BLAKE MEDICAL CENTER

MEDICAL STAFF BYLAWS

Effective 2004

Revised 2006

Revised 2007

Revised 2010

Revised 2012

Revised 2014

PREAMBLE

Recognizing that the Medical Staff is responsible for the quality of the medical care in the Hospital and must accept and assume this responsibility subject to the ultimate authority of the Hospital Governing Body, and that the cooperative efforts of the Medical Staff, the Chief Executive Officer and the Governing Body are necessary to fulfill the Hospital's obligations to its patients; the physicians, osteopaths, dentists, podiatrists, and psychologists practicing in this Hospital hereby organize themselves into a single Medical Staff in conformity with the Bylaws, hereinafter stated. Each appointee to the Medical Staff has the responsibility for the exercise of professional judgment in the care and treatment of patients and in accordance with legal and accreditation requirements, as delegated to the medical staff through its clinical departments, services and committees, the duties and responsibilities set forth in these Bylaws, the policies and procedures on Medical Staff Appointment, Reappointment and Clinical Privileges, Policy for Allied Health Professionals, and for the supervising and monitoring of the quality of care provided by physicians, dentists, podiatrists, psychologists and others in the Hospital, and for the making of recommendations concerning applications for appointment, reappointment and clinical privileges and activities; and, the Medical Staff recognizes and accepts its role and responsibilities in the efforts of the Hospital to foster prevention, amelioration and cure of illness, disease and injury, and to provide or assist in providing medical education and continuing medical education of medical staff appointees, other health care professionals, and nurses; therefore, to discharge these duties and responsibilities to provide an orderly process concerning the election, meeting, duties and procedures, the officers, clinical departments and services, committees as described in these Bylaws assume responsibility for the fulfilling of those duties and functions as delegated to them by the Board of Trustees.

ARTICLE I

DEFINITIONS

1. Medical Staff shall include physicians holding unlimited license in the State of Florida to practice all branches of medicine and surgery, osteopaths, duly licensed dentists, podiatrists and psychologists who are privileged to care for patients in the Hospital.

2. Board of Trustees means the Governing Body of the Hospital, which is the group responsible for conducting the ordinary business affairs of the Hospital, which for the purposes of these Bylaws, and except as the content otherwise requires, shall be deemed to act through the authorized actions of the officers of the corporation and through the Chief Executive Officer of the Hospital.

3. Executive Committee means the Executive Committee of the Medical Staff.

4. Chief Executive Officer (CEO) means the Administrator appointed by the Governing Body to act in its behalf in the overall management of the Hospital. The term "Chief Executive Officer" includes a duly appointed Acting Administrator serving when the CEO is away from the Hospital. The Medical Staff may rely on all actions of the CEO as being actions of the Board of Trustees taken pursuant to a proper delegation of authority from the Board of Trustees.

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5. Administration means the executive members of the administration of the Hospital.

6. Practitioner means an appropriately licensed member of the Medical Staff; unless otherwise limited, any physician, oral surgeon, dentist, podiatrist or psychologist who is approved by the Staff, or, in the case of an applicant, who has applied for staff membership or clinical privileges at the Hospital.

7. Attending physician is the physician to whose service the patient is admitted.

8. Clinical Privilege is authorization granted by the Board of Trustees to an applicant, Medical Staff appointee, or other independent practitioner to render specific professional, diagnostic, therapeutic, medical, dental or surgical patient care services in the Hospital within defined limits.

9. Data Bank is the National Practitioner Data Bank implemented pursuant to Health Care Quality Improvement Act of 1986, 42 U.S.C.A. §11101 et seq.

10. Hospital is Blake Medical Center, 2020 59th Street West, Bradenton, Florida 34209 that is owned and operated by HCA Health Services, Inc. of Florida, a proprietary corporation.

11. Physician is an individual who has received a doctor of medicine or doctor of osteopathy degree and is currently licensed to practice in the State of Florida.

12. Dentist shall be interpreted to mean a doctor of dental surgery (DDS) or doctor of dental medicine (DMD).

13. Podiatrist shall be interpreted to be a doctor of podiatric medicine (DPM).

14. Psychologists must have a Doctorate in the field of clinical psychology.

15. Allied Health Professional is defined as an individual, not a member of the Medical Staff or a Hospital employee, who is trained in some aspect of evaluation or treatment of human illness and who is allowed after approval by the Board to perform such specified services to patients at the Hospital under the responsibility and supervision of a staff member.

16. Rules and Regulations of the Medical Staff are components of these Bylaws.

17. Fair Hearing Plan is attached to these Bylaws.

18. Completed application with supportive documents means that all questions on any application form are answered, signed, and supporting documents shall include verification of licensure, education, training, past and present affiliations and reference letters, insurance coverage, DEA registration.

19. Good standing means that the Medical Staff appointee is not under suspension or any restriction regarding staff appointment or admitting privileges at the Hospital.

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20. Professional Review Activity means any action or recommendation of any review body which is taken or made in the conduct of professional review activity, which is based on the competence or professional conduct of a staff appointee, and which affects or may adversely affect the clinical privileges or appointment of the staff appointee.

21. Professional Review Body means the Board of Trustees or any Board committee which conducts professional peer review activity, and includes any committee of the Medical Staff when assisting the Board in a professional peer review activity.

22. Unassigned patient means any individual who comes to the Hospital for care and treatment who does not have an attending physician; or whose attending physician or designated alternate is unavailable to attend the patient; or who does not want the prior attending physician to provide his/her care while a patient at the Hospital.

23. Close by Rule: Residence/office close enough to provide continuous care to patient and provide access to respond to emergency situation within 30 minutes.

24. Staff year is the year beginning January 1 and ending December 31.

25. Words used in these Bylaws shall be read as the masculine and feminine gender, and as singular or plural, as the content requires. The captions, headings are for convenience only and are not intended to limit or define the scope or effect of any provision of the Bylaws.

26. Staff dues or application fees may be assessed at the discretion of the Executive Committee and Board of Trustees. Dues shall be payable upon request. Failure to pay dues after two written notices shall be construed as voluntary resignation from the staff.

ARTICLE II

NAME, PURPOSES AND RESPONSIBILITIES

1. Name. The name of the Staff shall be the Medical Staff of Blake Medical Center.

2. Purposes. The purposes of the Staff are:

a. To provide that all patients admitted to or treated in any of the facilities, department or services of the Hospital shall receive the best possible care commensurate with acceptable standards and available community resources;

b. To provide a high level of professional performance of all members of the Medical Staff through the appropriate delineation of privileges to practice in the Hospital and the continuous (ongoing) review and evaluation of the activities of all individuals granted privileges in the Hospital;

c. To serve as a primary means for accountability to the Board concerning professional performance of practitioners authorized to practice at the Hospital and for quality assessment and improvement;

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d. To provide an educational setting that will assist in maintaining patient care standards and encourage continuous advancement in professional knowledge and competency;

e. To adopt rules and regulations for proper functioning of the Medical Staff;

f. To provide a means whereby issues concerning the Medical Staff and the Hospital may be discussed by the Medical Staff with the Governing Body and the Chief Executive Officer;

g. To support programs associated with community public health needs;

h. To assure that there will be medical staff representation at all deliberations affecting the medical staff;

i. To assist the Board by serving as professional review body in conducting professional review activities. References to quality assessment and improvement refer to improving organizational performance.

3. Responsibilities. The Medical Staff shall account and report to the Board of Trustees and the Administration with the appropriate recommendation regarding the quality assessment and improvement activities of the Hospital by means of:

a. Mechanism for appointment and reappointment of competent, qualified practitioners and the delineation of clinical privileges;

b. Continuing medical education programs;

c. Utilization review programs;

d. Evaluation of patient care;

e. Pursuing corrective action with respect to practitioners, individuals granted clinical privileges and allied health professionals when warranted;

f. Develop and monitor compliance with these Bylaws, the Rules and Regulations and other Hospital policies; and

g. Identify community health needs and establishing institutional goals.

The staff shall assist the Board in establishing mechanisms to assure that all patients with the same health problem are receiving the same level of care in the Hospital, to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care for identifying opportunities to improve patient care and for identifying and resolving problems.

4. Conditions for Performing Credentialing and Performance Improvement Activities. Medical Staff Officers and other Medical Staff Leaders performing Credentialing or P.I. Activities shall do so under the following conditions:

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a. The activities such leaders undertake will be performed on behalf of the Hospital;

b. The activities will be performed in good faith;

c. The activities will follow procedures set forth in the Medical Staff Bylaws and other related documents;

d. The activities performed under these conditions shall qualify for the protections and immunities of the Health Care Quality Improvement Act and indemnification by the Hospital.

5. Reporting. The Medical Staff shall take all actions necessary to assist the Governing Body and the Hospital with the reporting requirements of the law, including HCQIA, governing professional review actions and/or disciplinary actions with respect to licensed professionals in connection with the Hospital.

The Staff shall, as required by law, report to the Data Bank, appropriate licensing boards and to the department of Health and Human Services any professional review actions, as defined in HCQIA, involving (a) a professional review action concerning competence or professional conduct that adversely affect the Staff membership or clinical privileges of a practitioner at the Hospital for a period longer than 30 days; or (b) the surrender or relinquishment of staff membership or clinical privileges of any practitioner at the Hospital while an investigation or proceeding related to competence or professional conduct is underway, or (c) the surrender or relinquishment of Staff membership or clinical privileges by a practitioner in order to induce the Hospital not to conduct such an investigation or proceeding.

The Staff may, at the discretion of its officers, report information to the Data Bank concerning Allied Health Professionals and other practitioners if, in the judgment of the officers, that information would be required to be reported if the practitioner were a physician and if such reporting promotes quality health care. A professional review action will be considered to adversely affect a practitioner or other person if it is considered adverse in the Fair Hearing Plan or under HCQIA. Reports shall contain such information as may be required by law, including the name of the involved practitioner, a description of the acts or omissions or other reasons for the action or, if known, for the surrender; and other information respecting the circumstances of the action or surrender required by HCQIA, licensing boards or the Data Bank. The practitioner will be notified before any reports are filed with the National Practitioner Data Bank.

6. Obtaining Reported Information. The Medical Staff shall request from the National Practitioner Data Bank information reported under HCQIA concerning any practitioner or other person, if

a. At the time he applies for Staff membership or clinical privileges at the Hospital;

b. At least once every two years for each such practitioner or person who is on the Staff or has been granted clinical privileges at the Hospital; and

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c. Any time the practitioner requests additional clinical privileges.

7. Relationship to the Board. The Staff shall coordinate its activities with the Board. The Staff shall, in such activities, develop, adopt and annually review these Bylaws and Rules and Regulations to be sure they are consistent with hospital policy and with applicable legal and other requirements. These Bylaws and Rules and Regulations, and any amendments or modifications thereto, are subject to and effective upon approval by the Board. Neither the Staff nor the Board may unilaterally amend these Bylaws. As required by the Medicare Conditions of Participation and other regulatory requirements, the Board of Trustees shall maintain complete and ultimate responsibility and authority over the Hospital and Medical Staff. The Board acknowledges that any approvals will not be unreasonably withheld.

The Board of Trustees shall require the Medical Staff to adopt and enforce Bylaws to carry out its Medical Staff functions. The Board of Trustees shall require that the Medical Staff Bylaws, Rules & Regulations, and policies comply with local, State and Federal law and regulations, and the requirements of the Medicare Hospital Conditions of Participation, and applicable accreditation standards. Medical Staff Rules and Regulations and Policies may contain the associated detail for provisions in the Medical Staff Bylaws. “Associated details” are the procedural steps necessary to describe, implement, enforce, or otherwise operationalize the provisions of the Bylaws.

The Medical Staff shall comply with and enforce the Medical Staff Bylaws, Rules and Regulations, and Policies and the Board of Trustees shall uphold the Medical Staff Bylaws that have been approved by the Board of Trustees.

8. Powers and Responsibilities of the Board of Trustees. The Hospital is owned by HCA Health Services, Inc. The Corporation retains all authority and control over the business, policies, operations, and assets of the Hospital via the Board of Directors. The Board of Directors is elected by the shareholders of the Corporation. The Board of Directors retains ultimate responsibility for the Hospital’s compliance with all applicable Federal, State, and local laws and regulations. The Board of Directors has delegated certain duties to the Corporation’s officers and to the Board of Trustees. The rights and duties delegated to the Board of Trustees, acting in its capacity as the authorized agent of the Corporation, and the governing body of the Hospital are described in these Bylaws.

The Board of Directors has appointed the Board of Trustees to assist and advise the CEO, the Corporation, the Board of Directors, and the Medical Staff. The primary function of the Board of Trustees shall be to assure that the Hospital and its Medical Staff provide quality medical care that meets the needs of the community. For this purpose, the Board of Directors has delegated to the Board of Trustees the authority to receive and evaluate periodic reports from the Medical Staff and its officers, to make decisions in compliance with the Corporation’s policies regarding Medical Staff appointments, reappointments, and the granting of clinical privileges, to oversee performance improvement, utilization review, risk management, and similar matters regarding the provision of quality patient care at the Hospital, and to establish policies regarding such matters. All officers, Medical Staff members, advanced practice professionals, employees, non-employees who provide patient care under an approved scope of practice, and other agents of the Hospital are

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subject to the control, direction and removal by the Board of Trustees. All Practitioners are subject to appointment, termination or modification of their Medical Staff Membership and/or clinical privileges by the Board of Trustees, based on factors deemed relevant by the Board of Trustees.

In a manner mutually agreeable to the Corporation and the Board of Trustees, the Board of Trustees shall report any matters of concern to the Corporation. Any such matters that are within the scope of duties of the Board of Trustees, but exceed the scope of their authority, such as issues related to financial management, can be referred back to the Corporation and the Board of Directors.

The Board of Directors, through its officers and the CEO, retains authority for the Hospital’s business decisions, adherence to HCA Ethics & Compliance Policies, and financial management, including long-range and short-range planning and budgeting, but may request the advice of the Board of Trustees on such matters. The Board of Directors expressly reserves the right to amend, modify, rescind, clarify, or terminate at any time and without notice any delegation of authority given to the Board of Trustees and, if deemed necessary by the Board of Directors, to overrule decisions made by the Board of Trustees.1

ARTICLE III

MEDICAL STAFF MEMBERSHIP

1. Nature of Membership. Staff membership is a privilege, which shall be extended by the Hospital and not a right of any physician, practitioner or other person. Membership and the exercise of clinical privileges shall be extended only to those practitioners who are professionally competent and who continuously meet the standards and requirements set forth in these Bylaws. No person shall admit or provide services to Hospital patients unless he is appointed to the Staff or has been granted clinical privileges. Appointment to the Staff shall confer on the appointee only such clinical privileges as are granted by the Board. For the purposes of these Bylaws, "membership in" is used synonymously with "appointment to" the Staff, except that the granting of clinical privileges does not automatically confer Staff membership or appointment. A person may be granted clinical privileges without staff membership or appointment. Temporary clinical privileges maybe granted as defined in Article VII, Section 7. Allied Health Professionals may be granted clinical privileges, however, will not be considered members or appointees of the medical staff.

2. Qualifications.

a. Only physicians, osteopath, dentists, podiatrists and psychologists permitted by law to practice in the State of Florida, who can document their background, experience, training, demonstrated competency, current Florida medical licensure, health status, current DEA license, proof of identity and either United States citizenship or

1 Joint Commission Medical Staff Standard 01.01.01; Joint Commission Leadership Standard 03.01.03; 42 C.F.R. § 482.12; 42 C.F.R. § 482.22; Fla. Administrative Code 59A-3.272; Fla. Administrative Code 59A-3.275.

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evidence of status as a lawful permanent resident of the United States 2and ability to work with others as to assure, in the judgment of the Medical Staff and the Governing Body, that any patient treated by them in the Hospital will be given a high quality of medical care, shall be qualified for membership on the Medical Staff. Applicants must be able to demonstrate that they can be available on a continuous basis, either personally or by arranging appropriate coverage, to respond to the needs of inpatients and Emergency Department patients in a prompt, efficient, and conscientious manner. (“Appropriate coverage” means coverage by another member of the Medical Staff with specialty-specific privileges equivalent to the Practitioner for whom he or she is providing coverage.)3

If the applicant is an out-of-state Practitioner who will be providing patient care in this state under an exception to state licensure requirements, the exception must be verified with the State licensure board and documented. Any conditions associated with the exception (i.e., that the exception requires that the Practitioner must be licensed in his/her home State) must also be verified and documented.4 No physician, osteopath, dentist, podiatrist or psychologist shall be entitled to membership on the Medical Staff, or be granted particular clinical privileges merely by virtue of the fact that he is duly licensed to practice medicine, osteopathy, dentistry, podiatry or psychology in this or in any other state, or that he is a member of some professional organization, or that he has in the past, or presently has, such privileges at another hospital.5 Under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship, or membership in a specialty body or society.6

b. Staff membership is additionally restricted to persons who are graduates of:

1. Recognized medical schools approved and accredited by the American Medical Association, American Association of Medical Colleges or a standard recognized accredited college of osteopathy, dentistry, podiatry, psychology; or

2. A foreign medical school and meet the qualifications for licensure prescribed by Section 458.311 of Florida Statutes (a part of the Florida Medical Practice Act).

c. Application for staff membership, Active or Consultant is restricted to persons who meet the following qualifications:

1. Board certification, or,

2. Alternatives to be considered including, but not limited to:

2 Joint Commission Leadership Standard 04.01.01; 42 C.F.R. § 482.11 3 42 C.F.R. § 482.12; EMTALA; Fla. Stat. § 395.1014; Fla. Stat. § 395.1014; Fla. Stat. §§ 458.3295 & 459.0145 4 42 C.F.R. § 482.11; Fla. Stat. 395.0191; Fla. Stat. § 458.303; Fla. Stat. § 459.002; Fla. Stat. § 466.002 5 42 C.F.R. §482.12; Fla. Stat. § 395.0191 6 42 C.F.R. § 482.12

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i. Fellowship or membership in specialty body or society approved by the American Board of Medical Specialties, Accreditation Council for Graduate Medical Education, American Medical Association, American Association of Medical Colleges and/or other resources and

ii. Clinical experience/management shall be considered when the applicant or practitioner being appointed or reappointed is not board certified or has not been recertified in that specialty board:

a) Medical education and training;

b) Licensure;

c) Experience and training;

d) Lists of procedures or treatments, outcomes, complications;

e) Patient risk categories;

f) Current eligibility to participate in Federal and State Healthcare Programs;

g) Are currently not excluded from participation in any Federal and State Healthcare Programs; and

h) Previous medical staff membership documentation of peer review from other health care facilities, where practitioner has been granted clinical privileges, if indicated.

iii. An applicant is required to have completed post doctorate training in his specialty in a duly accredited residency program. The applicant must have completed at least two consecutive years in the same residency program. It is required that the practitioner graduated while both the school and the program were fully accredited and approved by the appropriate board. If the applicant has not met the above minimum residency requirements due to his specialty, individual consideration will be given to demonstrated excellence in medical training or consistent practice of medicine of high quality as determined by the Executive Committee.

3. Physicians, practitioners, allied health professionals, shall all meet the requirements for continuing education as established by their respective Professional Boards (DBPR). As validation of continued education in the practitioner's field of practice, each practitioner must provide documentation at the time of initial appointment, and reappointment (including elevation from associate status) of continuing education demonstrating that, at least part of the continuing education is pertinent to

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the clinical privileges requested or held at this Hospital and the patient population served.

i. Members of the Medical Staff shall at all times abide by the Codes of Ethics of the American Medical Association, American Osteopathic Association, American Dental Association, or if not a physician or dentist, the professional principles or codes of ethics appropriate to his profession. As a condition of appointment or reappointment, practitioner must pledge to provide competent, humane and efficient care, seeking consultation with other practitioners where appropriate to do so; delegate in the absence of the staff member, the responsibility for diagnoses or care of his patients only to a practitioner who is qualified to undertake such responsibility.

ii. No aspect of medical staff membership or particular clinical privileges shall be denied on the basis of sex, race, creed, color, or national origin or on the basis of any other criterion unrelated to professional ability, judgment, or the delivery of optimal achievable quality patient care in the Hospital.

iii. A separate record is maintained for each staff member.

iv. Have or agree to make appropriate coverage arrangements (as determined by the Credentials Committee) with other members of the Medical Staff for those times when the individual will be unavailable.7 Members of the medical staff, or alternate coverage, shall respond to requests from Hospital personnel for emergency care situations within approximately thirty (30) minutes. Initial contact may be by telephone or two-way communication. When subsequent consultation is required, the practitioner shall be available within approximately thirty (30) minutes of the time the consultation is needed.

v. Have proof of identity and either United States citizenship or evidence of status as a lawful permanent resident of the United States.8

vi. If the applicant is an out-of-state Practitioner who will be providing patient care in this state under an exception to state licensure requirements, provide documentation to verify the State licensure board requirements and any other conditions associated with the

7 42 C.F.R. § 482.12; EMTALA; Fla. Stat. § 395.1014; Fla. Stat. § 395.1014; Fla. Stat. §§ 458.3295 & 459.0145 8 Joint Commission Leadership Standard 04.01.01; 42 C.F.R. § 482.11

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exception (i.e., that the exception requires that the Practitioner must be licensed in his/her home State).9

vii. Maintain professional liability as required by these Bylaws and the Board of Trustees.

3. Basic Responsibilities: Except as otherwise provided in these Bylaws, each Staff member shall:

a. Provide continuous care and supervision to his patients at the generally recognized professional level of quality, competency and efficiency established by the Hospital;

b. Abide by these Bylaws and rules and regulations and all other rules, polices and regulations of the Hospital;

c. Discharge such Staff, department, committee and Hospital functions for which he is responsible including, as appropriate, emergency service care; and

d. Prepare and complete in a timely manner the medical and other required records for all patients for whom he provides care in the Hospital.

e. Sign an agreement by the applicant to provide continuous care and supervision of his patients, to abide by the Medical Staff Bylaws, Rules and Regulations, and to accept committee assignments, consultation assignments, serve as preceptor and accept emergency room call.

f. Physicians, practitioners, allied health professionals shall meet the requirements for continuing education as established by their respective professional boards (DBPR). Practitioner must provide documentation at the time of appointment of continuing education demonstrating that at least part of his continuing education is pertinent to the clinical privileges requested or held at the Hospital and the patient population served.

g. Particular qualifications:

1. Only physicians, dentists, podiatrists, psychologists and allied health professionals granted membership and/or clinical privileges will be permitted to provide care to any patient.

2. All dental and podiatric patients must receive the same basic medical assessment/evaluation as any patient(s) admitted to other services. Surgical procedures performed by dentists or podiatrists shall be under the overall supervision of the department chairperson for Surgery. A physician (MD/DO) member of the medical staff must be responsible for the care and

9 42 C.F.R. § 482.11; Fla. Stat. 395.0191; Fla. Stat. § 458.303; Fla. Stat. § 459.002; Fla. Stat. § 466.002

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supervision of any medical or psychiatric10 problems that may be present at the time of admission or that may arise during hospitalization. The MD/DO is responsible for performing an admission history and physical on dental patients.

3. Those podiatrists appropriately credentialed may complete the history and physical on podiatric patients.

4. Patients may be admitted to the Hospital only on the orders of a licensed Practitioner with admitting privileges at the Hospital. All Hospital patients must be under the care of a Member of the Medical Staff or under the care of a Practitioner who shall be directly under the supervision of a Member of the Medical Staff. All patient care shall be provided by or in accordance with the orders of a Practitioner who meets the Medical Staff criteria and procedures for the privileges granted, who shall have been granted privileges in accordance with those criteria by the Board of Trustees, and who shall be working within the scope of those granted privileges.11

5. Medical History and Physical Examination Requirements. Clinical privileges for performing a medical history and physical examination shall be delineated. The medical history and physical examination shall be completed and documented by a qualified Physician, a qualified Oromaxillofacial Surgeon, or other qualified licensed individual in accordance with State law and Hospital policy. A medical history and physical examination shall be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but always prior to surgery or a procedure requiring anesthesia services. An updated examination of the patient, including any changes in the patient’s condition, must be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient’s condition, must be completed and documented by a Qualified Physician, a Qualified Oromaxillofacial Surgeon, or other qualified licensed individual in accordance with State law and Hospital policy.12

4. Terms of Appointment. Initial appointments and reappointments shall be made by the Board upon the recommendation of the Staff. Reappointments shall be made by the Board upon recommendation of the Staff. Initial appointments shall be for a period of one year, subject to an extension period in these Bylaws. Reappointments shall, under no circumstances, be for a period of over two years. Reappointments shall be staggered so that

10 42 C.F.R. § 482.12 11 42 C.F.R. § 482.12 12 42 C.F.R. § 482.12

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to the extent possible, approximately half of all members of the Staff are subject to reappointment each year.

5. Practitioner Employees. Any practitioner employed by the Hospital who wishes to become a Staff member or exercise clinical privileges must apply for and maintain medical staff membership or exercise clinical privileges in the same manner as other practitioners. Contract/agreement shall include a statement defining its effect on medical staff membership and/or clinical privileges should the contract expire or terminate.

6. Leave of Absence. A Medical Staff Member or Allied Health Practitioner; may obtain a voluntary leave of absence for a period not to exceed one year by submitting written notice to the Chief of Staff advising approximate period of leave . If a physician is unable to provide services required by the patients and Hospital for a period of greater than six weeks, they should request a Leave of Absence. Acceptance of such request shall be at the discretion of the Chief of Staff with the concurrence of the Executive Committee and the Chief Executive Officer/Administrative designee of the Hospital. Reason for the leave must be validated to demonstrate that without the leave, the practitioner would experience undue hardship. During such leave, the member's privileges and prerogatives shall be suspended. At least 30 days prior to termination of the leave, the Staff member may request reinstatement of his privileges and prerogatives by written request to Chief of Staff and the CEO, which shall include a summary of his activities during his leave. The CEO shall forward the request to the Executive Committee, which shall make a recommendation to the Board as to reinstatement. Failure to request reinstatement shall result in automatic termination of Staff membership.

Upon acceptance of request for reinstatement, monitoring of the practitioner may be required and if indicated, the Executive Committee, or through the Credentials Committee, shall establish criteria and time frame for specific preceptorship. Report of monitoring shall be made to the executive committee at the end of the designated period.

Failure without good cause to request reinstatement, or to provide summary of activities as defined above, shall be deemed as voluntary resignation and result in automatic termination of membership and clinical privileges. A practitioner, whose privileges are terminated, shall be entitled to the procedural rights as defined in these Bylaws, Fair Hearing Plan.

The practitioner, who applies for membership subsequent to termination after a leave, shall submit an application and adhere to the process specified for initial application.

ARTICLE IV

CATEGORIES OF STAFF

1. Categories. The Medical Staff shall be divided into active, associate, courtesy, consultant, and honorary categories. Every staff member with the exception of those in the honorary category must maintain his residence and office close enough to the Hospital to provide

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continuous care to his patients. Members in the active, associate and courtesy categories shall have admitting privileges.

2. Active Staff

a. Qualifications. The active staff shall consist of practitioners who meet the qualifications for Staff membership and at least one of the following:

i. Regularly admit patients to, or are otherwise regularly involved in, the care of patients in the Hospital. Such patient contacts shall include hospital admissions, same-day surgery, observation, rehabilitation unit, sub-acute care and consultations; or

ii. Assume all the functions and responsibilities of membership on the active staff including emergency service care and consultations assignments; or

iii. Serve in a leadership role including Department Chair; membership on Medical Executive Committee, Board of Trustees, or other Medical Staff and hospital committees;

iv. Provide supervisory duties by serving as medical director of a hospital department or service line or proctoring of provisional staff.

The Board may, in its discretion, establish a minimum number of patient admissions in order to be appointed to the active staff.

b. Prerogatives. Subject to availability of beds, each member of the active staff may admit patients without limitation, except as otherwise provided in these Bylaws or the Rules and Regulations; exercise such clinical privileges as are granted to him; vote on all matters presented at Staff meetings and of the departments and committees of which he is an appointee and holds a Staff, department or committee office.

c. Responsibilities. Each member of the active staff shall discharge the responsibilities of Staff members as required in these Bylaws; provide continuous care and supervision of his patients in the Hospital or arrange for suitable alternative; attend Staff and department meetings; and perform such further duties as may be required of him under these Bylaws or the Rules and Regulations where appropriate, care for unassigned patients, emergency service care on a rotational basis, consultation and participation in quality and monitoring activities, including evaluation of associate (provisional) appointees.

3. Associate (Provisional) Staff

a. Qualifications. The associate staff shall consist of all initial appointees to the Staff. Associate staff members shall be granted clinical privileges on a provisional basis as provided in this section and in Article VII, Section 5, Clinical Privileges. Associate staff shall be eligible for advancement to membership on the active,

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courtesy, or consulting staff, but their status shall not be as full member of the Staff until such achievement occurs. Each associate staff member shall be assigned to a clinical department and his performance shall be evaluated by the department chairperson or his designee to determine his eligibility for advancement to another category of Staff. Appointments and clinical privileges granted to the associate staff member shall be for a period of one year. This period may be extended up to an additional 120 days on the recommendation of the Department Chairperson to which he is assigned and/or the Credentials Chairperson if there has not been adequate opportunity to observe his professional performance due to the lack of utilization of the Hospital or care of sufficient number of patients. Any decision to extend the provisional period for appointment to the associate staff privileges shall not be deemed adverse action involving the associate staff member and shall not entitle him to procedures afforded by the Fair Hearing Plan. After completion of the period for which associate staff membership and provisional privileges have been granted, the appointee shall be advanced to active, courtesy, or consulting staff status, in which case his clinical privileges shall no longer be provisional in nature, or his appointment and privileges shall be terminated. The department chairperson to whom he is assigned shall submit a report and recommendation concerning the appointee to the credentials committee prior to the end of the extended period. The report and recommendation shall be considered at the next meeting of the credentials committee which shall make a recommendation to the Executive Committee concerning the termination of staff membership or clinical privileges or advancement in staff category. The Executive Committee shall consider the recommendation and shall thereafter make its recommendation to the Board. The Board shall promptly review the Executive Committee recommendation and make its decision concerning such matters.

b. Prerogatives Each member of the associate staff may admit patients to the Hospital under the same conditions as active staff members and may exercise such clinical privileges as are granted to him. Members of the associate staff must attend the regular Staff meeting, may serve on committee(s) and vote on matters before committee(s).

c. Responsibilities. Associate staff members shall discharge the same responsibilities as those required of active staff members if they expect to become members of the active staff upon completion of the associate staff period. Otherwise, they shall discharge the basic responsibilities of staff members as required in these Bylaws, provide emergency service care on a rotational basis, accept unassigned patients and perform such other duties, as may be required under these Bylaws or the Rules and Regulations. Failure to fulfill those responsibilities shall be grounds for termination of clinical privileges or denial of reappointment or advancement.

4. Courtesy Staff.

a. Qualifications. The courtesy staff shall consist of practitioners qualified for membership, but who only occasionally use the Hospital. The Board, in its discretion, states that patient contacts (admissions, consults and procedures) be

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limited to a total of twelve per calendar year for a courtesy staff member. During acute bed shortage, admitting privileges may be curtailed.

b. Prerogatives. Each member of the courtesy staff may admit patients to the Hospital and exercise such clinical privileges as are granted to him. Courtesy staff members are not required to attend annual Staff meetings or department meetings and are ineligible to vote, or hold office. Attendance is encouraged.

c. Responsibilities. Each member of the courtesy staff shall discharge the basic responsibilities of Staff members as required in these Bylaws; provide continuous care and supervision to his patients in the Hospital; or arrange for suitable alternative for such care and supervision; and perform such further duties as may be required of him under the Bylaws or rules and regulations. At the discretion of the Board, members of the Courtesy staff may be required to provide emergency service care and serve as a preceptor.

5. Consulting Staff

a. Qualifications. The consulting staff shall consist of practitioners who are available to consult with Staff members on a case-by-case basis. Psychologists shall be considered consulting staff upon successful completion of the Associate Staff Category and Board approval.

b. Prerogatives. Consulting staff members may consult with Staff members with respect to patients when asked to do so. Consulting staff may not admit patients to the Hospital; may attend staff meetings when invited, but may not vote at Staff or department meetings or hold office. Appointments to the Consulting Staff shall be made by invitation only, such invitations are to be initiated by the Credentials Committee or by the Administrator based on Hospital and community need for specialty services and approved by the Executive Committee and the Board of Trustees.

c. Responsibilities. Each member of the consulting staff shall discharge the basic responsibilities of Staff members as required in these Bylaws and perform such other duties as may be required under these Bylaws or the Rules and Regulations. Consultants are expected to arrange for suitable alternative for patient care consultation.

6. Limitation of Prerogatives. The prerogatives of Staff members in these Bylaws are general and may be limited or restricted by special conditions attached to the practitioner's appointment or reappointment by state law or regulations, other provisions of these Bylaws, the Rules and Regulations or other policies, commitments, contracts or agreements of the Hospital.

a. Qualifications. Special Need privileges may be granted under unusual conditions by the Chief of Staff and/or the Chief Executive Officer. These privileges shall not extend for more than 48 hours. Should a practitioner have repetitive monitoring of a practitioner on the Hospital staff, the authority granted shall be limited to

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observation of the same practitioner, if repetitive assessments are required, dates of observations must be provided to the medical staff coordinator for processing.

b. Prerogatives. Such privileges may be extended only to physicians who are acting as preceptors for specific diagnostic or therapeutic invasive procedure or to harvest organs through coordination through a recognized organ procurement program.

c. Responsibilities. Practitioners acting as preceptors not associated with the facility must provide a copy of their current Florida State license and insurance coverage limits and copy of clinical privileges currently held at another healthcare facility can be verified. Prior to performing any patient care activities, the practitioners must notify the Medical Staff Office, provide the above documents and inform the manager and medical department chairperson and seek their approval. Authority to monitor cases, participate as necessary to demonstrate techniques or participate in the procedure to promote patient safety may be granted by the Chief of Staff, the department chairperson if available and the CEO.

Harvest organ practitioners may not be required to provide such documents if they function under the auspices of an agency, such as LifeLink. The practitioner will have no access to the appeal process or any rights of members or those with clinical privileges if request is denied.

7. Medico-Administrative Physicians

a. Qualifications. Physician(s) employed by the Hospital in such a position must achieve medical staff membership status in compliance with these Bylaws.

b. Prerogatives. Each member fulfilling a medico-administrative position may admit patients to the Hospital; exercise such clinical privileges as are granted to him; attend meetings of Staff, departments and committees of which he is an appointee. Such physician shall not have medical staff membership or clinical privileges terminated without due process.

c. Responsibilities. Each member shall discharge the basic responsibilities of Staff members as required in these Bylaws, and perform such duties as may be request of him under these Bylaws, or the Rules and Regulations.

8. Honorary Staff.

a. Qualifications. The honorary staff shall consist of practitioners recognized for their outstanding reputations, their noteworthy contributions to the health and medical sciences, or their previous longstanding service to the Hospital. Honorary staff members need not be residents of the community. They shall be recommended by the Executive Committee, subject to the approval of the Board.

b. Prerogatives. Honorary staff members shall not be eligible to admit patients to the Hospital or perform clinical privileges in the Hospital. They may attend Staff meetings, but may not vote at Staff meetings or hold office.

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c. Responsibilities. Each member of the honorary staff shall abide by these Bylaws and other policies and rules of the Hospital and abide by the ethical principles governing practitioners.

9. Waiver of Qualifications. The required qualifications may be waived in specific instances upon recommendation of the Executive Committee with the approval of the Board upon determination that the best interests of the Hospital and patients will be served.

10. Authority of the Board. Staff appointments and clinical privileges shall be granted, modified, suspended and revoked only by the Board, except as specifically and expressly provided in these Bylaws.

ARTICLE V

ALLIED HEALTH PROFESSIONALS

1. Dependent Practitioners. Allied health professionals (“AHP”) are those who may by law or these Bylaws provide patient care only under the supervision or direction of a practitioner. Categories/types of AHPs eligible for clinical privileges shall be approved by the Board of Trustees and shall be credentialed through the same processes as a Medical Staff Member, as described herein, and shall be granted clinical privileges as either a dependent or independent healthcare professional as defined State laws and in these Bylaws. The Board of Trustees has determined the categories of individuals eligible for clinical privileges as an AHP are physician assistants (PA), certified registered nurse anesthetists (CRNA), anesthesiology assistants (AA), clinical psychologists (Ph.D.), advanced registered nurse practitioners (ARNP), and clinical nurse specialists (CNS).13

2. Eligibility. Qualified Allied health professionals who are duly licensed or certified as required by state law and satisfy the qualification requirements of these Bylaws shall be eligible to provide specified services in the Hospital. Allied health professionals may not be Members of the Medical Staff, shall not be eligible to vote or hold office within the Medical Staff organization and may not have admitting privileges.14

3. Qualifications. Allied health professionals shall document their qualifications, status, clinical competence, training, demonstrated ability and physical and mental health status with sufficient adequacy to demonstrate that (a) they can exercise judgment within their areas of competence, although a Staff member may be ultimately responsible for patient care; (b) they may participate directly in patient care within the scope authorized by law and the Hospital; and, (c) they are qualified to provide a needed service in the Hospital. Allied health professionals must be determined, on the basis of documented references, to adhere strictly to the ethics of their respective professions and work cooperatively with others; may be individually assigned to an appropriate clinical department; and shall discharge the basic obligations of Members of the Medical Staff as required in these Bylaws; abide by these Bylaws, the Rules and Regulations, and all other rules, policies and procedures, guidelines, and other requirements of the Medical Staff and the Hospital, as

13 Joint Commission Medical Staff Standard 06.01.05; 42 C.F.R. § 482.12; 42 C.F.R. § 482.22; Fla. Stat. § 395.0191 14 Joint Commission Medical Staff Standards 03.01.01 & 06.01.05 ; 42 C.F.R. § 482.22; Fla. Stat. § 395.0191

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applicable to his/her activities in association with the Hospital.15 Additionally, allied health professionals shall furnish evidence of professional liability insurance in such amounts as may be required by the Board.

4. Procedure for Specification. An Allied health professional shall submit an application for specified services on a form provided and approved by the CEO. The application shall be evaluated by the department chairperson and the Credentials Committee shall recommend to the Executive Committee the scope of services which the applicant may be permitted to furnish. If recommended, the Executive Committee shall furnish a report and recommendation to the Board. If approved by the Board, the Allied health professional will be assigned to the department appropriate to his training. In the discretion of the Medical Staff, or if required by Hospital licensing, certification or accreditation bodies, categories or classes of Allied health professionals shall be subject to specified credentialing procedures. When an Allied health professional’s employment by or association with a member of the Medical Staff with clinical privileges is terminated, any clinical privileges held at the Hospital will be terminated. Allied health professionals will not be covered by other provisions of these Bylaws relating to granting, modifying, suspending or revoking medical staff privileges.

5. Prerogatives. An Allied health professional may provide (a) specified patient care services solely under the supervision or direction of a Staff physician, as authorized by law and these Bylaws; (b) write orders only to the extent permitted by law and the Credentials Committee, and in any event not beyond the scope of his license or certificate; (c) serve on committees when invited, (d) attend department meetings when invited; and (e) exercise such other prerogatives as may be approved by the Staff or any Staff or any department or committee with the approval of the Executive Committee. Allied health professionals may be accorded disparate treatment based on qualifications, abilities and competence, subject to the requirements of law.

6. Supervision & Responsibilities. All activities of Allied health professionals who provide care under the supervision or direction of a practitioner shall be under the direct and immediate supervision of the Staff member, but such supervision shall not require the physical presence of the Staff member unless otherwise required by law. The terms of the accountability of the Allied health professional to the Medical Staff Member and the terms for supervision of the Allied health professional by a Medical Staff Member shall be documented in a sponsorship agreement between the Allied health professional and the sponsoring Medical Staff Member. In addition to a complete application, as defined in these Bylaws, a sponsorship agreement shall be on file at the Hospital.16 If any other Hospital employee questions the authority or instructions of an Allied health professional either to act or to issue instructions outside the presence of the supervising Staff member, the Hospital employee may delay acting until the supervising practitioner has validated the order or instructions of the allied health professional.

15 Joint Commission Medical Staff Standards 03.01.01 & 06.01.05; Joint Commission Leadership Standards 01.03.01 & 04.01.01; 42 C.F.R. § 482.11; 42 C.F.R. § 482.12; 16 Joint Commission Medical Staff Standards 03.01.01 & 06.01.05 ; 42 C.F.R. § 482.11

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Each Allied health professional shall retain appropriate responsibility within his area of professional competence for the care of each patient in the Hospital for whom he is providing services; participate as appropriate in quality assessment and improvement activities required of the Staff and in discharging other Staff functions as may be required from time to time; attend all meetings of departments and committees as may be required; and maintain professional liability insurance in the amounts as determined by the Board.

7. Evaluation. The respective departments shall examine, recommend, limit and delineate the scope of activities within the Hospital of Allied health professionals who are duly licensed or certified and who provide services as employees or sponsored by Staff members, under the supervision or direction of a practitioner, subject to the recommendations of the credentials committee, the Executive Committee and the approval of the Board.

8. Approval. Except as specifically permitted in Section 9 of this article, no Allied health professional shall provide patient services in the Hospital until he has been approved by the Board. First, the Allied health professional shall submit to the department on a form approved by the Hospital sufficient information on his qualifications and abilities. When employed/sponsored by a Staff member, the form shall be signed by the AHP and the Staff member. The department chairperson shall review and forward his recommendation to the Credentials Committee. Credentials Committee shall promptly review and evaluate the application and shall make a recommendation to the Executive Committee. If the recommendation is favorable, it shall include the recommendation as to the scope of activities which the Allied health professional (AHP) will be permitted to undertake, the department assignment and any restrictions or limitations. This process will be repeated through Executive Committee and the Board shall have final approval. If approved, the Allied health professional shall be permitted to render specified patient services, subject to the prerogative of the Board to modify, suspend or revoke such approval at any time.

9. Provisional Nature of Approval. Initial approval shall be considered provisional in nature. Performance shall be observed and evaluated by the department chairperson or if AHP is a dependent professional employed by member of the Medical Staff, the AHP shall be evaluated by a department manager in which performance may be observed and evaluated. Such approval will be for a period of one year and may be extended no longer than an additional 120 days on the recommendation of the department chairperson if there is inadequate opportunity to review his performance due to lack of care to a sufficient number of patients. After completion of provisional period, for which services have been approved, (a) the AHP may be approved for rendering specified services for a period of two years, subject to the right of the Board to modify, limit, restrict, suspend or terminate such approval at any time, or (b) his approval shall be terminated. The chairperson of the department to which the allied health professional is assigned shall submit a report and recommendation concerning such approval prior to the end of the provisional period. The report and recommendation shall be considered at the next credentials committee meeting, which shall make a recommendation to the Executive Committee.

The Executive Committee shall consider the recommendation and then make its recommendation to the Board. The Board shall promptly review the recommendation and make its decision concerning the matter.

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10. Temporary Services. On request and recommendation of a member of the active staff and appropriate department chairperson, the CEO and Chief of Staff may permit an AHP to temporarily provide patient services within the Hospital for a period not to exceed 90 days. In such cases the recommending employer or sponsoring physician staff Member shall be responsible for supervising the Allied health professional. Such action may be taken on the basis on information provided which may be relied on as to the competence and qualifications of the Allied health professional. When there is no urgency, the CEO shall in such cases verify the AHP's current licensure or certification and shall obtain current information as to his professional insurance coverage and any pending professional liability actions or proceedings. Any denial of such a request shall be final and nonappealable.

11. Exception. Allied health professionals may (a) be sponsored by a medical staff member to provide a needed adjunct service to hospitalized patients or (b) provide a specified service through a contractual agreement between the Hospital and agency/employer. Documentation of clinical competency, licensure and insurance will be handled by Human Resources Department for contracted professional services

12. Scope of Activities. The Board shall determine the scope of activities, which each AHP may undertake. Such determination shall be furnished in writing to the AHP and shall be final and nonappealable, except as specifically and expressly provided in these Bylaws. Any decision as to an AHP who is employed by a Staff member shall be valid only as long as the AHP remains an employee of the Staff member and the Staff member remains on staff. The chairperson of the department in which the AHP renders services shall oversee the activities of the AHP.

13. Biannual review. At the time of reappointment, the AHP shall submit a renewal application for specified services on a form provided and approved by the CEO. The procedure for review shall incorporate review of current licensure or certification, professional liability information, as well as review of activities in the Hospital, performance compliance with these Bylaws and rules and regulations, ethics and conduct, relations with Staff members and Administration, clinical and/or technical skills, as indicated in part by the results of quality assessment and improvement activities and such other information as may be appropriate.

14. Fair Hearing

a. The opportunity for a fair hearing shall not be offered to an AHP based on the denial of initial application for clinical privileges or scope of practice/service.

b. Should there by a recommendation from the Credentials Committee or Medical Executive Committee that the clinical privileges or scope of practice/services of an AHP be restricted or revoked, the AHP will be promptly notified by certified mail and they may request an opportunity to be heard within 30 days of receipt of the written notice.

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c. The CEO will appoint a panel of three (3) members to include the CEO and additional panel members. Other panel members may include the Chief of Staff, Vice-Chief of Staff, and an AHP other than the AHP requesting the hearing. No member of the hearing panel shall have had a role in making the recommendation to restrict, revise or revoke the clinical privileges or scope of practice/services of the AHP.

d. The AHP shall have the opportunity to present information, but not to have counsel or to present witnesses. The hearing will be limited to one (1) hour in duration.

e. Should the determination of the hearing panel be favorable, a written recommendation will be returned to the Committee that initially made the recommendation for restriction, revision or revocation of the clinical privileges or scope of practice/services of the AHP.

f. Should the recommendation of the hearing panel be adverse, the AHP will have the opportunity to appeal the decision to the Chairman of the Board of Trustees or a Joint Conference Committee, in the same manner outlined for the hearing panel.

g. The Chairman of the Board of Trustees or a Joint Conference Committee shall hear the appeal and consider the recommendation of the hearing panel. The decision of the Chairman of the Board of Trustees or the Joint Conference Committee shall be final.

ARTICLE VI

APPOINTMENT AND REAPPOINTMENT

Part A - Appointments

1. Application.

a. Contents. Each Request for Consideration (RFC) or the Reappointment Request for Consideration (RRFC) shall be in writing, submitted on the prescribed form approved by the Board and signed by the applicant. The completed RFC or RRFC must be returned within sixty days to the Administrator from the date that it was mailed to the applicant. If not returned within that time period, it will be presumed that the applicant has voluntarily forfeited his application request at the Hospital. The application shall be deleted and shall not be entitled to the procedural rights in the Fair Hearing Plan. When a Request for Consideration (RFC) or the Reappointment Request for Consideration (RRFC) is received that is complete and meets all Threshold Eligibility Criteria, it will be processed by the CPC and submitted to the Hospital as an application. When an individual does not satisfy one or more of the Threshold Eligibility Criteria, the individual shall be notified by the CPC that the Request for Consideration (RFC) or the Reappointment Request for Consideration (RRFC) that does not satisfy a Threshold Eligibility Criterion

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will not be processed. The completed application form shall include, without limitation17

i. A statement that the applicant has received and read the current Staff Bylaws, Rules and Regulations and policies and that he agrees to be bound by them if appointment or clinical privileges are granted and in all matters relating to consideration of his application without regard to whether membership or clinical privileges are granted;

ii. Detailed information concerning the applicant's qualifications;

iii. Specific requests stating the Staff category and clinical privileges requested;

iv. The names of at least three practitioners, who will provide references as to his education, experience, clinical ability, ethical character and ability to work with others, and at least one of whom practices in the same specialty and has worked with and personally observed the current professional performance of the applicant;

v. Report any current or past facility affiliations

vi. Information as to previously successful or currently threatened or pending challenges to any licensure, certification or registration (including by any state or the Drug Enforcement Administration) or the voluntary relinquishment of such licensure, certification, or registration; voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital; and involvement in a professional liability action, including any final judgments and settlements;

vii. Current information as to the applicant's professional liability insurance coverage, including evidence of coverage for all clinical privileges requested;

viii. Information as to all malpractice cases, actions or proceedings against him, either pending, settled or filed;

ix. Information as to current health status including a statement from the individual that his/her health status is such that he/she has the ability to perform the clinical privileges that he/she is requesting;18

x. Current provider status and UPIN number as well as information concerning the suspension or termination for any period of time of the right or privilege to participate in Medicare, Medicaid, any other government

17 Joint Commission Medical Staff Standards 03.01.01 & 06.01.05; Fla. Stat. § 395.0191 18 Joint Commission Medical Staff Standards 03.01.01 & 06.01.05; 42 C.F.R. § 482.12; Fla. Stat. § 395.0191

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sponsored program, or any private or public medical insurance program, and information as to whether the applicant is currently under investigation and;

xi. Such other information as may be required in order to evaluate the applicant.

b. Certain Statements. The application shall include a statement that the applicant understands and agrees:

i. To abide by the provisions of these Bylaws, including specifically those relating to privileges and immunities;

ii. A pledge by the applicant that includes an agreement to provide continuous care to patients;

iii. A statement releasing from any and all liability those persons to whom such privileges and immunities provisions of these Bylaws are intended to benefit;

iv. A statement that the applicant agrees that when an adverse ruling is made concerning his appointment, Staff status or clinical privileges, he will exhaust all remedies afforded by these Bylaws before resorting to formal legal action or commencing legal proceedings;

v. A statement from the individual that his/her health status is such that he/she has the ability to perform the clinical privileges that he/she is requesting;19

vi. A statement that the applicant will have and continuously maintain professional liability insurance covering acts and occurrences involving professional activities during the period Staff membership and clinical privileges are granted, as approved by the Board, with coverage for all clinical privileges granted;

vii. A statement that the applicant will, if his application is approved, report final judgments or settlements involving professional liability claims or proceedings to the Hospital within ten days after entered or made;

viii. And a statement that the applicant will, if his application is approved, notify the Hospital within ten business days of his receipt of a sanction or notice to sanction from any peer review or professional review organization, and any sanction or notice of intent to sanction or to revoke, suspend or modify his license from any state licensing or regulatory authority.

c. Obligations. By applying for Staff membership and/or clinical privileges, each applicant:

19 Joint Commission Medical Staff Standards 03.01.01 & 06.01.05; 42 C.F.R. § 482.12; Fla. Stat. § 395.0191

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i. Signifies his willingness to appear for interviews regarding his application;

ii. Authorizes the Hospital to consult with practitioners at other hospitals and health care facilities with which the applicant has been associated, and with others who may have information bearing on his competence, physical abilities, character and ethical qualifications;

iii. Agrees to notify the Medical Staff Office and the Risk Manager within three (3) working days of any change in eligibility for payments by third-party payors or for participation in Medicare, including any sanctions imposed or recommended by the federal Department of Health and Human Services, and/or the receipt of a PRO citation and/or quality denial letter concerning alleged quality problems in patient care;

iv. Consents to the Hospital's inspection of all hospital records and documents that may be material to an evaluation of his professional qualifications and competence to carry out the clinical privileges he requests, as well as his moral and ethical qualifications for Staff membership;

v. Consents to the Hospital's obtaining information from peer review and professional review organizations, boards and committees and authorizes the release of such information to the Hospital;

vi. Releases from liability all persons specified in these Bylaws to the fullest extent permitted by law;

vii. Agrees by submitting an application, that if he is appointed to the Medical Staff or granted clinical privileges, he will cooperate with the Hospital in matters involving its policies and procedures, and to participate in hospital peer review, utilization review, and quality assessment and improvement activities; further

viii. Agrees that the Medical Staff may obtain an evaluation of the applicant by an outside consultant selected by the Medical Staff if the Medical Staff considers it appropriate;

ix. Agrees to abide by all local, State and Federal laws and regulations, Joint Commission and other accreditation standards as they apply within the Hospital, and State licensure and professional review regulations and standards, as applicable to the applicant’s professional practice;20

x. Utilize the Electronic Health Record (EHR) system of the Hospital;21

20 Joint Commission Medical Staff Standards 03.01.01 & 06.01.05; Joint Commission Leadership Standards 01.03.01 & 04.01.01; 42 C.F.R. § 482.11 21 Joint Commission Medical Staff Standard 05.01.03; Joint Commission Leadership Standards 01.03.01 & 04.01.01; 42 C.F.R. § 482.11

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d. Exception. The CEO may refuse to accept an application for initial appointment on the basis of an exclusive professional contract, which the Hospital has entered into for the rendition of services within a department. The CEO shall promptly notify the applicant in writing that the application cannot be processed because of the existence of such an exclusive contract. No applicant whose application is denied on such basis shall be afforded any of the procedural rights provided in the Fair Hearing Plan.

2. Burden on Applicant. The applicant shall have the responsibility of producing a fully complete application and such other information as may be reasonably requested for a proper evaluation of his experience, background, training, demonstrated ability, previous performance, current competence, physical and mental health status and of resolving any doubts about such matters. The applicant shall have a continuing responsibility to provide updated information to the Hospital, if any information in the application changes between the date it is submitted and the date on which final action and a final decision on the application is taken or made.

If the applicant notifies the Hospital of any exclusion from participating in any federally funded healthcare programs, the processing of the application will not continue until the exclusion has been lifted.

3. Verification. Upon the receipt of a completed Request for Consideration (RFC) or Recredentialing Request for Consideration (RRFC) form, the Credentials Processing Center shall arrange to verify the qualifications and obtain supporting information relative to the RFC or RRFC. The Credentials Processing Center shall consult primary sources of information about the individual’s credentials, where feasible. Completion of a background check, verifications of licensure, controlled substance registration, specialty board certification, and professional liability claims history, a query of the NPDB, queries of the OIG Sanction Report, GSA List, and State exclusion list, if applicable, and collection of any other information necessary to verify that the individual satisfies all Threshold Eligibility Criteria shall be done within 150 days prior to the Board of Trustees receiving the application. If there are delays in completing the RFC or RRFC, any of these verifications or queries that were done more than 150 days before the Board of Trustees is scheduled to receive the application shall be repeated. Verification may be made by a letter or computer printout obtained from the primary source or it may be verbally or electronically transmitted (e.g., telephone, facsimile, email, Internet) information when the means of transmittal is directly from the primary source to the Credentials Processing Center and the verification is documented. If the primary source has designated another organization as its officially-designated agent in providing information to verify credentials, the Credentials Processing Center (CPC) may use this other organization as the designated equivalent source. The Credentials Processing Center or Hospital shall promptly notify the individual of any problems in obtaining required information. Any action on an application shall be withheld until it is completed; meaning that all information has been provided and verified, as defined in these Bylaws. 22 It shall be the responsibility of the applicant to see that a report from the director of his training program

22 Joint Commission Medical Staff Standard 03.01.01 & 06.01.05; Fla. Stat. § 395.0191

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and letters from his personal references, including any required peer recommendations, are submitted directly to the CEO by such persons. An application shall be considered complete only after all required documents and information have been collected, received and verified. The verification and committee process may take approximately 60 days.

After verification is accomplished and the application is fully complete, the CEO shall transmit a copy of the application and supporting materials to the chairperson of each department in which the applicant seeks privileges and request documented opinions and recommendations as to Staff appointment or clinical privileges. The department chairperson may conduct a personal interview of the applicant and may request additional information from the applicant, if he deems it necessary, in which event the applicant shall promptly furnish the requested information. Thereafter, the department chairperson shall prepare a written report and recommendations as to Medical Staff appointment and, if appointment is recommended, Medical Staff category and department, clinical privileges to be granted and any special conditions to the appointment. The reasons for an adverse recommendation shall be stated, and the report shall then be transmitted to the Credentials Committee. The Committee approval process may take approximately 30 days. If additional information is required of the applicant, the process may take approximately 60 days.

4. Credentials Committee Action. The Credentials Committee shall review the application; supporting materials; the report of department chairperson and such other available information as may be relevant to the applicant's qualifications. If an applicant has litigation pending which relates to his medical practice, or other issues require more information or clarification, the report may be delayed until the issues are addressed and a decision can be made. As promptly as practicable after the date the committee receives the information, the committee shall transmit a written report and recommendation to the Executive Committee as to Staff appointment and, if appointment is recommended, as to Medical Staff category and department, clinical privileges to be granted and any special conditions to the appointment. The reason for each adverse recommendation shall be stated.

5. Executive Committee and Board Action. At its next regular meeting after receiving the Credentials Committee report, the Executive Committee shall consider the report and such other available information as may be relevant to the applicant's qualifications. The Executive Committee may request additional information from the applicant if such information might be helpful in its evaluation of the application, and the applicant shall promptly furnish the requested information.

The Executive Committee shall then prepare a written report and recommendation to the Board as to Staff appointment and, if appointment is recommended, as to Staff category and department, clinical privileges to be granted and any special conditions to the appointment. The reasons for each adverse recommendation shall be stated. The Committee may defer action where the deferral is not solely for the purpose of causing delay.

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When the recommendation is favorable, the CEO shall forward it promptly to the Board for action at its next regular meeting. If the recommendation of the Executive Committee is adverse, the CEO shall promptly notify the applicant. Such notice shall contain the information prescribed in the Fair Hearing Plan. In such case, the applicant shall be entitled to the procedural rights provided in the Fair Hearing Plan, and the recommendation need not be transmitted to the Board until after the applicant has exercised or waived such rights.

No applicant shall be entitled to the procedural rights provided in the Fair Hearing Plan if an adverse decision is made as a result of the applicant's failure to submit a completed application within sixty days.

6. Subsequent Consideration. If after the procedural rights provided in the Fair Hearing Plan are exercised, the Executive Committee makes a favorable recommendation, it shall be processed as in the case of any other favorable recommendation. If, however, the recommendation remains adverse, the CEO shall promptly notify the applicant. Also in such case, the CEO shall notify the Board, but the Board shall take no action until the applicant has exercised or waived his right to appellate review as provided in the Fair Hearing Plan.

After all of the applicant's procedural rights have been exercised or waived, the Board shall act on the application. The Board may approve or deny the application and may accept or reject the recommendation of the Executive Committee. The decision of the Board shall be final, and notice of its decision shall be transmitted by the CEO to the Executive Committee and the chairperson of the department for which privileges were requested. Also, the CEO shall promptly notify the applicant.

7. Reapplication. An applicant who has received an adverse decision regarding appointment and/or clinical privileges shall not again be considered for at least two years after final notice of the decision is sent. Any such application shall be processed as an initial application.

8. Provisional Privileges. All privileges granted shall initially be provisional in nature. Each practitioner granted clinical privileges shall be observed and evaluated by the department chairperson in the manner provided in Article IV, Section 3 and Article VII, Section 5.

Part B - Reappointments

1. Information. Each Staff year the CEO shall ask each Staff member, excluding Honorary members, or other individual exercising clinical privileges whose appointment or grant of privileges is expiring to furnish specific information in writing as to any changes he wishes in his Staff appointment or clinical privileges. The information shall be furnished within the time specified by the CEO in the format of a Reappointment Request for Consideration (RRFC).23 Such information shall include:

23 Joint Commission Medical Staff Standard 03.01.01 & 06.01.05; Fla. Stat. § 395.0191

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a. Continuing training, education, experience and current competence qualifying the Staff appointee for the privileges. CME’s are required to be related at least in part to the clinical privileges of the physician;

b. Professional competence, clinical judgment and professional performance in the treatment of patients;

c. Ethics and conduct;

d. Attendance at Staff meetings and participation in Staff affairs;

e. Compliance with these Bylaws and the Rules and Regulations;

f. Use of Hospital facilities;

g. Relations with other Staff members and attitude toward patients, the Hospital and the public;

h. Health status and condition and evidence relating thereto as may reasonably be requested;

i. Current licensure;

j. Current or past facility affiliations;

k. Clinical and/or technical skills, as indicated in part by the results of quality assessment and improvement activities;

l. Previously successful or currently pending challenges to any licensure or registration or the voluntary relinquishment of such licensure or registration;

m. Voluntary or involuntary termination of medical staff membership or limitation, reduction or loss of clinical privileges at another hospital;

n. Activities of any professional or peer review organization or sanctions imposed by any such organization or any licensing board or regulatory authority;

o. Any pending or settled legal proceedings involving professional liability claims;

p. Current provider status and UPIN number as well as information concerning the suspension or termination for any period of time of the right or privilege to participate in Medicare, Medicaid, any other government sponsored program, or any private or public medical insurance program, and information as to whether the applicant is currently under investigation and;

q. Continued eligibility to participate in any Federal and State Healthcare Programs. The practitioner must notify the Medical Staff Office and the Risk Manager within three (3) working days of any change in eligibility for payments by third-party payors or for participation in Medicare, including any sanctions imposed or

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recommended by the federal Department of Health and Human Services, and/or the receipt of a PRO citation and/or quality denial letter concerning alleged quality problems in patient care,

r. Utilization of the Hospital, and

s. Such other information about the appointee's professional qualifications, ethics and ability that may bear on his ability to provide quality patient care, including information as to the continuing accuracy of the information required for initial appointment.

The burden of providing complete information shall be on the applicant, as in the case of an initial appointment. The Staff member or other person furnishing such information shall have a continuing responsibility to provide updated information if any information furnished changes between the date information is submitted and the date on which final action or a final decision on reappointment is taken or made. Failure to return the requested information and supporting documents within sixty days from the date the application was mailed to applicant may result in automatic termination of membership at the end of the applicant's current term, unless the Chief of Staff grants an extension for reasonable extenuating circumstances.

When a Reappointment Request for Consideration (RRFC) is received that is complete and meets all Threshold Eligibility Criteria, it will be processed by the CPC and submitted to the Hospital as an application. When an individual does not satisfy one or more of the Threshold Eligibility Criteria, the individual shall be notified by the CPC that the Request for Consideration (RFC) or the Reappointment Request for Consideration (RRFC) that does not satisfy a Threshold Eligibility Criterion will not be processed.24

2. Minimum Activity. In order to allow accurate assessment of the quality of patient care within the facility, a minimum of six (6) patient care contacts (admissions, consultations or procedures) will be required within a two (2) year period to maintain ones Hospital affiliation and Medical Staff privileges. Combinations of any of the three (3) - consultation, admission or procedures - on the same admission count as one patient contact. Failure to maintain such minimum activity may result in the voluntary relinquishment of clinical privileges granted without the right to any fair hearing or due process. Certain specialties may be exempted from the requirement at the discretion of the Executive Committee and Board of Trustees.

3. Verification. Upon the receipt of a completed Recredentialing Request for Consideration (RRFC) form, the Credentials Processing Center shall arrange to verify the qualifications and obtain supporting information relative to the RFC or RRFC. The Credentials Processing Center shall consult primary sources of information about the individual’s credentials, where feasible. Completion of a background check, verifications of licensure, controlled substance registration, specialty board certification, and professional liability claims history, a query of the NPDB, queries of the OIG Sanction Report, GSA List, and

24 Joint Commission Medical Staff Standard 03.01.01 & 06.01.05; Fla. Stat. § 395.0191

31

State exclusion list, if applicable, and collection of any other information necessary to verify that the individual satisfies all Threshold Eligibility Criteria shall be done within 150 days prior to the Board of Trustees receiving the application. If there are delays in completing the RFC or RRFC, any of these verifications or queries that were done more than 150 days before the Board of Trustees is scheduled to receive the application shall be repeated. Verification may be made by a letter or computer printout obtained from the primary source or it may be verbally or electronically transmitted (e.g., telephone, facsimile, email, Internet) information when the means of transmittal is directly from the primary source to the Credentials Processing Center and the verification is documented. If the primary source has designated another organization as its officially-designated agent in providing information to verify credentials, the Credentials Processing Center (CPC) may use this other organization as the designated equivalent source. The Credentials Processing Center shall promptly notify the individual of any problems in obtaining required information. Any action on an application shall be withheld until it is completed; meaning that all information has been provided and verified, as defined in these Bylaws.25

When verification is accomplished and the application is complete, the CEO shall transmit the information to the chairperson of each department in which the appointee requests privileges. The verification process may take approximately 60 days.

4. Department Action. The department chairperson shall act on the information and shall promptly furnish his written report and recommendation to the Credentials Committee that the appointment be renewed, renewed with modified Staff category or clinical privileges, or terminated, setting forth the reasons therefore if a recommendation is adverse. Peer recommendations shall be part of the basis for the development of recommendations for reappointment. If the department chairperson considers it necessary or appropriate, he may request additional information from the applicant concerning his application, and the applicant shall promptly furnish the requested information. The Committee approval process may take approximately 30 days. If additional information is required of the applicant the process may take approximately 60 days.

5. Credentials Committee Action. The Credentials Committee shall at the next scheduled meeting review the information, reports and recommendations and all other available information on appointees. The committee shall also consider the results of quality assessment and improvement activities to be used in part to determine professional performance and clinical competence. If the committee considers it necessary or appropriate, it may request additional information from an applicant concerning his application, and the applicant shall promptly furnish the requested information. The committee shall transmit to the Executive Committee its written report and recommendations as to each appointee, specifying the reasons if the recommendation would deny reappointment, deny a change in Staff category or clinical privileges, or reduce privileges.

6. Executive Committee Action. The Executive Committee shall review the information, reports and recommendations and all other available information on appointees. If the committee considers it necessary or appropriate, it may request additional information

25 Joint Commission Medical Staff Standard 03.01.01 & 06.01.05; Fla. Stat. § 395.0191

32

from an applicant concerning his application, and the applicant shall promptly furnish the requested information. The committee shall promptly transmit to the Board its report and recommendations as to each appointee. If the recommendation would deny reappointment, deny a change in Staff category or clinical privileges or reduce privileges of an appointee, the report shall set forth the reasons therefore, and in such event the CEO shall promptly notify the appointee as provided in the Fair Hearing Plan. In such case, the Medical Staff member or other individual exercising clinical privileges shall be entitled to the procedural rights provided in the Fair Hearing Plan.

7. Board Action. The Board shall act on each request at its next regular meeting based on the reports, recommendations and other available information pertinent to each applicant. The decision of the Board shall be final, and notice of the decision shall be transmitted by the CEO to the Executive Committee and each appointee being considered. Reappointments shall be for a period of two years.

Part C - Other

1. Modifications of Appointment. A Staff appointee may, either in connection with reappointment or at any other time, request modification of his Staff category, department assignment or clinical privileges by submitting a request in writing to the CEO. Such request shall be processed in substantially the same manner as requests for appointment or clinical privileges. If new or additional privileges are granted, they shall be considered provisional in nature, as in the case of initial privileges granted.

2. Notices. Any notices of adverse decisions on appointments, reappointments or other requests in this Article shall be deemed to have been properly given to the applicant or appointee if in writing and personally delivered with a receipt requested or deposited in the United States certified or registered mail, postpaid, to the address of the applicant or appointee on his application or to his last known address.

3. Timeliness. All persons or groups shall act promptly in the application and review process.

4. Assistance. The Hospital, the CEO, the Staff or any committee involved in the review or evaluation of applications of Staff appointment or reappointment or clinical privileges may (a) obtain the assistance of independent consultants or others; (b) consider the results of quality assessment/improvement activities of other hospitals or health care institutions with respect to the applicant; (c) request or require the applicant to submit to interviews with consultants who may be retained to assist in the review or evaluation process; (d) request that specific patient records or categories of records of patients treated by the applicant be submitted for review, subject to appropriate protection of patient confidentiality, and (e) require detailed statements, data and information concerning matters that may impact the applicant's qualifications, professional competence or conduct, including information concerning threatened or pending legal or administrative proceedings.

5. Profiling. In evaluating applications for appointment or reappointment, the quality of care provided to the patient is the primary focus. The basis for privilege determinations for

33

continuation of privileges shall include, in addition to the above listed information, the results of ongoing professional practice evaluation as provided for in the Hospital’s policies.26 Practitioner profiles will include performance-based patterns of treatment, clinical outcomes, patient satisfaction.

6. Hospital Need and Ability to Accommodate. No person shall be appointed to the Medical Staff or shall be granted clinical privileges if the Hospital is unable to provide adequate facilities and support services for the applicant or his/her patients. The Board of Trustees may decline to accept, or have the Medical Staff review requests for Medical Staff membership and/or particular clinical privileges in connection with appointment, reappointment, the initial granting of clinical privileges, requests for revision of clinical privileges, the renewal of clinical privileges or otherwise on the basis of the following:

a. Availability of Facilities/Support Services. Clinical privileges shall be granted only for the provision of care that is within the scope of services, capacity, and capabilities of the Hospital. Prior to granting of a clinical privilege, the resources necessary to support the requested privilege shall be determined to be currently available, or available within a specified time frame. Resource considerations shall include whether there is sufficient space, equipment, staffing, financial resources or other necessary resources to support each requested privilege.27

ARTICLE VII

CLINICAL PRIVILEGES

1. Exercise. Every practitioner or other individual providing clinical services at the Hospital shall, except as expressly provided in these Bylaws, be entitled to exercise only those privileges specifically granted to him by the Board.

2. Admitting Privileges. Only Staff members may be granted admitting privileges. The privilege to admit shall be delineated, and is not automatic.

3. Applications and Evaluations. Each application for appointment and reappointment must contain a request for the specific clinical privileges desired by the applicant. An application for only clinical privileges shall contain the same information and statements as an application for Staff membership. An applicant for clinical privileges shall be subject to the same obligations as are imposed upon an applicant for Staff appointment, as provided in Article VI, Part A, Sections 1 and 2, Appointment and Reappointment.

A request by a Staff member for a modification of privileges must be supported by documentation of training and experience supportive of the request. Applications and requests for clinical privileges shall be evaluated on the basis of the practitioner's education, training, performance, demonstrated ability, judgment, experience, health status, references, professional liability experience and other relevant information,

26 Joint Commission Medical Staff Standard 04.04.05, 06.01.05 & 08.01.03; 42 C.F.R. § 482.21 27 Joint Commission Medical Staff Standard 06.01.01; 42 C.F.R. § 482.12

34

including an evaluation by the clinical departments in which such privileges have been sought.

The criteria for granting clinical privileges shall also include the ability of the Hospital to provide supportive services for the applicant and his patients and patient care needs for additional persons with the applicant's skill and training.

The basis for privileges determinations for periodic reappointment or otherwise shall include documentation of observed clinical performance, documented results of patient care evaluation and treatment, review of Staff records which document the applicant's delivery of medical care, organizational performance, and quality improvement activities required by these Bylaws and the Rules and Regulations, and evaluations of the applicant's physical and mental capabilities. Clinical privileges granted or modified on initial appointment, reappointment or otherwise shall also be based on pertinent information concerning clinical performance obtained from other sources, especially other hospitals and health care facilities where a practitioner exercises clinical privileges.

The Hospital or any committee of the Staff may, in its discretion, obtain an evaluation of the applicant by a consultant selected by the Hospital or the committee, as provided in these Bylaws.

All such information shall be maintained in the individual Staff file of the applicant or appointee.

The Medical Staff member shall be granted access to the individual’s credentials file, subject to the following provisions:

a. Timely notice of such shall be made by the member to the Chief of the Medical Staff or Chief of Medical Staff s designee;

b. The member may review, and receive a copy of, only those documents provided by or addressed personally to the member. A summary of all other information, including peer review committee findings, letters of reference, proctoring reports, complaints, etc., shall be provided to the member in writing, by the designated officer of the Medical Staff, within a reasonable period of time as determined by the Medical Staff. Such summary shall disclose the substance, but not the source of the information summarized;

c. The review shall take place in the Medical Staff Office, during normal work hours, with an Officer or designee of the Medical Staff present.

Sex, race, creed, national origin or disability which does not affect ability to safely and appropriately exercise the clinical privileges requested shall not be used in making decisions regarding the granting or denying of clinical privileges.

4. Delineation. Clinical privileges shall be delineated on an individual basis. The delineation of an individual's privileges shall include the limitations, if any, on the individual's

35

privileges to admit and treat patients or direct the course of treatment for which patients are admitted.

5. Provisional Privileges. All clinical privileges granted shall initially be considered to be provisional in nature. Each individual who is granted privileges shall be assigned to a clinical department, and his performance shall be observed and evaluated by the department chairperson or his designee. All such grants of privileges shall be for a period of at least one-year. This period may be extended for an additional 120 days on the recommendation of the chairperson of the department to which the individual is assigned, if there has not been adequate opportunity to observe his professional performance due to lack of utilization of the Hospital for care of a sufficient number of patients.

Any decision to extend the period for provisional privileges shall not be deemed to be adverse action and shall not entitle an individual to the procedures afforded by the Fair Hearing Plan. After completion of the period for which provisional privileges have been granted, such individual may be granted clinical privileges that are for the same period as those granted to other members of the Staff, or his privileges shall be terminated. The chairperson of the department to which he is assigned shall submit a report and recommendation concerning such appointee to the Credentials Committee prior to the end of the provisional period. The report and recommendation shall be considered at the next meeting of the credentials committee, which shall make a recommendation to the Executive Committee concerning the privileges granted.

The Executive Committee shall consider the recommendation and shall thereafter make its recommendation concerning such privileges to the Board. The Board shall promptly review the Executive Committee recommendation and make its decision concerning the matter.

6. Emergency Privileges. In an emergency, any practitioner, to the extent permitted by his license and regardless of department, Staff status or clinical privileges, shall be permitted to do and be assisted by Hospital personnel in doing everything possible to save the life of a patient or save the patient from serious harm, using every facility of the Hospital if necessary, including calling for any necessary or desirable consultation. When the emergency no longer exists, the practitioner must request any privileges needed which he does not otherwise hold in order to continue to treat the patient. If such privileges are denied or if he does not wish to request such privileges, the patient shall be assigned to an appropriate active staff member. An emergency shall be considered as a condition in which serious or permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger.

7. Temporary Staff Membership with Privileges.

a. Circumstances. On the recommendation of the chairperson of the department in which clinical privileges will be exercised if possible or the Chief of Staff, the CEO or, in his absence, his designee may grant temporary Staff membership with temporary privileges in the following circumstances to a practitioner:

36

i. After receipt of a complete application with all supporting documents and verifications, thereof and approved by the Credentials Committee for staff membership, an appropriately licensed and qualified practitioner may be granted temporary Staff membership with temporary privileges for a period not to exceed ninety consecutive days. In such cases the applicant shall act under the supervision of the chairperson of the department to which he is assigned. It must reasonably appear from the information available that a favorable decision on the application, considering the applicant's qualifications, ability and judgment, is likely. Temporary privileges may include admitting privileges. An applicant awaiting processing of a complete application for Medical Staff membership shall be eligible for temporary privileges only after submitting a complete application and only under the following conditions:

a) There are no current or previously successful challenges to licensure or registration;

b) There are no adverse membership actions at another hospital; and,

c) There are no adverse actions against the applicant’s privileges at another hospital.

Any denial of temporary Staff membership or temporary privileges shall be final and non-appealable.28

Temporary Staff Membership Category may apply to practitioners who are qualified for membership (Article III), to fulfill an important patient care need that cannot be otherwise met by the existing members of the Medical Staff or currently privileged AHPs subject to the following rules. After a written request by the applicant and staff sponsor and on the recommendation of the Chief of Staff, the CEO or their designee may grant temporary staff membership upon approval. Temporary Staff membership shall be granted regarding specifically delineated privileges not to exceed 120 consecutive days. The Temporary Staff Membership may consult for the purposes of complying with training, accreditation, or regulatory requirements. They shall not have admitting privileges and will be exempt from county residency requirements. The Category will not be available to local practitioners who are not staff members. They will assume all responsibilities noted in Article III of the Bylaws. Temporary clinical privileges shall automatically expire at the end of the specified period, without recourse by the Practitioner under the Fair Hearing Procedure.

b. Qualifications and Verification. Prior to temporary privileges being granted, an applicant for such privileges must demonstrate that he/she possesses a current license within this State, a current and unrestricted DEA registration reflecting an in-state address for the State of Florida (if the Practitioner will be prescribing or administering controlled substances), evidence of ability to perform the temporary

28 Joint Commission Medical Staff Standards 06.01.03

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privileges requested, current competence related to the temporary privileges requested, documentation of professional liability insurance coverage as required by the Board of Trustees, and for Practitioners a signed Physician Acknowledgement Statement must be submitted prior to performing any patient care. Qualifications for temporary privileges shall be verified from a primary source or designated agent of the primary source, and documented. The National Practitioner Data Bank shall be queried prior to the granting of temporary privileges. Additionally, the Hospital shall verify the applicant’s status as an Ineligible Person. For this purpose, the applicant shall provide his/her Medicare NPI, and the Hospital shall check the OIG Sanction Report, the GSA List, and the State Exclusion List. If the applicant is excluded from such participation, temporary privileges shall not be granted; any exclusion subsequent to having been granted temporary privileges shall result in immediate termination of such privileges without any right to the hearing and appeal procedures pursuant to the Fair Hearing Plan. When applying for temporary privileges, each applicant shall agree to be bound by the Medical Staff Bylaws, Rules and Regulations, departmental rules and regulations, and applicable Hospital policies.29

c. Termination. On the discovery of any information or the occurrence of any event of a professionally questionable nature about a practitioner's qualifications or ability to exercise any of the temporary privileges granted, the Chief of Staff, after consultation with the department chairperson responsible for supervision, may terminate privileges, and such decision shall be final and nonappealable under the Fair Hearing Plan or otherwise. Monitoring. The granting of temporary privileges should be limited to rare, unusual, special or unique circumstances. In granting temporary privileges, special requirements may be imposed in order to monitor and assess the quality of care rendered by the practitioner exercising such privileges.30

8. Disaster Privileges.

Disaster privileges may be granted during an emergency situation such as natural disaster, war or other significant disruption of community services, including healthcare services, which creates demands exceeding the capacities or capabilities of the Hospital to handle in a normal or routine way. Potential disaster situations shall be described in the Hospital Emergency Operations Plan and are defined as any occurrence that inflicts destruction or distress and that creates demands exceeding the capacities or capabilities of the Hospital to handle in a normal or routine way. Such occurrence may be due to a natural or a man-made disaster. Upon activation of the Hospital’s Emergency Operations Plan and in a situation in which the Hospital is not able to meet immediate patient needs, temporary disaster privileges may be granted to an appropriately qualified Practitioner as described above in Article VII(7)(b) based upon the needs of the Hospital to augment staffing due to the disaster situation and the presentation of the following documentation:

a. Proof of Florida licensure

29 Joint Commission Medical Staff Standards 06.01.03 & 06.01.13 30 Joint Commission Medical Staff Standards 06.01.13, 08.01.01, 08.01.03 & 09.01.01

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b. Proof of current hospital privileges held elsewhere including current delineation of privileges enjoyed by the practitioner

c. Proof of existing professional liability coverage, minimum as established by the Board

d. Current valid government issued photo identification

The above must be provided to the Medical Staff Office and confirmed as acceptable either by the CEO and the chairperson of the appropriate department or the Chief of Staff prior to the practitioner seeing, examining or treating a patient. Privileges shall be approved by the Hospital Emergency Incident Commander (Chief Executive Officer/designee) upon recommendation by the Chief of Staff or the EOP designated Medical Staff Director. All decisions to grant temporary disaster privileges are at the discretion of the Hospital Emergency Incident Commander or designees, and shall be evaluated on a case-by-case basis in accordance with Hospital and patient care needs.

Scope of privileges for the practitioner shall be established at the time they are granted with temporary assignment to the appropriate department. Medical Staff Office shall seek appropriate verification of presented documents as described above in Article VII(7)(b), as conditions permit. Verification shall be completed within 72 hours from the time the volunteer Practitioner presents to the organization, or as soon as possible in an extraordinary situation that prevents verifications within 72 hours. The Hospital shall make a decision, based on information obtained regarding the credentials and professional practice of the Practitioner, within 72 hours of the volunteer Practitioner presenting to the Hospital regarding whether to continue the disaster privileges initially granted. Continuing privileges shall be approved by the Hospital Emergency Incident Commander (Chief Executive Officer/designee) or the Operations Chief, if that position is activated as part of the EOP, upon recommendation by the Chief of Staff or the EOP designated Medical Staff Director. In the event that verification of information results in an inability to confirm the qualifications of the Practitioner, privileges should be immediately terminated. When the emergency situation no longer exists, or when Medical Staff Members can adequately provide care, temporary disaster privileges terminate.

Upon approval, the Practitioner should be issued appropriate Hospital security identification as required by the Hospital.31 The Chief of Staff or the EOP designated Medical Staff Director shall also assign a Member of the Medical Staff to be responsible for supervising Practitioners granted temporary disaster privileges, through direct observation, mentoring, or clinical record review. Practitioners who are employees of any Federal agency, and Practitioners acting on behalf of a Federal agency in an official capacity, temporarily or permanently in the service of the United States government, whether with or without compensation, are subject to professional liability for malpractice committed within the scope of employment under the provisions of the Federal Tort Claims Act. Temporary privileges granted to Practitioners who are acting as agents of the Federal government shall be limited in their privileges at this Hospital to the scope of their

31 Joint Commission Emergency Management Standard 02.01.01, 02.02.13 & 02.02.15

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Federal employment. These disaster privileges shall not exceed the disaster response and recovery period or thirty (30) days, whichever is less, and shall not be renewed. These privileges will be granted at will and may be terminated at any time by the CEO or Chief of Staff when the practitioner's services are no longer needed. Under no circumstances shall a practitioner granted disaster privileges be entitled to the appeal process provisional of these Bylaws.

9. New/Transpecialty Procedures. Any procedure or request for clinical privileges that is either new to the Hospital or that overlaps more than one department will initially be reviewed by the Medicine or Surgery Department Committee and forwarded to the Credentials Committee. The Credentials Committee may request information from one or more departments or practitioners, or may create an ad-hoc committee as deemed necessary to establish Credentialing criteria, or make recommendations regarding a request for privileges for a new or transpecialty procedure. The recommendation of the Credentials Committee will be forwarded to the Executive Committee for its review and recommendation to the Board of Trustees. Prior to accepting a request for a specific privilege, the resources necessary to support the privilege shall be determined to be currently available, or available within a specified time frame. Hospital leaders shall determine whether sufficient space, equipment, staffing, and financial resources are in place or will be available within a specified time frame to support each privilege. The clinical privileges available for request shall be approved by the Board of Trustees, based on this determination of Hospital leaders.32

10. New Clinical Services and/or Programs. Physicians may request privileges, which may involve or require a new clinical program or service. The need and appropriateness for establishing the new clinical program or service will be reviewed by the departmental review committee and forwarded to the Credentials Committee. The Credentials Committee may request additional information from the appropriate department, or may create an ad-hoc committee in order to formulate a recommendation to the Executive Committee. As promptly as practicable after formulation of its recommendation, the Credentials Committee shall transmit a written report and recommendation to the Executive Committee for its review and action. Prior to accepting a request for a specific privilege, the resources necessary to support the privilege shall be determined to be currently available, or available within a specified time frame. Hospital leaders shall determine whether sufficient space, equipment, staffing, and financial resources are in place or will be available within a specified time frame to support each privilege. The clinical privileges available for request shall be approved by the Board of Trustees, based on this determination of Hospital leaders.33

11. Telemedicine Services. No telemedicine services by physicians not on this medical staff will be allowed unless approved by the Executive Committee and the Board of Trustees.

32 Joint Commission Medical Staff Standard 06.01.01 33 Joint Commission Medical Staff Standard 06.01.01

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Providers that exclusively provide telemedicine services may not vote as a Member of the Medical Staff.34

12. Voluntary Resignations. Voluntary resignations from the Medical Staff will occur on receipt of a letter of resignation and acceptance by the Executive Committee and Board of Trustees pending completion of all Medical Staff responsibilities. Resignations will not be accepted until all Medical Records are completed.

ARTICLE VIII

CORRECTIVE ACTION

1. Informal Inquires. Any person may provide information to the Medical Staff about the conduct, performance, or competence of a Practitioner or other individual with clinical privileges. When reliable information, including the results of quality assessment or performance improvement activities, indicates that an individual may have exhibited acts, demeanor, conduct or professional performance reasonably likely to be (1) detrimental to patient safety or to the delivery of quality of patient care within the Hospital, (2) unethical, (3) unprofessional, inappropriate, disruptive or harassing, (as defined in Medical Staff and Hospital Policies, including sexual harassment), (4) contrary to the Medical Staff Bylaws, Medical Staff Rules and Regulations, or Medical Staff Policies, or (5) below applicable professional standards, the Chief of Staff, appropriate Department or Committee Chairperson, or Chief Executive Officer shall make sufficient inquiry to satisfy him/herself that the concern or question raised is credible. Any Professional Review Body as defined under the Health Care Quality Improvement Act of 1986 shall have the power to conduct an informal inquiry of a Practitioner and conduct a collegial intervention. Upon written request to the medical executive committee after a period of 3 years if no further action is taken or issues arise then the medical executive committee may at their discretion remove these papers from the practitioners file.

2. Collegial Interventions. These Bylaws encourage the use of progressive steps by Medical Staff leaders and Hospital management, beginning with collegial and educational interventions, to address issues pertaining to clinical competence or professional conduct. The goal of these collegial interventions is to prompt voluntary actions by the individual to resolve an issue that has been raised. Initial collegial interventions may be made prior to resorting to formal corrective action, when appropriate. Such collegial interventions on the part of Medical Staff leaders in addressing the conduct or performance of an individual shall not constitute corrective action, shall not afford the individual subject to such interventions to the right to a Hearing and Appeal, and shall not require reporting to the State Board of Medical Examiners and subsequently to the NPDB, except as otherwise provided in these Bylaws. Although these Bylaws encourage the use of collegial interventions, based on the specific facts and circumstances collegial interventions are not appropriate in all cases and it may be necessary to take immediate action or bypass collegial interventions. Collegial intervention is a part of the Hospital's professional review activities and may include, but is not limited to, the following:

34 42 C.F.R. § 482.22; Fla. Stat. § 395.0191

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a. Advising colleagues of applicable policies, such as policies regarding appropriate behavior, emergency call obligations, and the timely and adequate completion of medical records;

b. Informal discussions or formal meetings regarding the concerns raised about conduct or performance, including the actions outlined in the Medical Staff Policy regarding Professional Conduct, that may be taken to address unprofessional or inappropriate conduct;

c. Proctoring, monitoring, consultation, and letters of guidance;

d. Sharing comparative quality, utilization, and other relevant information, including any variations from clinical protocols or guidelines, in order to assist individuals to conform their practices to appropriate norms;

e. Written letters of guidance, reprimand or warning regarding the concerns about conduct or performance;

f. Notification that future conduct or performance shall be closely monitored and notification of expectations for improvement;

g. Suggestions or recommendations that the individual seek continuing education, consultations, or other assistance in improving performance, including behavioral contracts;

h. Warnings regarding the potential consequences of failure to improve conduct or performance; and/or,

i. Requirements to seek assistance for a health issue, as provided in these Bylaws.

The relevant Medical Staff leader(s), in consultation with the Chief Executive Officer, may determine whether a matter should be handled in accordance with another policy (e.g., code of conduct policy, practitioner health policy, peer review policy) or should be referred to the MEC for further action.

The relevant Medical Staff leader(s) will determine whether to document a collegial intervention effort. Any documentation that is prepared will be placed in an individual's confidential file. The individual will have an opportunity to review the documentation and respond to it. The response will be maintained in the individual's file along with the original documentation.

No action taken pursuant to this Section shall constitute an investigation or a corrective action.35

35 Joint Commission Medical Staff Standard 08.01.03, 09.01.01, 10.01.01 & 11.01.01; Fla. Stat. § 395.0191 & 395.0193

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3. Initiation. Whenever the activities or professional conduct of a practitioner or other individual with clinical privileges are considered to conflict with the standards of the Staff, disruptive to Hospital operations, or are detrimental to patient safety or quality of care, corrective action against the practitioner may be initiated by any Staff officer, any department chairperson, any chairperson of a medical staff committee, the CEO or the Board. All requests for corrective action shall be in writing to the Chief of Staff and shall be supported by reference to the specific activities or conduct, which constitutes the grounds for the request. If an investigation is initiated, the practitioner will be notified. The Chief of Staff shall notify the CEO and keep him fully informed of all proceedings and action taken. The Chief of Staff shall also notify the Board, as well as the chairperson of the department in which the questioned activities or conduct occurred, requesting an investigation.

4. Investigation. The Chief of Staff or, at his direction, the chairperson of the department to which the request for investigation is made, may immediately appoint an ad hoc committee of at least three members of the active staff to investigate the matter. The committee must request an interview with the practitioner, and he shall cooperate with the committee in its investigation. As promptly as practicable after the request for investigation is made, the chairperson of the ad hoc committee shall transmit a written investigation report to the Chief of Staff. The initiation of a formal investigation shall not preclude the imposition of suspension or restriction of clinical privileges under these Bylaws36

5. Action on Report. As soon as practicable following receipt of the ad hoc committee report, the Chief of Staff shall forward the report to the Executive Committee, which shall take action on the request. The action may include, without limitation, rejecting the request; issuing a warning, a letter of admonition or a letter of reprimand; recommending terms of probation or requirements of consultation; recommending reduction, suspension or revocation of clinical privileges; recommending a change in Staff category or limitation of Staff prerogatives; recommending suspension or revocation of Staff appointments; or referring the matter to the Board for any of such actions. Any adverse action shall entitle the practitioner to the procedural rights afforded by the Fair Hearing Plan, except as provided in the Fair Hearing Plan.

6. Summary Suspension.

a. Action. Whenever a practitioner willfully disregards these Bylaws or Hospital policies, or whenever his conduct may require that immediate action be taken to protect the life of a patient or to reduce the substantial likelihood of imminent injury to the health or safety of any patient, employee or other person in the Hospital, the Chief of Staff, Vice-Chief of Staff, or Department Chairperson with the concurrence of the CEO, may summarily suspend the Staff appointment or all or any of the practitioner's clinical privileges. The summary suspension shall become effective immediately upon imposition. The CEO shall immediately notify the Executive Committee of the suspension.

36 Joint Commission Medical Staff Standard 09.01.01; Joint Commission Leadership Standards 01.03.01; Fla. Stat. § 395.0191 & 395.0193

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b. Executive Committee Decision. Upon summary suspension of a practitioner, the Executive Committee shall direct that an investigation be conducted by persons designated by the Executive Committee to determine the need for the suspension or further action concerning the practitioner. Prior to, or as part of, this investigation, the individual may be given an opportunity to meet with the Medical Executive Committee, and any such meeting shall not be considered a hearing pursuant to the Fair Hearing Plan. Within 14 days thereafter, the Executive Committee shall meet to review the results of the investigation. The Executive Committee may, as a result of the investigation,37 recommend modification, continuation or termination of the summary suspension, and may take such further action concerning the Staff membership and clinical privileges of the practitioner, as it considers appropriate.

If the investigation is completed within 14 days from the date of the suspension and the investigation does not result in adverse action, as defined in the Fair Hearing Plan, the practitioner shall not be entitled to the procedural rights of the Fair Hearing Plan. If the Executive Committee does not recommend immediate termination of the suspension, or if further adverse action, as defined in the Fair Hearing Plan, is taken as a result of the investigation, the practitioner shall be afforded the right to appellate review as provided in the Fair Hearing Plan, but the terms of the summary suspension shall remain in effect pending a final decision by the Board. The chairperson of the Executive Committee or the chairperson of the department to which the practitioner is assigned shall arrange for alternative medical coverage of the suspended practitioner's patients in the Hospital. The wishes of the patient shall be considered in the selection of an alternative practitioner.

7. Automatic Suspensions. If a Staff appointee's license or other legal credential authorizing him to practice is revoked or suspended by a state licensing authority, he shall immediately and automatically be suspended from practicing in the Hospital by the CEO and his staff membership shall automatically be terminated. A practitioner or other professional with clinical privileges who does not maintain professional liability insurance as required in these Bylaws shall be automatically suspended until he furnishes adequate and satisfactory evidence of such coverage. A practitioner whose DEA number is revoked or who is suspended from prescribing scheduled drugs as recognized by the DEA shall immediately and automatically be divested by the CEO of his Staff membership and all clinical privileges. In regard to actions restricting a practitioner's right to prescribe non-scheduled drugs, the Executive Committee may consider and take such action, as it deems necessary.

When a physician notifies the Hospital of any exclusion from any federally funded programs, they will automatically be suspended until the exclusion has been lifted.

8. Medical Records.

a. Failure to Complete. An automatic suspension of a practitioner's admitting and/or consulting privileges shall, after warning of delinquency, be imposed by the Chief

37 Joint Commission Medical Staff Standard 09.01.01 & 10.01.01; Fla. Stat. § 395.0191 & 395.0193

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of Staff for failure to complete medical records in a timely fashion. Medical records include inpatient, outpatient, emergency, observation and other records. The suspension shall continue until the records are completed, unless the practitioner satisfies the Chief of Staff that he has a justifiable excuse for such failure. At the time of suspension, any hospital inpatients under the suspended physician’s care will continue to be the responsibility of the suspended physician. Under extenuating circumstances, the Chief of Staff may require the suspended physician to evaluate/admit selective patients.

b. A practitioner is expected to complete medical records documentation, required dictation and/or authentication within 30 days of discharge in accordance with the Health Information Management policy and procedure.

c. If a practitioner is repeatedly suspended for medical record documentation violations, membership and clinical privileges may be suspended or permanently revoked. "Repeatedly" means three or more such suspensions under subparagraph (a) within any twelve-month period.

9. Appropriate Access – Information Services includes all information contained in the Meditech System, Health Information Management and associated documents. Passwords allow individual access to be used only by physician to whom it is assigned. It is a violation of appropriate access to lend/share/transfer the password. Penalties for violation may include verbal or written sanction, suspension or revocation of Medical Staff membership and Clinical Privileges. See Hospital Policy #IS.AA.015.

10. DISCIPLINARY ACTION – ANY APPLICANT WHO KNOWINGLY WITHHOLDS INFORMATION OR PROVIDES FALSE INFORMATION ON AN APPLICATION FOR APPOINTMENT OR REAPPOINTMENT TO THE MEDICAL STAFF SHALL BE SUBJECT TO DENIAL OF APPOINTMENT OR REAPPOINTMENT OR DISCIPLINARY ACTION INCLUDING REMOVAL FROM THE MEDICAL STAFF.

ARTICLE IX

CLINICAL DEPARTMENTS

1. Departments. The Staff will be organized into clinical departments. The Executive Committee may create, eliminate, subdivide or combine departments, subject to the approval of the Board. The medical staff departments are the Department of Medicine and the Department of Surgery. The Department of Medicine includes, but is not limited to, allergy, arthritis/rheumatology, cardiology, dermatology, emergency medicine, endocrinology, gastroenterology; general medicine/family practice; hematology and oncology; infectious disease; internal medicine; nephrology; neurology;; physical rehabilitation; psychology; psychiatry; pulmonary medicine; radiation oncology and radiology.

The Department of Surgery includes, but is not limited to, anesthesia, general dentistry, general surgery, gynecology, neurosurgery, open heart, otolaryngology, ophthalmology,

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oral/maxillofacial, orthopedics, pathology, podiatry, plastics, thoracic, trauma services, urology and vascular specialties.

2. Organization. Each department shall be organized as a separate part of the Staff and shall have a chairperson approved by the Board with the duties and responsibilities provided in these Bylaws.

3. Assignment to Departments. Each Staff member shall be assigned to one department by the Executive Committee upon recommendation of the credentials committee, and may be granted clinical privileges in one or more other departments in the same manner. The exercise of clinical privileges within any department shall be subject to the rules and regulations of the department and the authority of the department chairperson.

4. Function of Departments. The primary function of each department is to implement specific review and evaluation activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided in the department. To carry out this overall function, each department shall:

a. Require patient care evaluation to be performed for the purpose of improving and/or maintaining the quality of care within the department. Each department shall monitor clinical work performed within the department. Department patient care evaluation shall be conducted through mechanisms that include review, evaluations, recommendations and subsequent action on findings relative to patient care within the department. Each department shall provide effective mechanisms to measure, assess, and improve organizational performance. Each department shall communicate to appropriate medical staff members the findings, conclusions, recommendations, and actions taken to improve organizational performance for each of the functions listed:

i. Through departmental and quality improvement activities relating to organizational performance, assessment and improvement of the quality of patient care and the performance of individuals with clinical privileges through member participation of each department in monitoring and evaluation of care; periodic review of the care; and communication of findings, conclusions, recommendations, and actions to members of the department.

a) Evaluation and improvement in the use of surgical and other invasive procedures;

b) Evaluation and improvement in the use of medications;

c) Evaluation and improvement in the use of blood and blood components;

d) The medical record review function, including timeliness and clinical pertinence review;

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e) Review and evaluation of morbidity and mortality;

f) Utilization management;

g) Infection surveillance;

h) Clinical risk management activities;

i) Pharmacy and therapeutics function;

j) Other review functions, including internal and external disaster plans, and Hospital safety.

When the findings of the assessment process are relevant to an individual's performance, the department shall be responsible for determining their use in peer review and/or the periodic evaluations of a practitioner's competence, especially in connection with continuing exercise of and reappointments of clinical privileges.

The effectiveness of all functions, the monitoring and evaluation of the quality of patient care provided by individuals with clinical privileges, surgical case review, drug usage evaluation, the medical record review function, blood usage review, the pharmacy and therapeutics function, and other review functions, shall be evaluated as part of the annual reappraisal of the Hospital's program to assess and improve quality.

b. Establish guidelines for the granting of clinical privileges within the department and submit through the Credentials Committee to the Executive Committee the recommendations required regarding the specific privileges each Staff member or applicant may exercise and the specified services that each Allied Health Professional may provide.

c. Conduct or participate in, and make recommendations regarding the need for, continuing education programs pertinent to changes in medical practice. Participation shall be considered at the time of reappointment to the Staff or renewal or revision of individual clinical privileges.

d. Monitor on a continuing basis adherence to: (1) Staff and Hospital policies and procedures; (2) requirements for alternate coverage and for consultations; (3) sound principles of clinical practice; (4) fire and other regulations designed to promote patient safety.

e. Collect data that is needed to design and assess new processes, assess the dimensions of performance relevant to functions, processes, and outcome, measure the level of performance and stability of important existing processes, identify areas for possible improvement of existing processes, and determine whether changes improve the processes.

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f. Measure the performance of processes and all the patient care and organizational functions identified by The Joint Commission manual. Processes measured on a continuing basis include those that (1) affect a large percentage of patients; (2) place patients at a serious risk if not performed well or performed when not indicated or performed when indicated; and/or (3) have been or likely to be a problem.

g. Assess collected data to determine whether design specifications for new processes were met, the level of performance and stability of important existing processes, priorities for a possible improvement of existing processes, actions to improve the performance of processes and whether changes in the processes resulted in improvement. The assessment shall include using statistical quality control techniques, comparing the data about the organization's processes and outcome over time, the organization's processes to the information from up-to-date sources about the design and performance of processes such as practice, guidelines or parameters and the organization's performance of processes and their outcomes to that of other organizations including using reference data basis. Assessments of data and mandate for continuous quality improvement team or process assessment within the organization shall be determined by the Quality Council.

h. Coordinate the patient care provided by the members of the department with nursing and other non-physician patient care services and with administrative support services.

i. Foster an atmosphere of professional decorum within the department appropriate to the practice of medicine.

j. Clinical Review Committee will represent the Departments by submitting written reports or minutes of Committee meetings to the Executive Committee on a regular basis concerning: (1) findings of the Committee's review and evaluation activities, actions taken thereon, and the results of such action; (2) recommendations for maintaining and improving the quality of care provided in the departments and the Hospital; and (3) such other matters as may be requested from time to time by the Executive Committee.

k. Information regarding the above will be provided to the Departments on a quarterly basis.

l. Establish such committees or other mechanisms as are necessary and desirable to properly perform the functions assigned to the department.

m. Periodically review Hospital and Staff policies and procedures pertaining to patient care and make recommendations regarding their modification, as needed.

5. Department Officers.

a. Appointments. The Board shall appoint for each clinical department, Staff members from the departments to serve as chairperson, vice chairperson for a

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period of one year, limited to three consecutive years of service. Each chairperson shall have demonstrated ability in at least one of the clinical areas of the department and be certified by an appropriate specialty board or affirmatively establishes, through the privilege delineation process, that he possesses comparable competence.

b. Manner of Selection. A list of eligible candidates for department officers shall be noted on the ballot that is mailed to respective department members of the active staff during the last quarter of the year or included in the notice of the annual meeting. The results of the vote for department officers shall be forwarded to the Board, which shall appoint all department officers.

c. Vacancies. In the event the chairperson of the department is unable to serve, resigns or is removed, the vice-chairperson shall succeed as chairperson. Any other vacancies in department offices shall be filled in the same manner as initial appointments.

d. Resignations and Removals. Any department officer may resign at any time by giving written notice to the Medical Executive Committee and, unless specified therein, the acceptance of such resignation shall not be necessary to make it effective. Any department officer may be removed by the Board upon the recommendation of the Medical Executive Committee. A three-fourths vote of the Executive Committee members present to remove a department officer shall constitute removal of the officer. At least two-thirds of the active staff members of the department may submit a request for removal of a department officer to the Board, specifying in writing the reason for the request. The Board shall take such action concerning the request, as it deems appropriate. Conditions for removal of an officer shall include:

i. Failure to perform the duties of office;

ii. Failure to comply with or support the enforcement of the Hospital and Medical Staff Bylaws, Rules and Regulations, or policies;

iii. Failure to support the compliance of the Hospital and the Medical Staff to applicable Federal and State laws and regulations, and the standards or other requirements of any regulatory or accrediting agency having jurisdiction over the Hospital or any of its services;

iv. Failure to maintain qualifications for office, specifically, failure to maintain active staff status in good standing; and/or,

v. Failure to adhere to professional ethics or any other action(s) deemed injurious to the reputation of, or inconsistent with the best interests of the Hospital or Medical Staff.

e. General Duties of Chairperson. Each department chairperson shall be responsible for the organization of the department and delegation of duties to department

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members to promote the best interests of patients. Members of departments shall be responsible to Department Chairperson as chief of the service and, through him, to the Chief of Staff.

Each department chairperson shall be responsible for:

i. All clinically related activities of the department;

ii. All administratively related activities of the department, unless otherwise provided for by the Hospital;

iii. Integrating the department into the primary functions of the Hospital;

iv. Coordinating and integrating of interdepartmental and intradepartmental services;

v. Developing and implementing policies and procedures that guide and support the provision of services;

vi. Recommending a sufficient number of qualified and competent persons to provide care, including treatment;

vii. Continuing surveillance of the professional performance of all individuals who have delineated clinical privileges in the department;

viii. Recommending to the Staff the criteria for clinical privileges in the department;

ix. Recommending clinical privileges for each member of the department;

x. Determining the qualifications and competence of departmental personnel who will provide patient care services and who are not licensed independent practitioners;

xi. Continuously assessing and improving the quality of care and services provided;

xii. Maintaining quality control programs, as appropriate;

xiii. Orienting and providing in-service training and continuing education of all persons in the department;

xiv. Recommending space and other resources needed by the department; and

xv. Participating in the selection of sources for needed services not provided by the department or the Hospital.

The department chairperson shall assess and make recommendations as to off-site sources for needed patient care services not provided by the department or the

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Hospital. In addition, the chairperson shall transmit to the Executive Committee, department recommendations concerning appointment and classification, reappointment and delineation of clinical privileges of practitioners, or specified services of allied health professionals, and corrective action with respect to practitioners in the department.

f. Duties of Other Officers. The vice-chairperson shall assume the duties of the chairperson in his absence.

6. Clinical Privileges. Subject to Article VII, each department shall establish its own criteria and shall define and delineate privileges for its members, consistent with these Bylaws and the policies of the Staff and the Board, for the granting of clinical privileges. Such definition and delineation shall be approved by the Executive Committee and the Board. Each department chairperson shall recommend to the Credentials Committee the clinical privileges for practitioners assigned to the department and for those requesting only clinical privileges in the department and recommendations concerning appointment, reappointment, classification and delineation of clinical privileges or special services and corrective action.

7. Attendance at Meetings. Each member of the active and associate staff shall be required to attend the annual staff meeting. If he is compelled to be absent from a meeting, he shall submit a written excuse within 30 days to the Chief of Staff either mailed or forwarded to the Medical Staff Office.

8. Special Appearance. If a patient's clinical course of treatment is scheduled for discussion at a meeting, the practitioner treating the patient may be notified to provide information concerning the case. The chairperson of the meeting shall provide advance notice of at least seven (7) days of the time, place and location of the meeting to the practitioner. If apparent or suspected deviation from the standard of clinical practice is involved, the notice shall include a statement of the issue involved.

ARTICLE X

OFFICERS

1. Officers. The officers of the Staff shall be the Chief of Staff, Vice Chief of Staff, Secretary/ Treasurer and Immediate Past Chief of Staff. Officers must be members of the active staff at the time of nomination and election and must continuously maintain good standing during their terms of office. Failure to maintain such status shall immediately create a vacancy in the office involved. To qualify for the position of Chief of Staff or Vice Chief of Staff, a Member of the Medical Staff must be a doctor of medicine or osteopathy.38

2. Nominations and Elections. Not less than 30 days before the annual Staff meeting, the Nominating Committee shall convene and submit to the Chief of Staff one or more qualified nominees for each office. The nominating committee consists of the chairperson of the Credentials Committee, who shall act as chairperson, the Chief of Staff and three

38 Joint Commission Leadership Standards 01.05.01; 42 C.F.R. § 482.12

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other members of the Active staff appointed by the chairperson. Each department shall have at least one representative on the committee. The committee shall report the names of the nominees to the Staff at least 7 days but not more than 30 days before the annual meeting. Nominations may be made by petition filed prior to the annual meeting.

As soon thereafter as reasonably possible, the names of the additional nominees will be reported to the Staff. If, before the election, all nominees refuse or are disqualified or are otherwise unable to accept nomination, the Nominating Committee shall submit one or more additional nominees at the annual meeting. Nominations may be accepted from the floor at the time of the annual meeting (with the exception of department chairpersons). Such nominations must be seconded. Voting at the annual meeting shall be by special written ballot. Voting by proxy shall not be permitted. A nominee shall be elected upon receiving a majority of the valid votes cast. If no candidate for an office receives a majority vote, a runoff election by secret written ballot shall be held at the meeting between the two candidates receiving the highest number of votes. If a tie results, the deciding vote shall be cast by the Board. The election shall become effective upon approval of the Board.

3. Board of Trustees Ratification/Indemnification. To afford the Medical Staff officers and others the full protections of the Health Care Quality Improvement Act, the Board of Trustees reserves the right, in its discretion to ratify the appointments of Medical Staff officers and other leaders, such as Department and Division officers, who will perform professional review regarding competence or professional conduct of Practitioners and other individuals requesting clinical privileges, such as credentialing or quality assessment/performance improvement activities. Ratification by the Board of Trustees is an indispensable prerequisite for the individual to assume the position as a Medical Staff officer, Department or Division officer. The Board of Trustees’ ratification shall serve as evidence that they are charged with performing important Hospital functions when engaging in professional review including credentialing or quality assessment/performance improvement activities. Such activities shall have the following characteristics:

a. The activities such leaders undertake shall be performed on behalf of the Hospital;

b. The activities shall be performed in good faith;

c. That any professional review action shall be taken:

d. In the reasonable belief that the action was in the furtherance of quality health care;

e. After a reasonable effort to obtain the facts of the matter;

f. After adequate notice and hearing procedures are afforded to the individual involved or after such other procedures as are fair to the individual under the circumstances; and,

g. In the reasonable belief that the action was warranted by the facts known after such reasonable effort to obtain facts and after meeting this Section.

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h. The activities shall substantially comply with these Bylaws, rules and regulations, or policies;

i. Medical Staff leaders who are performing activities meeting the above listed criteria shall qualify for indemnification for those activities through the Hospital.39

4. Term. Officers shall be elected for a term of one year and until their successors are duly elected and have qualified. A vacancy in any office shall be filled by the Executive Committee for the unexpired portion of the term, subject to the automatic succession of the vice chief of staff as provided herein. No person may serve in the same position for more than three consecutive terms.

5. Resignations and Removals. Any officer may resign at any time by giving written notice to the Executive Committee and, unless specified therein, the acceptance of such resignation shall not be necessary to make it effective. Any officer may be removed by the Staff at a special meeting called for such purpose. A petition for removal shall be submitted to the CEO by at least 30% of the Executive Committee and, upon receipt thereof, the CEO shall call a meeting of the Executive Committee to be held within 30 days to consider and act upon the petition. An officer shall be removed upon receiving at least a majority of the valid votes cast at the meeting of the Executive Committee in favor of removal. If a tie results, the deciding vote shall be cast by the Board. If an officer resigns or is removed, his successor shall be filled in the same manner as any other vacancy. Should a position be vacated for medical or unanticipated reasons beyond anyone's control, the members of the Executive Committee shall recommend a successor to the Board for approval.

6. Chief of Staff. The Chief of Staff shall serve as chief administrative officer of the Medical Staff and shall have general overall supervision of the affairs of the Staff. He shall:

a. Assist in coordinating the activities of the Administration, the nursing staff, allied health professionals and other non-physician patient care services with those of the Staff;

b. Call, preside at and be responsible for the agenda of Medical Staff meetings;

c. Be responsible to the Administration and the Board for the quality and efficiency of clinical services and professional performance in the Hospital and the effectiveness and quality of patient care;

d. Develop and implement, in conjunction with department chairpersons, methods for credentials review, delineation of privileges, educational programs, utilization review and quality /performance improvement;

e. Communicate and represent the opinions, policies, concerns, needs and grievances of the Medical Staff to the CEO and the Board;

39 Joint Commission Leadership Standards 01.03.01; Health Care Quality Improvement Act; Fla. Stat. §§ 395.0191, 395.0193, 395.0197, 766.101, 766.1015

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f. Be responsible for enforcement of these Bylaws, and the Rules and Regulations, implementation of sanctions when indicated and Staff compliance with procedures in all instances when corrective action has been requested or taken against a practitioner;

g. Act as representative of the Staff to the public, as well as to other health care providers, other organizations, the Administration, the Board, and government and voluntary organizations;

h. Appoint and discharge chairpersons of all Medical Staff committees, standing, special, or multi disciplinary, except the Executive Committee and the Nominating Committee, and serve as ex-officio member of all other Medical Staff committees, except the Nominating Committee;

i. Receive and interpret the opinions, policies and directives of the Administration and the Board to the Staff;

j. Serve as chairperson of the Executive Committee; and

k. Perform all duties incident to the function of principal administrative officer of the Staff.

7. Vice Chief of Staff. The vice chief of staff shall perform the duties of the Chief of Staff in the absence or inability of the Chief of Staff to perform. He shall serve as vice chairperson of the Medical Executive Committee, chairperson of the Quality Council and Bylaws Committee and shall perform such additional duties as may be assigned by the Chief of Staff or the Board.

8. Secretary/Treasurer. The Secretary-Treasurer shall be a Member of the Medical Executive Committee. The secretary/treasurer shall, subject to the direction of the Chief of Staff, keep or cause to be kept the minutes of Staff meetings; assure that all notices of Staff meetings are given as provided in these Bylaws; and in general perform all duties incident to the office of secretary and such other duties as may be assigned by the Chief of Staff.

ARTICLE XI

COMMITTEES

Part A - Committees

1. Standing Committees. The standing committees shall be: Medical Executive Committee, Nominating Committee, Credentials Committee, Oncology Committee, Clinical Review Committee, Trauma Quality Management Committee, and Trauma Peer Review Committee. Members of standing committees shall be appointed and removed in the same manner as members of operating committees, except as specifically provided in these Bylaws or as otherwise recommended by the Medical Executive Committee and approved by the Board.

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2. Tenure. Except as otherwise expressly provided in these Bylaws, each member of a standing committee shall be appointed for a term of one year, and until his successor is appointed or elected, unless sooner removed. Members of operating committees shall be appointed for similar terms, unless the committee is established for a specified lesser period of time. Vacancies on any Staff committee shall be filled in the same manner in which original appointment to such committee is made.

3. Medical Executive Committee.

a. Composition. The Medical Executive Committee shall consist of the Chief of Staff, Vice Chief of Staff, Secretary/Treasurer, Immediate Past Chief of Staff, if such persons are available and capable of serving, the Chairpersons of each clinical department, the Trauma Medical Director and two members at large. One member at large shall be the Chairperson of Credentials Committee and the other to be selected by the Nominating Committee. All Medical Staff members are eligible for membership on the Medical Executive Committee. The Chief of Staff shall serve as chairperson. The CEO shall serve as an ex-officio member without vote.

b. Responsibilities and Authority. The Medical Executive Committee shall meet at least ten times a year and shall maintain a permanent record of its proceedings and actions. The Medical Executive Committee shall be responsible for making recommendations directly to the governing body for its approval.

Such recommendations will pertain to at least the following:

i. The structure of the medical staff;

ii. The mechanism used to review credentials and to delineate individual clinical privileges;

iii. Recommendations of individuals for Staff membership;

iv. Recommendations for delineated clinical privileges for each eligible individual;

v. The participation of the Staff in organizational performance improvement activities,

vi. The mechanism used to conduct, evaluate, and revise such activities;

vii. The mechanism by which membership on the Staff may be terminated; and

viii. The mechanism for fair hearing procedures.

The committee shall consider and act on all matters affecting the Staff which are not of a clinical nature, shall act on behalf of the Staff in intervals between Staff meetings, subject to the limitations of these Bylaws, and shall:

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i. Coordinate the activities and general policies of Staff committees and clinical departments;

ii. Receive and act on committee and department reports;

iii. Implement Staff policies, which are not otherwise the responsibility of the departments;

iv. Provide liaison between the Staff and the CEO, and between the Staff and the Board;

v. Recommend action on matters of a medical administrative nature to the Board;

vi. Make recommendations on matters of Hospital management to the Board;

vii. Account to the Board for the overall quality and efficiency of medical care provided to patients in the Hospital;

viii. Keep the Staff abreast of the accreditation program and the accreditation status of the Hospital;

ix. Evaluate the effectiveness of Staff committees and performance of Staff functions and take appropriate action to improve or terminate them;

x. Report on its activities at Staff meetings;

xi. Review and evaluate reports concerning, and monitor the conduct and clinical performance of allied health professionals; and

xii. Participate in identifying community health needs and in setting Hospital goals and implementing programs to meet those needs.

c. Quality/Performance Improvement. The Medical Executive Committee shall ensure that provisions are made for the effective performance of Staff functions as provided in these Bylaws or as the Board may reasonably require, and for the adequacy of the Hospital's quality improvement plan. Among other matters, the quality/performance improvement program shall take into account readmissions, medical records evaluation, risk management reports, infection control, blood utilization, pharmacy reports, medications use, medication errors, laboratory reports, radiology reports, other diagnostic reports, use of surgical and other invasive procedures, use of experimental drugs and procedures, patient and employee complaints, evaluation of methods and criteria used in granting and delineating clinical privileges, utilization review, appropriateness of patient discharges, and other factors. The effectiveness of all Staff functions shall be evaluated as part of an annual reappraisal of the Hospital's program to assess and improve quality.

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4. Nominating Committee. The Nominating Committee shall consist of the Chairperson of Credentials Committee, who shall act as the chairperson, the Chief of Staff and three members of the active staff appointed by the chairperson. Each department shall have at least one representative on the committee. The committee shall meet not less than 30 days before the annual meeting and report the names of the nominees to the Medical Staff at least 7 days but not more than 30 days before the annual meeting.

5. Credentials Committee.

a. Composition and Duties. The Credentials Committee shall consist of members of the Active Staff so selected as to ensure representation of the major clinical specialties, hospital-based specialties and the medical staff at large. The committee shall meet at least ten times a year or more as needed, as scheduled by the chairperson to investigate the character and qualifications of all applicants for membership on the Staff and clinical privileges. The committee shall submit at the regular and other meetings of the Medical Executive Committee a report of:

i. Its findings and recommendations with regard to appointments, reappointments, modifications of appointments, and suspensions and revocations of appointments to the Staff and privileges to be granted, modified, suspended or revoked;

ii. Additionally, the committee shall evaluate the character and qualifications of all allied health professionals who apply to render specified services and shall make recommendations concerning their applications;

iii. Submit to the Medical Executive Committee a report of its recommendations with regard to:

a) Associate staff members and grants or extensions of provisional privileges; privileges to be granted to physicians employed on a part-time basis in the emergency department;

b) New transpecialty procedures requested by physicians; new clinical programs or services to the Hospital; and privileges to be granted to health care professionals other than practitioners.

b. Appointments and Reappointments. Each year the committee shall submit to the executive committee recommendations with regard to reappointment of members of the Staff and allied health professionals whose appointments are expiring, along with any recommendations it may have regarding changes in Staff status or clinical privileges. The recommendations of the committee shall be based upon a review of the:

i. Performance of Staff members, attendance at Staff and committee meetings,

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ii. Hospital utilization, comments regarding Staff members received from the operating committees,

iii. Review of recommendations from the chairpersons of the clinical departments, which shall include consideration of the physical and mental capabilities of the members of that department.

iv. Review and evaluate the qualifications, competence and performance of allied health professionals and provisional status appointees and make recommendations with respect thereto.

v. Investigate, review and report on matters involving clinical or ethical misconduct of any practitioner.

6. Oncology Committee. The Oncology Committee is a multi-disciplinary committee whose purpose is to promote cancer care in the Hospital and the community in areas of prevention, diagnosis, pre-treatment evaluation, surgery, therapeutic rehabilitation, surveillance, care of the dying patient(s) and education.

a. Composition. The committee shall consist of at least one board-certified physician representative from surgery, medical oncology, radiation oncology, diagnostic radiology, and pathology and nonphysician member representation from the Cancer Program Administrator, nursing, quality, case management, and the cancer registrar. The Oncology Committee chairperson is designated to provide the medical direction for the program, while the Cancer Program Administrator is accountable for administrative and operational management of the program.

b. Responsibilities. The committee responsibilities include the following:

i. Develops and evaluates the annual goals and objectives for the clinical, educational and program activities related to cancer;

ii. Promotes a coordinated, multi-disciplinary approach to patient management;

iii. Ensures that educational and consultative cancer conferences cover all major sites and related issues;

iv. Ensures that an active supportive care system is in place for patients, families and staff;

v. Monitors quality management and improvement through completion of studies focusing on quality, access to care and outcomes;

vi. Promotes clinical research;

vii. Supervises cancer registry and ensures accurate and timely abstracting, staging and follow-up reporting;

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viii. Encourages data usage and regular reporting;

ix. Ensures content of the annual report meets requirements and that the report is published by the required date, and

x. Upholds medical ethical standards.

7. Trauma Quality Management Committee. The Trauma Quality Management Committee is a multi-disciplinary committee whose purpose is to provide trauma care by conducting concurrent and/or retrospective review of trauma cases referred by the Trauma Medical Director or Trauma Program Manager. Decisions are made by consensus to encourage discussion and input from the trauma surgeons as well as involved subspecialty liaisons.

a. Composition. The committee shall be chaired by the Trauma Medical Director or designee, who retains final decision-making authority for committee actions. The committee consists of physician liaisons from the following specialties: emergency medicine, anesthesia, orthopedic surgery, neurosurgery, radiology, and general surgeons on the trauma call panel. Non-physician committee members include the trauma program manager, other members of the facility trauma service, hospital administration representative, radiology director, and nursing directors from OR, ER, and ICU.

b. Responsibilities. The committee is responsible for the following:

i. Review of cases identified by trauma quality indicators as defined by the hospital, State of Florida trauma standards, and The American College of Surgeons Committee on Trauma.

ii. Promoting a coordinated, multidisciplinary approach to trauma care and patient management

iii. Addressing, assessing and correcting trauma program and system issues.

iv. Recommending and/or taking action on cases where the committee finds opportunities for improving performance, system process, or outcomes.

v. Evaluation and documentation of the effectiveness of actions taken to ensure problem resolution, improvements in patient care, ort improved patient outcomes.

8. Trauma Peer Review Committee. The Trauma Peer Review Committee is a multi-disciplinary committee whose purpose is to conduct concurrent and/or retrospective of selected outcomes including mortalities, complications, and sentinel events with objective identification of issues and appropriate responses.

a. Composition. The committee shall be chaired by the Trauma Medical Director or designee. The committee consists of physician liaisons (as appropriate) from the following specialties: emergency medicine, anesthesia, orthopedic surgery,

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neurosurgery, radiology, and all general surgeons on the trauma call panel. Non-physician committee members include the trauma program manager and a representative from the quality department.

b. Responsibilities. The committee is responsible for objective review of outcomes for patients with trauma services.

c. Peer Review Information. All peer review information shall be kept private and confidential. A Practitioner, other individual with clinical privileges, or other Hospital staff Member who participates or has participated in a peer review process at the Hospital shall treat all peer review information as private, confidential and privileged and shall not disclose peer review information obtained, generated or compiled during a peer review process in which he/she participates unless specifically and expressly authorized by the Hospital to do so or as required by law.

d. Records and Minutes: shall be maintained as per Article XI, Part B, 4.

9. Practitioner Health Committee.

a. Composition. The Practitioner Health Committee shall be composed of three voting members who shall be active Medical Staff members in good standing. Practitioner Health Committee members shall be selected based on their knowledge, skills and expertise in identification and management of Practitioner health issues. Practitioner Health Committee members shall be appointed by the Chief of Staff.

b. Duties. The Practitioner Health Committee shall perform the key functions of the Practitioner Health program as outlined in the Medical Staff’s Practitioner Health and Wellness Policy. The Practitioner Health Committee shall:

1. Recommend education for all Medical Staff and Hospital staff regarding Practitioner health issues, including how to identify and report potential issues;

2. Develop and recommend policies for the Practitioner Health Program, such policies to include self-referral, referral by others, evaluating credibility of a reported concern, resources for evaluation, diagnosis and treatment, maintaining confidentiality, monitoring Practitioners under rehabilitation, intervening when patient safety is at risk, and taking appropriate actions;

3. Evaluate self-referrals and third party reports regarding potential Practitioner health issues;

4. Conduct investigations of potential Practitioner health issues;

5. Make recommendations for treatment and rehabilitation regarding Practitioner health issues;

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6. Monitor individuals under treatment and rehabilitation for Practitioner health issues;

7. Make recommendations for reinstatement of clinical privileges following an individual’s treatment and rehabilitation for Practitioner health issues.

c. Meetings and Reports. The Practitioner Health Committee shall meet at least annually to review the Practitioner Health program and policies, and shall determine the frequency of other meetings based on frequency of activities related to reporting and monitoring Practitioner health issues.40

10. Quality/Peer Review Committee.

a. Composition. The Quality/Peer Review Committee shall be composed of between 6 and 10 voting members who shall be active Medical Staff members in good standing. The voting membership shall include at least three (3) active Medical Staff representatives of each of the Medical Staff Departments. In addition to the Chief Executive Officer and the Chief Medical Officer, the ex-officio members without vote may also include the Director of Quality Management and the Risk Manager. The Quality/Peer Review Committee shall also have the option of calling upon any Member of the Medical Staff or other individual with clinical privileges to serve on the committee on an ad hoc basis to provide clinical review and recommendations to the committee, their appointment subject to the approval of the Chief of Staff acting on behalf of the Medical Executive Committee and the Board of Trustees in this singular capacity. Ad hoc members of the committee shall be bound by the confidentiality requirements of the committee and shall be provided indemnification while serving on the committee, subject to the provisions of Article X(3). Ad hoc members of the committee shall not have voting rights on the committee.

b. Duties and Authority.. The Quality/Peer Review Committee shall perform the key function of Quality Assessment/Performance Improvement, as described in these Bylaws, under the oversight and direction of the Medical Executive Committee. The Quality/Peer Review Committee shall plan, implement, coordinate and promote ongoing Medical Staff leadership and participation in the Hospital’s performance improvement program through the activities of the Medical Staff Departments, committees with a quality review function, and other assigned activity groups, as described in the Performance Improvement Plan. Additionally, the Quality/Peer Review Committee shall ensure that when the findings of the quality assessment process (either aggregate data or single events) are relevant to an individual’s performance, the committee shall conduct peer review or an ongoing evaluation of the individual’s competence and make recommendations accordingly. In addition, the Quality/Peer Review Committee shall perform the following specific functions:

40 Joint Commission Medical Staff Standards 11.01.01

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1. Participate in an annual evaluation of the Hospital’s Performance Improvement program and in the development or revisions to the Performance Improvement Plan, including making recommendations for the establishment of priorities for the program.

2. Ensure that Medical Staff quality assessment and performance improvement activities address applicable review requirements found in regulatory and accreditation laws, regulations, and standards. Also ensure that the activities address the scope of patient care provided and are effective by reviewing the reports of the Medical Staff Departments and any other Medical Staff or Hospital quality review groups and making recommendations to the Medical Executive Committee.41

11. Operating Committees. Operating committees may be created and abolished by the Chief of Staff with the approval of the Executive Committee. The operating committees shall discharge such responsibilities as may be assigned to them as defined in Medical Staff Policy and Procedure addressing Committees: Composition, Functions and Responsibilities. The Chief of Staff shall designate the chairperson of each committee.

The chairperson shall designate members and vice chairperson. Members of committees need not be staff members or practitioners. The Chief of Staff may from time to time appoint one or more additional persons as ex officio non-voting members of operating committees. Administrative staff appointments shall be made after consultation with, and approval of, the CEO. Any member of an operating committee may be removed by the Chief of Staff with the approval of the Executive Committee, whenever in his judgment the best interests of the Hospital will be served by such removal.

Part B - Committee Procedures

1. Notice. Notice of any meeting may be given orally and not less than two days before the meeting. Committee or department meetings shall be held according to an established schedule and notices shall be posted in the medical staff bulletin board and/or electronic information systems, and/or delivered either in person, by mail or fax. Notice shall include the date, time and location of meetings. Such posting, electronic or voice mail shall constitute actual notice to the persons concerned. A list for the year is provided to the chairperson and members of all committees at the beginning of the medical staff year.

2. Quorum. A quorum shall constitute those voting members present at any department or standing or scheduled committee meeting, but in no event less than two (2) members. Once a quorum is established, the business of the meeting may continue and all action taken shall be binding even though the number of voting members may decrease at a later time in the meetings.

41 Joint Commission Medical Staff Standards 05.01.01, 07.01.01, 08.01.01, 08.01.03, 09.01.01 & 10.01.01; Joint Commission Leadership Standards 01.03.01

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3. Manner of Acting. The act of a majority of the committee members present at a meeting, at which a quorum is present, is the action of the committee. Action may be taken at a meeting without a meeting if members have been contacted prior to the meeting, issues discussed and their opinion or vote has been provided to the chairperson either verbally or in writing, setting forth the action by a majority of the members of the committee entitled to vote.

4. Minutes. There shall be a recorder for each committee who shall prepare minutes or reports of each meeting which shall record attendance of members, and include recommendations, conclusions and action taken. Minutes shall be signed by the chairperson, approved at the next scheduled meeting and maintained in a permanent file. Minutes shall be available for inspection by committee members for any proper purpose, subject to any policies concerning confidentiality of records and information.

5. Procedures. Each committee may formally or informally adopt its own rules of procedure, which shall not be inconsistent with the terms of its creation or these Bylaws.

6. Required Attendance. Each member of the Active and Associate (Provisional) Staff shall be required to attend the annual general staff meeting. All Staff are encouraged to attend regular department and committee meetings. Meeting attendance will not be used by the Credentials Committee in evaluating members at the time of reappointment.

7. Committee Composition and Functions. The composition and functions, including the duties and responsibilities of the committees shall be maintained by the Staff and the committee and shall be consistent with the provisions of these Bylaws or medical staff policy.

a. Staff Functions. Provisions shall be made, either through assignment to the Executive Committee or to other appointed staff committees or to the departments for:

i. The effective performance of the Staff functions;

ii. All other Staff functions required by these Bylaws and the Hospital's quality/ performance improvement plan, and

iii. Such other Staff functions as the Executive Committee or the Board require.

iv. Supportive policies and procedures exist that define the responsibilities of each function

8. Reports. Each committee shall report its activities, findings and recommendations to the Executive Committee. A copy of all reports, records and evaluations of each committee shall be kept and maintained in minute book of the committee. A policy addressing the duties and responsibilities of a committee shall be maintained in the medical staff office.

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9. Delegation by CEO. The CEO may designate another member of the Administration in his place on any committee on which he serves.

ARTICLE XII

MEETINGS

1. Regular Meeting. A regular, annual staff meeting shall be held during the last quarter of the Staff Year at a time and place designated by the Executive Committee for the purpose of reviewing reports from officers and committees, electing officers and transacting other business as may properly come before the meeting.

2. Special Meetings. A special meeting of the Medical Staff may be called at any time at the written request of the Chief of Staff, the Executive Committee, or any ten members of the active staff by written request, to be held at such date, time and place as shall be designated in the notice of the meeting. No business shall be transacted at any special meeting except that stated in the notice calling the meeting.

3. Notice. Notice of date, time and place of any regular special meeting shall be given not less than seven (7) nor more than thirty (30) days prior to a regular/special meeting by written notice delivered personally or sent by mail to each member of the active staff at his business address shown on Staff records. The Executive Committee or Chief of Staff may send notice to members of other categories of the Staff, the CEO, members of Administration and others. If mailed, the notice shall be deemed delivered when it is deposited, postage prepaid, in the United States mail.

4. Quorum. At least thirty (30) percent of the total membership of the Active and Associate Staff at the regular annual staff meeting or special meeting shall constitute a quorum for the transaction of business, except if less than such number is present, a majority of active and associate staff members present may adjourn the meeting without further notice until a quorum is present.

5. Manner of Acting. The act of the majority of active and associate Staff members present in person at a meeting at which a quorum is present shall be the act of the Staff. Members may not vote by proxy. No action of the members shall be valid unless taken at a meeting at which a quorum is present, except that any action which may be taken at a meeting may be taken without a meeting if a consent in writing, and signed by a majority of the members entitled to vote. Action of the majority through this mechanism shall constitute the act of the Staff.

6. Minutes. The Secretary/Treasurer shall prepare minutes of each meeting, which shall include a record of attendance and the vote taken on each matter. Minutes shall be signed by the presiding officer and maintained in a permanent file. Minutes shall be available for inspection by Staff members for any proper purpose, subject to any policies concerning confidentiality of records or information.

7. Procedures. The Chief of Staff or in his absence, the Vice Chief of Staff shall preside at Staff meetings. Meetings shall be conducted in an orderly manner.

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8. Attendance Requirement. Each member of the Active and Associate Staff shall be required to attend the regular annual staff meeting unless written excuse is submitted to the Chief of Staff through the Medical Staff Office within thirty (30) days to maintain privileges. If absent and written excuse is not provided as noted, privileges will be suspended for thirty (30) days.

ARTICLE XIII

PRIVILEGES AND IMMUNITIES

1. Agreement of Applicants and Practitioners. Any applicant for staff privileges, and every practitioner and member of the Staff, and everyone having or seeking privileges to practice his profession or to render specified services in the Hospital agrees that the provisions of this Article shall specifically control with regard to his relationship to the Staff, other members of the Staff, members of the Board, and the Hospital. By submitting an application for membership, by accepting appointment or reappointment to the Staff or clinical privileges, by exercising staff privileges, including temporary privileges, and by seeking to render and rendering specified services, each practitioner and each allied health professional specifically agrees to be bound by the provisions of this Article during the processing of his application and at any time thereafter, and they shall continue to apply during his appointment or reappointment.

2. Privileges. Any act, communication, report, recommendation or disclosure concerning any applicant for Staff membership, clinical privileges or specified services performed, given or made by any practitioner or member of the Staff42 at the request of any authorized representative of the Staff, the Administration, the Board, the Hospital or any other health care facility or provider for the purpose of providing, achieving or maintaining quality patient care in the Hospital or at any other health care facility shall be privileged to the fullest extent permitted by law. Such privilege shall extend to members of the Staff, the CEO, Administration Officials, Board members and their representatives and to third parties that furnish information to any of them to receive, release or act upon such information. Third parties shall include individuals, firms, corporations and other groups, entities or associations from whom information has been requested or to whom information has been given by a member of the Staff, authorized representatives of the Staff, the Administration or the Board.

3. Immunity. There shall, to the fullest extent permitted by law, be absolute immunity from civil liability arising from any act, communication, report, recommendation or disclosure performed, given or made, even if the information involved would otherwise be privileged. No action, cause of action, damage, liability or expense shall arise or result from or be commenced with respect to any such act, communication, report, recommendation or disclosure.

Such immunity shall apply to all acts, communications, reports, recommendations and disclosures performed, given or made in connection with or for or on behalf of any

42 Fla. Stat. §§ 395.0191, 395.0193, 395.0179, 766.101 & 766.1015

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activities of any other health care facility or provider including, without limitation, those relating to:

a. Applications for appointment to the medical staff or for clinical privileges or specified services,

b. Periodic appraisals or reviews for reappointments, clinical privileges or specified services,

c. Corrective action or disciplinary action, including suspensions or revocations of clinical privileges or Staff membership or licenses to practice medicine,

d. Hearings and appellate review,

e. Medical care evaluations,

f. Peer review evaluations,

g. Utilization reviews, and

h. Any other hospital, departmental, service or committee activities related to quality patient care, professional conduct or professional relations. Such matters may concern, involve or relate to, without limitation, such person's professional qualifications, clinical competency, character, fitness to practice medicine, physical and mental condition, ethical or moral standards or any other matter that may or might have an effect or bearing on patient care.

4. Release. In furtherance of and in the interest of providing quality patient care, each applicant for clinical privileges or specified services, practitioner, member of the Staff and Allied Health Professional shall, by requesting or accepting staff privileges or specified services, release and discharge from loss, liability, cost, damage and expense, including reasonable attorneys' fees, such persons who may be entitled to the benefit of the privileges and immunities provided in this Article, and shall, upon request of the Hospital or any officer of the Staff, execute a written release in accordance with the tenor and import of this Article.

5. Nonexclusivity. The privileges and immunities provided in this Article shall not be exclusive of any other rights to which those who may be entitled to the benefit of such privileges and immunities may be entitled under any statute, law, rule, regulation, bylaw, agreement, vote of members or otherwise, and shall inure to the benefit of the heirs and legal representatives of such persons.

ARTICLE XIV

GENERAL PROVISIONS

1. Medical Staff Rules and Regulations. Subject to the approval of the Board, the Executive Committee, acting on behalf of the Medical Staff and after first communicating a proposed

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Rule or Regulation or Medical Staff Policy to the Medical Staff, 43shall adopt such Rules and Regulations as may be necessary to implement these Bylaws. The Rules and Regulations shall relate to the proper conduct of Staff organizational activities and shall embody the level of practice required of each Staff appointee. Changes or amendments to the Rules and Regulations shall be communicated to the Medical Staff. In the event of a documented need for an urgent amendment of the Medical Staff Rules and Regulations or Medical Staff Policies to comply with law or regulation or accreditation standards, the Medical Executive Committee may provisionally adopt, and the Board of Trustees may provisionally approve the urgent amendment without prior notification of the voting members of the Medical Staff. In such cases, the voting members of the Medical Staff shall be immediately notified by the Medical Executive Committee of the urgent amendment within ten (10) days after the Board of Trustees has approved the amendment. The voting members of the Medical Staff shall have an additional twenty (20) days within which to retrospectively review the amendment and provide written comment to the Medical Executive Committee. If there are no comments opposing the provisional amendment, then the provisional amendment shall become final. If there are comments opposing the provisional amendment, then the Medical Staff process for conflict management shall be implemented, and a revised amendment shall be submitted to the Board of Trustees if necessary.44

2. Department Rules and Regulations. Subject to the approval of the Executive Committee and the Board, each department may formulate its own rules and regulations for the conduct of its affairs and the discharge of its responsibilities. Such rules and regulations shall not be inconsistent with these Bylaws and the Rules and Regulations of the Staff or other policies of the Hospital. Any proposed rule, regulation, or policy, or an amendment thereto, must be communicated to the Executive Committee for their review and recommendation prior to being submitted to the Board for final action.45

3. Professional Liability Insurance. Each practitioner and other individuals granted clinical privileges or approved to render specified services in the Hospital shall continuously maintain in force professional liability insurance in not less than the minimum amounts as may from time to time be determined by the Board with full coverage for all clinical privileges or services which may be provided in the Hospital. Unless the Board specifically provides an exception, the minimum amount of such insurance shall be $250,000 per occurrence and $750,000 per named insured. Policy coverage shall be applicable to the entire tenure of appointment. Upon request, each practitioner shall provide satisfactory evidence of such coverage to the Executive Committee, including full information as to exceptions or exclusions from coverage, and shall immediately notify the Executive Committee of any change in such coverage. Each such policy shall provide that it will not be canceled except on 30 days prior notice to the Hospital.

4. Forms. Application forms and other prescribed forms required by these Bylaws for use in connection with Staff appointments, reappointments, delineation of clinical privileges,

43 Joint Commission Medical Staff Standards 01.01.01 44 Joint Commission Medical Staff Standards 01.01.01 45 Joint Commission Medical Staff Standards 01.01.01

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corrective action, notices, recommendations, reports and other matters shall be prepared by the Executive Committee, subject to approval of the Board.

5. No Implied Rights. Nothing contained herein is intended to confer any rights or benefits upon any individual or to confer any private right, remedy or right of action upon any person, except as expressly set forth herein, and except as expressly provided in this Article. These Bylaws and the Rules and Regulations are intended for internal Hospital use only and solely for the governance of the internal affairs of the Hospital. No person is authorized to rely on any provisions of these Bylaws or the Rules and Regulations except as specifically provided herein, and no person may personally enforce any provision hereof, except as specifically provided. These Bylaws and the Rules and Regulations are intended for professional internal use and governance only.

6. Pronouns. All pronouns and any variations thereof in these Bylaws and the Rules and Regulations shall be deemed to refer to the masculine, feminine, or neuter, singular or plural, as the identity of the person or persons may require, unless the context clearly indicates otherwise.

7. Notices. Any notices, demands, requests, reports or other communications required or permitted to be given hereunder shall be deemed to have been duly given if in writing and delivered personally or deposited in the United States first class mail, postpaid, to the person entitled to receive notice at his last known address, except as otherwise provided in these Bylaws or in the Rules and Regulations.

8. Distribution. The officers of the Staff shall ensure that a copy of these Bylaws and the Rules and Regulations, and all amendments thereto, are given to each applicant for privileges and each member of the Staff and are continuously available to members of the Staff upon request.

9. No Contract Intended. It is understood that these Bylaws and the Rules and Regulations do not create, nor shall be construed as creating, a verbal or implied contract of any nature between or among the Hospital or the Board or the Staff and any member of the Staff or any person granted clinical privileges or entitled to perform specified services. Any clinical or other privileges are simply privileges, which permit conditional use of the Hospital facilities, subject to the terms of these Bylaws and Rules and Regulations. Any provisions of these Bylaws may be amended, altered, modified or repealed at any time as provided in these Bylaws.

However, the provisions of this article and Article V: Allied Health Professionals and other provisions taking the form of an agreement or an indemnity or a release shall be binding upon the practitioners, Staff members and those granted clinical privileges in the Hospital.

10. Confidentiality. Members of the Staff shall respect and preserve the confidentiality of all communications and information relating to Credentialing, peer review and quality assessment and improvement activities. Any breach of this provision, except as required by law, shall subject the Staff member to corrective action.

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11. Conflicts of Interest. Practitioners shall disclose any conflict of interest or potential conflict of interest in any transaction, occurrence or circumstance which exists or may arise with respect to his participation on any committee or in his activities in medical staff affairs, including in departmental activities and in the review of cases. Where such a conflict of interest exists or may arise, the practitioner shall not participate in the activity or, as appropriate, shall abstain from voting, unless the circumstances clearly warrant otherwise. This provision does not prohibit any person from voting for himself nor from acting in matters where all others who may be significantly affected by the particular conflict of interest consent to such action. Further, nothing herein shall prohibit any hearing panel member from participating in appellate review as permitted in the Fair Hearing Plan.

12. No Agency. Physicians and practitioners shall not, by virtue of these Bylaws or Staff appointment, be authorized to act on behalf of, or bind the Hospital, and shall not hold themselves out as agents, apparent agents or ostensible agents of the Hospital, except where specifically and expressly authorized in a separate written contract with the Hospital.

13. Entire Bylaws. These Bylaws are the entire medical staff Bylaws of the Hospital and supersede any and all prior medical staff Bylaws, which, by adoption hereof, shall be automatically repealed.

14. Adoption and Amendments. These Bylaws, including the Rules and Regulations and the Fair Hearing Plan, shall be adopted when approved by the Staff and the Board. Amendments, revisions, modifications and restatements of these Bylaws may be proposed by any clinical department, committee or member of the Staff. Such proposals shall be referred to the Bylaws Committee for evaluation.

The Bylaws Committee shall meet and report its recommendations to the Medical Executive Committee. The Medical Executive Committee shall report proposed amendments to the Bylaws46 to the Medical Staff at the next regular or special meeting called for such purpose. These Bylaws may be amended by two-thirds vote of the Active Medical Staff present at a regular or special meeting or by written ballot, provided that membership is advised of the proposed amendments in the official notice of the meeting. The notice shall include the exact wording of the existing Bylaws language, if any, and the proposed change(s).47

If approved by the Board, after consulting with the Executive Committee, the proposal shall become effective. If an amendment or modification involves a significant change, as determined by the Executive Committee, revised texts shall be furnished to all members of the Staff and individuals who have been granted clinical privileges.

Board approval shall not be unreasonably withheld, but any decision of the Board shall be final. Neither the Medical Staff nor the Board may unilaterally amend these Bylaws.

46 Joint Commission Medical Staff Standards 01.01.01 47 Joint Commission Medical Staff Standards 01.01.01

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15. Review. These Bylaws shall be subject to periodic review. The Bylaws Committee shall meet at least annually to review and revise content when appropriate to reflect the Hospital's current practice with respect to the Medical Staff organization and functions.

The Bylaws of the Medical Staff will sunset every five years. The Bylaws Committee shall review the entire Bylaws and rewrite as needed at that time.

16. Conflicts. In the event that these Bylaws, including the Fair Hearing Plan, shall conflict with the Rules and Regulations, the provisions of these Bylaws shall control.

17. Conflict Management/Resolution.

a. Conflicts Between the Board of Trustees and the Medical Executive Committee

The Medical Staff, in partnership with the Board of Trustees, will make best efforts to address and resolve all conflicting recommendations in the best interests of patients, the Hospital, and the members of the Medical Staff. When the Board of Trustees plans to act or is considering acting in a manner contrary to a recommendation made by the Medical Executive Committee, the Medical Staff officers shall meet with the Board of Trustees, or a designated committee of the Board of Trustees and Administration, and seek to resolve the conflict through informal discussions. If these informal discussions fail to resolve the conflict, the Chief of Staff or the Chairperson of the Board of Trustees may request initiation of a formal conflict resolution process. The formal conflict resolution process will begin with a meeting of the Joint Conference Committee within thirty (30) days of the initiation of the formal conflict resolution process.

To address Board of Trustees-Medical Staff conflicts, the Joint Conference Committee shall be composed of:

• Three officers of the Medical Staff

• One other Medical Executive Committee member

• The Chairperson, Vice-Chairperson, and Secretary of the Board of Trustees or other designees of the Board of Trustees

• The Chief Executive Officer or designee

If the Joint Conference Committee cannot produce a resolution to the conflict that is acceptable to the Medical Executive Committee and the Board of Trustees within 30 days of the initial meeting, the Medical Staff and the Board of Trustees shall enter into mediation facilitated by an outside party. The Medical Executive Committee and Board of Trustees shall together select the third-party mediator, the costs for which shall be shared equally by the Hospital and the Medical Staff. The Medical Executive Committee and the Board of Trustees shall make best efforts to collaborate together and with the third-party mediator to resolve the conflict. The Board of Trustees and the Medical Executive Committee shall each designate at least three people to participate in the mediation. Any resolution arrived at during such meeting shall be subject to the approval of the Medical

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Executive Committee and the Board of Trustees, in accordance with the provisions of Medical Staff Bylaws and the Articles of Incorporation and Bylaws of the Hospital. If, after 90 days from the date of the initial request for mediation from an outside party, the Medical Executive Committee and Board of Trustees cannot resolve the conflict in a manner agreeable to all parties, the Board of Trustees shall have the authority to act unilaterally on the issue that gave rise to the conflict.

If the Board of Trustees determines, in its sole discretion, that action must be taken related to a conflict in a shorter time period than that allowed through this conflict resolution process in an attempt to address an issue of quality, patient safety, liability, regulatory compliance, legal compliance, or other critical obligations of the Hospital, the Board of Trustees may take provisional action that will remain in effect until the conflict resolution process is completed.

In addition to the formal conflict resolution process herein described, the Chairperson of the Board of Trustees or the Chief of Staff may call for a meeting of the Joint Conference Committee at any time and for any reason to seek direct input from the Joint Conference Committee members, clarify any issue, or relay information directly to Medical Staff leaders, the Board of Trustees, or Administration.48

b. Conflicts Between the Medical Staff and the Medical Executive Committee

The Medical Executive Committee, as representatives of the Medical Staff, will make best efforts to address and resolve all conflicting recommendations in the best interests of patients, the Hospital, and the members of the Medical Staff. When the Medical Executive Committee plans to act or is considering acting in a manner contrary to the wishes of the voting members of the Medical Staff, the Medical Staff shall present their recommendations to the Medical Executive Committee with a written petition signed by at least ten percent (10%) of the voting members of the Medical Staff. The Medical Staff officers shall meet with members of the Medical Staff representing the Medical Staff’s recommendations as set forth in the petition and seek to resolve the conflict through informal discussions. The Medical Staff representing the Medical Staff’s recommendations as set forth in the petition may also communicate directly with the Board of Trustees regarding the conflicting recommendations. If these informal discussions fail to resolve the conflict, the Chief of Staff, the dissenting representatives of the Medical Staff, or the Chairperson of the Board of Trustees may request initiation of a formal conflict resolution process. The formal conflict resolution process will begin with a meeting of the Joint Conference Committee within thirty (30) days of the initiation of the formal conflict resolution process.

To address Medical Executive Committee-Medical Staff conflicts, the Joint Conference Committee shall be composed of:

• Three officers of the Medical Staff

48 Joint Commission Medical Staff Standards 01.01.01; Joint Commission Leadership Standards 01.01.01, 01.03.01, 01.05.01, 02.01.01, 02.02.01, 02.04.01 & 04.02.01; See also FN 1

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• Three voting members of the Medical Staff representing the recommendations in the written petition

• The Chairperson of the Board of Trustees

• The Chief Executive Officer or designee

If the Joint Conference Committee cannot produce a resolution to the conflict that is acceptable to the Medical Executive Committee and the Medical Staff within 30 days of the initial meeting, the Medical Executive Committee and the Medical Staff shall enter into mediation facilitated by an outside party. The Medical Executive Committee and the three voting members of the Medical Staff representing the recommendations in the written petition shall together select the third-party mediator, the costs for which shall be paid in total by the Medical Staff. The Medical Executive Committee and Medical Staff shall make best efforts to collaborate together and with the third-party mediator to resolve the conflict. The Medical Executive Committee and the Medical Staff shall each designate at least three people to participate in the mediation. Any resolution arrived at during such meeting shall be subject to the approval of the Medical Executive Committee and the Board of Trustees, in accordance with the provisions of Medical Staff Bylaws and the Articles of Incorporation and Bylaws of the Hospital. If, after 90 days from the date of the initial request for mediation from an outside party, the Medical Executive Committee and Medical Staff cannot resolve the conflict in a manner agreeable to all parties, the Board of Trustees shall have the authority to act unilaterally on the issue that gave rise to the conflict.

If the Board of Trustees determines, in its sole discretion, that action must be taken related to a conflict in a shorter time period than that allowed through these conflict resolution process in an attempt to address an issue of quality, patient safety, liability, regulatory compliance, legal compliance, or other critical obligations of the Hospital, the Board of Trustees may take provisional action that will remain in effect until the conflict resolution process is completed.

In addition to the formal conflict resolution process herein described, the Chairperson of the Board of Trustees or the Chief of Staff may call for a meeting of the Joint Conference Committee at any time and for any reason to seek direct input from the Joint Conference Committee members, clarify any issue, or relay information directly to Medical Staff leaders, the Board of Trustees, or Administration.49

49 Joint Commission Medical Staff Standards 01.01.01; Joint Commission Leadership Standards 01.01.01, 01.03.01, 01.05.01, 02.01.01, 02.02.01, 02.04.01 & 04.02.01; See also FN 1

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Approved and Adopted by the Medical Staff of Blake Medical Center on .

, Chief of Staff

, Secretary of the Medical Staff

Approved by the Board of Trustees of Blake Medical Center on October.

, Chairperson of the Board

Approved by the Administration of Blake Medical Center on October.

, Chief Executive Officer

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