board may

affirm, modify or reverse the recommendation, refer the matter for further review and recommendation, or make its own decision in light of the Board’s ultimate legal responsibility.

(3) Within 30 days after receipt of the Review Panel’s recommendation, the Board

shall render a final decision in writing, including specific reasons, and shall deliver a copy to the affected individual by Special Notice. A copy of the Board’s decision shall also be provided to the Chief Medical Officer, President of the Medical Staff and Medical Executive Committee.

(4) Except where the matter is referred for further action, as set forth above, the

decision of the Board following the appeal shall be effective immediately and shall not be subject to further review. If the matter is referred for further action and recommendation, such recommendation will be promptly made to the Board in accordance with the instructions given by the Board.

(5) No applicant or Medical Staff Member shall be entitled to more than one hearing

and one appellate review on any matter which may be the subject of an appeal. If the Board ultimately denies initial appointment and/or initial Clinical Privileges, denies reappointment or revokes or terminates appointment and/or Clinical Privileges of a current Member, that individual may not apply for staff appointment or for those Clinical Privileges for a period of five years unless the Board provides otherwise.


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5.E.6. Exceptions to Hearing Rights (1) Contract Practitioners

The hearing rights of this Part 5 do not apply to Practitioners who have contracted with the Hospital to provide clinical services. Rather, such Practitioners’ rights to exercise of Privileges shall be governed by the terms of their individual agreements with the Hospital. However, the hearing rights of this Part 5 shall apply as required by law if an action is taken that must be reported under federal or Florida law, and/or a Practitioner’s Medical Staff membership, or Privileges that are independent of the Practitioner’s contract, are reduced, terminated, or suspended for reasons relating to the Practitioner’s competence or professional conduct that could affect patient care.

(2) Allied Health Practitioners Whenever the Medical Executive Committee makes a recommendation, or the

Board, without a prior adverse recommendation from the Medical Executive Committee, makes a preliminary recommendation, that entitles the AHP to request a hearing, the CEO shall provide the Allied Health Professional with written notice of the recommendation, the reasons therefore and the time period within which the Allied Health Professional can request a hearing. AHPs shall be entitled to request hearings under the same circumstances set forth in Sections 5.A.1. and 5.A.2. of these Bylaws, except that no AHP shall be entitled to Medical Staff membership or a hearing or appeal as a result of the Hospital's refusal to grant Medical Staff membership to such individual. If a hearing is requested, the President shall name and CEO shall appoint a committee of three (3) unbiased medical staff members and allied health professionals with clinical privileges to hear the Allied Health Professional’s objections to the proposed action or recommendation no sooner than thirty days from the date of the request. A record of the hearing shall be made. The MEC and the individual shall each have the right to call and examine witnesses and may be represented by counsel, though counsel shall not present the case, nor call, examine, or cross-examine witnesses. The committee shall make a recommendation, which shall be in writing, reflect consideration of the information presented at the hearing, and be provided to the Allied Health Professional, the Medical Executive Committee, and the Board. The committee shall recommend in favor of the Medical Executive Committee (or Board, as applicable) unless the Allied Health Professional shows that the recommendation or preliminary determination was arbitrary, capricious, or not supported by substantial facts.

The Allied Health Professional and the Medical Executive Committee each have the right to appeal the committee’s recommendation by submitting written statements to the Board within thirty days of receipt of the recommendation. The Board, or a committee thereof, shall review the parties’ written submissions. If the appeal is reviewed by a committee, it shall promptly provide the parties and


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the Board with its recommendation. Upon consideration of the hearing committee recommendation and the information presented at appeal, the Board shall take final action and shall thereupon provide all parties with its decision, and the reasons therefore, in writing.

5.E.7 Documentation and Reporting (1) The Medical Staff will document all peer review matters, collegial intervention

efforts, investigations, and corrective action implemented in accordance with these Bylaws. Professional review actions will be reported in accordance with federal and Florida law.


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PART 6: Rules and Regulations and Policies 6.A. OVERVIEW

These Bylaws describe the fundamental principles of Medical Staff self-governance and accountability to the Board. Accordingly, the key standards for Medical Staff membership, appointment, reappointment, and privileging are set out in these Bylaws. Additional provisions, including, but not limited to, procedures for implementing the Medical Staff standards may be set out in the Medical Staff Rules and Regulations, or in policies adopted or approved in accordance with these Bylaws. Neither the organized medical staff nor the governing body may unilaterally amend the medical staff bylaws or rules and regulations.

6.B. MEDICAL STAFF RULES

The Medical Staff shall initiate and adopt such rules as it may deem necessary and shall periodically review and revise its rules to comply with current Medical Staff practice. New rules or changes to the Medical Staff’s Rules and Regulations (proposed rules) may emanate from any responsible committee, department, Medical Staff officer, or by petition signed by at least 10 percent of the voting Members of the Medical Staff. Additionally, Hospital administration may develop and recommend proposed rules, and in any case should be consulted as to the impact of any proposed rules on Hospital operations and feasibility. Proposed rules shall be submitted to the Medical Executive Committee for review and action, as follows (1) the Medical Executive Committee shall not act on the proposed rule until the

Medical Staff has had a reasonable opportunity to review and comment on the proposed rule.

(2) Medical Executive Committee approval is required, unless the proposed rule is one generated by petition of at least 10 percent of the voting Members of the Medical Staff. In this latter circumstance, if the Medical Executive Committee fails to approve the proposed rule, it shall notify the Medical Staff. The Medical Executive Committee and the Medical Staff each has the option of invoking or waiving the conflict management provision in these Bylaws.

(3) If conflict management is not invoked within 30 days it shall be deemed waived.

In this circumstance, the Medical Staff’s proposed rule shall be submitted for vote, and if approved by the Medical Staff pursuant to these Bylaws, the proposed rule shall be forwarded to the Board for action. The Medical Executive Committee may forward comments to the Medical Staff and the Board regarding the reasons it declined to approve the proposed rule.

(4) If conflict management is invoked, the proposed rule shall not be voted upon or

forwarded to the Board until the conflict management process has been


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completed, and the results of the conflict management process shall be communicated to the Medical Staff and the Board.

(5) With respect to proposed rules generated by petition of the Medical Staff,

approval of the Medical Staff requires the affirmative vote of a majority of the voting Members of the Medical Staff on the matter, provided at least 14 days' advance written notice, accompanied by the proposed rule, has been given, and at least 10 votes have been cast.

(6) Following approval by the Medical Executive Committee or the voting Medical

Staff as described above, a proposed rule shall be forwarded to the Board for approval, which approval shall not be withheld unreasonably. The rule shall become effective immediately following approval of the Board or automatically within 60 days if no action is taken by the Board.

6.C. MEDICAL STAFF POLICIES

(1) Policies shall be developed as necessary to implement more specifically the general principles found within these Bylaws and the Medical Staff Rules and Regulations. New or revised policies (proposed policies) may emanate from any responsible committee, department, Medical Staff officer, or by petition signed by at least 10 percent of the voting Members of the Medical Staff. Proposed policies shall not be inconsistent with the these Bylaws, the Hospital bylaws, Medical Staff Rules and Regulations or other policies, and upon adoption shall have the force and effect of these Bylaws

(2) Medical Executive Committee approval is required, unless the proposed policy is

one generated by petition of at least 10 percent of the voting Members of the Medical Staff. In this latter circumstance, if the Medical Executive Committee fails to approve the proposed policy, it shall notify the Medical Staff. The Medical Executive Committee and the Medical Staff each has the option of invoking or waiving the conflict management provisions of these Bylaws.

(a) If conflict management is not invoked within 10 days it shall be deemed

waived. In this circumstance, the Medical Staff’s proposed policy shall be submitted for vote, and if approved by the Medical Staff pursuant to these Bylaws, the proposed policy shall be forwarded to the Board for action. The Medical Executive Committee may forward comments to the Medical Staff and the Board regarding the reasons it declined to approve the proposed policy.

(b) If conflict management is invoked, the proposed policy shall not be voted upon or forwarded to the Board until the conflict management process has been completed, and the results of the conflict management process shall be communicated to the Medical Staff and the Board.


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(c) Approval of the Medical Staff shall require the affirmative vote of a majority of the voting Members of the Medical Staff on the matter, provided at least 14 days' advance written notice, accompanied by the proposed policy, has been given and at least 10 votes have been cast.

(d) Following approval by the Medical Executive Committee or the voting

Medical Staff as described above, a proposed policy shall be forwarded to the Board for approval, which approval shall not be withheld unreasonably. The policy shall become effective immediately following approval of the Board or automatically within 60 days if no action is taken by the Board.

6.D. CONFLICTS BETWEEN THE MEDICAL STAFF AND THE MEDICAL EXECUTIVE

COMMITTEE

In the event of conflict between the Medical Executive Committee and the Medical Staff (as represented by written petition signed by at least 10 percent of the voting Members of the Medical Staff) regarding a proposed or adopted rule or policy, or other issue of significance to the Medical Staff, the President of Staff shall convene a meeting with the Medical Staffs’ representative(s). The foregoing petition shall include a designation of up to five Members of the voting Medical Staff who shall serve as the Medical Staffs’ representative(s). The Medical Executive Committee shall be represented by an equal number of Medical Executive Committee members. The Medical Executive Committee’s and the Medical Staffs’ representative(s) shall exchange information relevant to the conflict and shall work in good faith to resolve differences in a manner that respects the positions of the Medical Staff, the leadership responsibilities of the Medical Executive Committee, and the safety and quality of patient care at the Hospital. Resolution at this level requires a majority vote of the Medical Executive Committee’s representatives at the meeting and a majority vote of the Medical Staffs’ representatives. Unresolved differences shall be submitted to the Board for its consideration in making its final decision with respect to the proposed rule, policy, or issue

6.E. CONFIDENTIALITY AND PEER REVIEW PROTECTION

Actions taken and recommendations made pursuant to these Bylaws shall be treated as confidential in accordance with applicable legal requirements and such policies regarding confidentiality as may be adopted by the Hospital and the Medical Staff. In addition, reports of actions taken pursuant to these Bylaws shall be made by the Chief Executive Officer to such governmental agencies as may be required by law.

6.F. HISTORIES AND PHYSICAL EXAMINATIONS The purpose of a medical history and physical examination is to determine whether there

is anything in the patient’s overall condition that would affect the planned course of the patient’s treatment, such as a medication allergy or a new or existing co-morbid condition that requires additional interventions that reduce risk to the patient.


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(1) A complete history and physical examination shall be recorded on the patient's chart within twenty-four (24) hours following admission. This report shall reflect a comprehensive current physical assessment by a Medical Staff Member or appropriate Allied Health Professional who has been granted Privileges or given permission by the Hospital to perform histories or physicals.

(2) If a history and physical examination has been performed within thirty (30) days

prior to admission, a durable, legible copy of this report may be used in the patient's Hospital medical record. If the history and physical has been completed prior to admission, the patient must be assessed and the inpatient medical record must be updated at the time of the admission to reflect any changes in the patient's condition since the date of the original history and physical or to state that there have been no changes in the patient's condition. All updates must be timed, dated and signed. Updates include prior to surgery and prior to all procedures requiring anesthesia.

(3) If the patient is admitted for less than twenty-four (24) hours, the history and

physical and discharge summary may be prepared in one document, to be called a “short stay summary."

(4) The medical record shall document a current, thorough physical examination prior

to the performance of inpatient surgery. When the history and physical examination are not recorded before a surgical procedure or any potentially hazardous diagnostic procedure, the procedure shall be canceled unless the attending Physician states in writing that an emergency situation exists, or that any such delay would be detrimental to the patient.

(5) The history and physical exam shall address whether a patient may be a victim of

abuse or neglect or is suffering from an addiction or emotional/behavioral disorder. If the circumstances indicate the presence of such a condition, a full assessment of the condition shall be conducted and documented in the patient's record.

(6) The history and physical exam may address whether the patient is likely to require

restraint or seclusion, any factors that may reduce the likelihood that restraint or seclusion will be necessary, and any pre-existing physical or psychological conditions that may cause the patient to experience restraint or seclusion in an adverse way.

(7) In the case of readmission of a patient, all previous records shall be available for

use by the attending Medical Staff Member. 6.G. OTHER RULES AND REGULATIONS

Medical staff rules and regulations as may be necessary to implement more specifically the procedural details of the concepts set forth in these Bylaws shall be adopted in


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accordance with this Part. Rules and regulations shall set standards of practice that are to be required of each individual exercising Clinical Privileges in the Hospital and shall act as an aid to evaluating performance under, and compliance with, these standards. Rules and regulations shall have the same force and effect as these Bylaws. If there is a conflict between these Bylaws and the rules, the Bylaws shall prevail.


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Part 7: Bylaw Amendments

All proposed amendments to these Bylaws shall be referred to the President of Staff, who shall report on them either favorably or unfavorably at the next regular meeting of the Medical Staff or at a special meeting called for such purpose. It is recognized that meetings and subsequent voting of the Medical Staff may be electronic. The President of Staff shall cause the proposed amendments to be posted on the medical staff bulletin board at least 14 days before that meeting. The President of Staff shall call for a vote on the proposed amendments at the meeting. To be adopted, an amendment must receive a majority of the votes cast by the voting Members of the Medical Staff who are present at the time of such vote and who do vote. Amendments so adopted shall be effective when approved by the Board. Neither the organized medical staff nor the governing body may unilaterally amend the medical staff bylaws or rules and regulations.


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Part 8: Adoption

These Bylaws are adopted and made effective upon approval of the Board, superseding and replacing any and all previous medical staff bylaws.

Approved by the Board on February 19, 2014

Ken Hamilton (Signature, Board Chairperson)

Adopted by the Medical Staff on January 21, 2014

Leonard Dunn, MD

(Signature, President of Medical Staff)

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