Bylaws of the Medical Staff of BMH, BPC, OHMC, Bellin Clinics · Bylaws of the Medical Staff of...

Bylaws of the Medical Staff of Bellin Memorial Hospital, Inc. Bellin Psychiatric Center, Inc. Oconto Hospital & Medical Center, Inc.

Bellin Clinics

Bellin Memorial Hospital, Inc.

Oconto Hospital & Medical Center, Inc.

Bellin Psychiatric Center, Inc.

Approved and Adopted Medical Staff Executive Committee August 8, 2017



Approved and Adopted Affirmative Vote by Majority of Active Medical Staff September 28, 2017



Approved and Adopted Bellin Health Systems Board of Directors October 24, 2017

With Amendments Approved through March 11, 2020

Includes: Part 1 – Organization and Structure Part 2 – Committee and Department Structure Part 3 – Credentialing, Privileging, and Peer Review Part 4 – Fair Hearing and Appeal Procedures Part 5 – Rules and Regulations Part 6 – Allied Health Professional Policy Part 7 – Amendments and Adoption

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TABLE OF CONTENTS Page

PART 1 – ORGANIZATION AND STRUCTURE .................................................................... 1

ARTICLE 1 .................................................................................................................................... 1

1.A. INTRODUCTION ............................................................................................................... 1

1.B. PURPOSE ............................................................................................................................ 1

1.C. AUTHORITY ....................................................................................................................... 1

1.D. DEFINITIONS .................................................................................................................... 2

ARTICLE 2 - COMPLIANCE WITH POLICIES AND RULES AND REGULATIONS .... 5

ARTICLE 3 - CATEGORIES OF THE MEDICAL STAFF .................................................... 6

3.A. MEDICAL STAFF APPOINTMENT WITH CLINICAL PRIVILEGES ......................... 6 3.A.1. Active Staff with Clinical Privileges: ........................................................................... 6 3.A.2. Courtesy Staff: .............................................................................................................. 7 3.A.3. Consulting Staff: ........................................................................................................... 7

3.B: MEDICAL STAFF APPOINTMENT WITHOUT CLINICAL PRIVILEGES ................. 8

3.B.1. Inactive Staff: ................................................................................................................ 8 3.B.2. Honorary Staff: .............................................................................................................. 8 3.B.3. Active Staff without Clinical Privileges: ...................................................................... 8

ARTICLE 4 - ORGANIZATION OF THE MEDICAL STAFF .............................................. 9

4.A. MEDICAL STAFF YEAR .................................................................................................. 9

4.B. OFFICERS OF THE MEDICAL STAFF ........................................................................... 9 4.B.1. Qualifications of Officers and Chairpersons: ................................................................ 9 4.B.2. President: ..................................................................................................................... 10 4.B.3. Vice President: ............................................................................................................ 11 4.B.4. Nomination and Election of Officers: ......................................................................... 11 4.B.5. Removal of Officers: ................................................................................................... 12 4.B.6. Vacancies in Office: .................................................................................................... 12 4.B.7. Conflict of Interest: ..................................................................................................... 12

4.C. MEETINGS OF THE MEDICAL STAFF ........................................................................ 13

4.C.1. Annual Staff Meeting: ................................................................................................. 13 4.C.2. Special Staff Meetings: ............................................................................................... 13 4.C.3. Quorum for Medical Staff Meeting: ........................................................................... 13

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4.D. COMMITTEE MEETINGS .............................................................................................. 13

4.D.1. Departmental Committee Meetings: ........................................................................... 13 4.D.2. Nondepartmental Committee Meetings: ..................................................................... 14

4.D.3. Special Committee Meetings: ........................................................................................ 15

4.D.4. Electronic Meetings and Voting: ................................................................................ 15 4.D.5. Quorum: ...................................................................................................................... 15 4.D.6. Minutes: ...................................................................................................................... 15

4. E. PROVISIONS COMMON TO ALL MEETINGS ........................................................... 15

4.E.1. Posting Notice of Meetings: ........................................................................................ 15 4.E.2. Attendance Requirements: .......................................................................................... 16 4.E.3. Rules of Order: ............................................................................................................ 16 4.E.4. Voting: ......................................................................................................................... 16

PART 2 – COMMITTEE AND DEPARTMENT STRUCTURE ........................................... 17

ARTICLE 5 - CLINICAL DEPARTMENTS ........................................................................... 17

5.A. LIST OF DEPARTMENTS .............................................................................................. 17

5.B. LIST OF SERVICES WITHIN DEPARTMENTS ........................................................... 17

5.C. FUNCTIONS OF DEPARTMENTS ................................................................................ 19

5.D. DEPARTMENT CHAIR ................................................................................................... 20

5.E. FUNCTIONS OF DEPARTMENT CHAIR ..................................................................... 21

5.F. VACANCIES IN OFFICE OF DEPARTMENT CHAIR ................................................. 22

5.G. DEPARTMENT MEMBERS ........................................................................................... 22

5.H. DIVISION LEADS ........................................................................................................... 22

ARTICLE 6 - NONDEPARTMENTAL COMMITTEES OF THE MEDICAL STAFF ..... 24

6.A. STRUCTURE .................................................................................................................... 24 6.A.1. Chair: ........................................................................................................................... 24 6.A.2. Functions of Nondepartmental Committee Chair: ...................................................... 24 6.A.3. Members: .................................................................................................................... 24

6.B. BHS MEDICAL EXECUTIVE COMMITTEE ................................................................ 25

6.B.1. Composition: ............................................................................................................... 25 6.B.2. Duties: ......................................................................................................................... 25 6.B.3. Meetings, Reports, and Recommendations: ................................................................ 27 6.B.4. Quorum: ...................................................................................................................... 27

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6.C. BYLAWS AND GOVERNANCE .................................................................................... 27 6.C.1 BYLAWS COMMITTEE ............................................................................................ 27

6.C.1.a. Composition: ......................................................................................................... 27 6.C.1.b. Duties: ................................................................................................................... 28 6.C.1.c. Meetings, Reports, and Recommendations: .......................................................... 28

6.C.2. PHYSICIAN AND APC HEALTH COMMITTEE ................................................... 28

6.C.2.a. Composition: ......................................................................................................... 28 6.C.2.b. Duties: ................................................................................................................... 28

6.C.3. SYSTEM CREDENTIALS COMMITTEE ................................................................ 29

6.C.3.a. Composition: ......................................................................................................... 29 6.C.3.b. Duties: ................................................................................................................... 29 6.C.3.c. Meetings, Reports, and Recommendations: .......................................................... 29

6.C.4. UTILIZATION REVIEW COMMITTEE .................................................................. 30

6.C.4.a. Composition: ......................................................................................................... 30 6.C.4.b. Duties: ................................................................................................................... 30

6.D. MEDICAL EDUCATION ................................................................................................ 31

6.D.1 CONTINUING MEDICAL EDUCATION COMMITTEE ........................................ 32 6.D.1.a. Composition: ......................................................................................................... 32 6.D.1.b. Duties: ................................................................................................................... 32 6.D.1.c. Meetings, Reports, and Recommendations: ......................................................... 33

6.D.2 MEDICAL EDUCATION COMMITTEE (for Undergraduate and Graduate Medical Education) ............................................................................................................................... 33

6.D.2.a. Composition: ......................................................................................................... 33 6.D.2.b. Duties: ................................................................................................................... 33 6.D.2.c. Meetings, Reports, and Recommendations: ......................................................... 34

6.E. CLINICAL QUALITY ...................................................................................................... 34

6.E.1. INSTITUTIONAL REVIEW BOARD ....................................................................... 34 6.E.2. INFECTION PREVENTION COMMITTEE ............................................................. 34

6.E.2.a. Composition: ......................................................................................................... 34 6.E.2.b. Duties: ................................................................................................................... 34 6.E.2.c. Meetings, Reports, and Recommendations: .......................................................... 35

6.E.3. PHARMACY AND THERAPEUTICS COMMITTEE ............................................. 35

6.E.3.a. Composition: ......................................................................................................... 35 6.E.3.b. Duties: ................................................................................................................... 36 6.E.3.c. Meetings, Reports, and Recommendations: .......................................................... 36

6.E.4. TRANSFUSION COMMITTEE ON BLOOD USAGE ............................................. 36

6.E.4.a Composition: .......................................................................................................... 36 6.E.4.b. Duties: ................................................................................................................... 37 6.E.4.c. Meetings, Reports, and Recommendations: .......................................................... 37

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6.E.5. PEER REVIEW AND QUALITY COMMITTEE ..................................................... 37 6.E.5.a. Composition: ......................................................................................................... 37 6.E.5.b. Duties: ................................................................................................................... 37 6.E.5.c. Meetings, Reports, and Recommendations: .......................................................... 38 6.E.5.d. Quorum ................................................................................................................. 38

6.F. MEDICAL INFORMATICS COMMITTEE .................................................................... 38

6.F.1. Composition: ............................................................................................................... 38 6.F.2. Duties: .......................................................................................................................... 39

6.F.3. Meetings, Reports, and Recommendations: ................................................................. 39

6.G. POPULATION HEALTH COMMITTEE ........................................................................ 40 6.G.1. Composition: ............................................................................................................... 40 6.G.2. Duties: ......................................................................................................................... 40 6.G.3. Meetings, Reports, and Recommendations: ................................................................ 40

6.H. CREATION OF STANDING COMMITTEES ................................................................ 40

6.I. SPECIAL COMMITTEES ................................................................................................. 41

PART 3 – CREDENTIALING, PRIVILEGING, AND PEER REVIEW .............................. 42

INTRODUCTION ....................................................................................................................... 42

ARTICLE 7 - APPOINTMENT TO THE MEDICAL STAFF .............................................. 43

7.A. QUALIFICATIONS FOR APPOINTMENT .................................................................... 43 7.A.1. General: ....................................................................................................................... 43 7.A.2. Specific Qualifications: ............................................................................................... 43 7.A.3. Waiver of Criteria: ...................................................................................................... 45 7.A.4. No Entitlement to Appointment: ................................................................................. 45 7.A.5. Nondiscrimination Policy: .......................................................................................... 46 7.A.6. Professional Conduct: ................................................................................................. 46 7.A.7. Participation in Organized Health Care Arrangement: ............................................... 46

7.B. GENERAL CONDITIONS OF APPOINTMENT AND REAPPOINTMENT ................ 46

7.B.1. Basic Responsibilities and Requirements for Applicants and Appointees: ................ 46 7.B.2. Burden of Providing Information: ............................................................................... 49 7.B.3. Grant of Immunity and Authorization to Obtain/Release Information: ....................... 50

ARTICLE 8 - INITIAL APPOINTMENT ................................................................................ 52

8.A. APPLICATION FORM .................................................................................................... 52

8.B. PROCEDURE FOR INITIAL APPOINTMENT .............................................................. 54 8.B.1. Application Review Process: ...................................................................................... 54 8.B.2. Submission of Application: ......................................................................................... 54 8.B.3. Department Chair Review Procedure: ........................................................................ 55

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8.B.4. Processing Applications with No Questions or Discrepancies: .................................. 56 8.B.5. System Credentials Committee Procedure: ................................................................. 57 8.B.6. System Credentials Committee Report: ...................................................................... 59 8.B.7. BHS Medical Executive Committee Procedure: ......................................................... 59 8.B.8. Action of the Board: .................................................................................................... 60

8.C. PROVISIONAL STATUS ................................................................................................ 60

8.C.1. Duration of Provisional Appointment: ........................................................................ 60 8.C.2. Duties of Provisional Appointees: .............................................................................. 61

ARTICLE 9 - CLINICAL PRIVILEGES ................................................................................. 62

9.A. CLINICAL PRIVILEGES ................................................................................................ 62 9.A.1. General: ....................................................................................................................... 62 9.A.2. Additional Clinical Privileges for Procedures Currently Available at a BHS Facility: .... 63 9.A.3. Clinical Privileges for New Procedures: ..................................................................... 64 9.A.4. Clinical Privileges for Dentists and Oral and Maxillofacial Surgeons: ...................... 65 9.A.5. Clinical Privileges for Podiatrists: .............................................................................. 65 9.A.6. Physician in Training: ................................................................................................. 65 9.A.7. Clinical Privileges After Age 65: ................................................................................ 66 9.A.8. Clinical Privileges that Cross Specialty Lines: ........................................................... 66 9.A.9. Telemedicine Privileges: ............................................................................................. 67

9.B. PROCEDURE FOR TEMPORARY AND LOCUM TENENS CLINICAL PRIVILEGES .. 68

9.B.1. Temporary Clinical Privileges for Applicants: ........................................................... 68 9.B.2. Locum Tenens: ............................................................................................................ 69 9.B.3. Special Requirements: ................................................................................................. 69 9.B.4. Termination of Temporary or Locum Tenens Clinical Privileges: ............................. 70

9.C. EMERGENCY CLINICAL PRIVILEGES ....................................................................... 70

ARTICLE 10 - REAPPOINTMENT ......................................................................................... 72

10.A. PROCEDURE FOR REAPPOINTMENT ...................................................................... 72 10.A.1. Application: ............................................................................................................... 72 10.A.2. Factors to be Considered: .......................................................................................... 73 10.A.3. Department Chair Procedure: ................................................................................... 74 10.A.4. Processing Applications with No Questions or Discrepancies: ................................ 74 10.A.5. System Credentials Committee Procedure: .............................................................. 76 10.A.6. BHS Medical Executive Committee Procedure: ....................................................... 77 10.A.7. Action of the Board: .................................................................................................. 78 10.A.8. Conditional Reappointments: .................................................................................... 78

ARTICLE 11 - COLLEGIAL, EDUCATIONAL, AND/OR INFORMAL PROCEEDINGS ... 80

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ARTICLE 12 - QUESTIONS INVOLVING MEDICAL STAFF APPOINTEES ................ 81

12.A. OVERVIEW AND GENERAL PRINCIPLES OF PEER REVIEW RELATED ACTIVITIES .............................................................................................................................. 81

12.A.1. Options Available to Medical Staff Leaders and Administration: ............................ 81 12.A.2. Documentation: ......................................................................................................... 81 12.A.3. No Recordings of Meetings: ..................................................................................... 82 12.A.4. No Right to Counsel: ................................................................................................ 82 12.A.5. No Right to the Presence of Others: ......................................................................... 82

12.B. COLLEGIAL INTERVENTION AND PROGRESSIVE STEPS .................................. 82

12.C. AUTOMATIC RELINQUISHMENT ............................................................................. 83

12.C.1. Failure to Complete Medical Records: ..................................................................... 83 12.C.2. Failure to Satisfy Eligibility Criteria: ........................................................................ 83 12.C.3. Criminal Activity: ..................................................................................................... 83 12.C.4. Failure to Provide Information: ................................................................................. 84 12.C.5. Failure to Attend a Mandatory Meeting: ................................................................... 84 12.C.6. Failure to Complete or Comply with Training or Educational Requirements: ......... 84 12.C.7. Failure to Comply with Request for Fitness for Practice Evaluation: ...................... 84 12.C.8 Action at Another BHS Facility: ................................................................................ 85 12.C.9. Reinstatement from Automatic Relinquishment and Automatic Resignation: ......... 85 12.C.10 Voluntary Relinquishment: ...................................................................................... 86

12.D. PROCEDURE FOR LEAVE OF ABSENCE ................................................................. 86

12.E. PROCEDURE FOR INVESTIGATING QUESTIONS INVOLVING MEDICAL STAFF APPOINTEES ............................................................................................................... 87

12.E.1. Initial Procedure: ....................................................................................................... 87 12.E.2. Initiation of Investigation: ......................................................................................... 88 12.E.3. Investigative Procedure: ............................................................................................ 88 12.E.4. Procedure Thereafter: ................................................................................................ 90

12.F. PRECAUTIONARY SUSPENSION OF CLINICAL PRIVILEGES ............................. 91

12.F.1. Grounds for Precautionary Suspension: .................................................................... 91 12.F.2. BHS Medical Executive Committee Procedure: ....................................................... 91 12.F.3. Care of Suspended Individual’s Patients: .................................................................. 92

ARTICLE 13 - PHYSICIANS UNDER CONTRACT WITH BHS ....................................... 94

PART 4 – FAIR HEARING AND APPEAL PROCEDURES ................................................ 95

ARTICLE 14 - FAIR HEARING AND APPEAL PROCEDURES ....................................... 95

14.A. INITIATION OF HEARING .......................................................................................... 95 14.A.1. Grounds for Hearing: ................................................................................................ 95 14.A.2. Actions Not Grounds for Hearing: ............................................................................ 96 14.A.3. Employment and Exclusive Arrangements: .............................................................. 97

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14.B. THE HEARING .............................................................................................................. 98

14.B.1. Notice of Recommendation: ..................................................................................... 98 14.B.2. Request for Hearing: ................................................................................................. 98 14.B.3. Notice of Hearing and Statement of Reasons: .......................................................... 98 14.B.4. Witness List: .............................................................................................................. 99 14.B.5. Hearing Panel, Presiding Officer, and Hearing Officer: ......................................... 100

14.C. PRE-HEARING AND HEARING PROCEDURE ....................................................... 102

14.C.1. General Provisions: ................................................................................................. 102 14.C.2. Time Frames: .......................................................................................................... 102 14.C.3. Provision of Relevant Information: ......................................................................... 102 14.C.4. Pre-Hearing Conference: ......................................................................................... 103 14.C.5. Provision of Information to the Hearing Panel: ...................................................... 104 14.C.6. Failure to Appear: ................................................................................................... 104 14.C.7. Record of Hearing: .................................................................................................. 104 14.C.8. Rights of Both Sides and the Hearing Panel at the Hearing: .................................. 104 14.C.9. Admissibility of Evidence: ...................................................................................... 105 14.C.10. Persons to Be Present: ........................................................................................... 105 14.C.11. Official Notice: ...................................................................................................... 105 14.C.12. Postponements and Extensions: ............................................................................ 106 14.C.13. Presence of Hearing Panel Members: ................................................................... 106 14.C.14. Post-Hearing Memoranda of Points and Authorities: ........................................... 106

14.D. HEARING CONCLUSION, DELIBERATIONS, AND RECOMMENDATIONS .... 106

14.D.1. Order of Presentation: ............................................................................................. 106 14.D.2. Basis of Decision: ................................................................................................... 106 14.D.3. Adjournment and Conclusion: ................................................................................ 107 14.D.4. Deliberations and Recommendation of the Hearing Panel: .................................... 107 14.D.5. Disposition of Hearing Panel Report: ..................................................................... 107

14.E. APPEAL PROCEDURE ............................................................................................... 107

14.E.1. Time for Appeal: ..................................................................................................... 107 14.E.2. Grounds for Appeal: ................................................................................................ 108 14.E.3. Time, Place, and Notice: ......................................................................................... 108 14.E.4. Nature of Appellate Review: ................................................................................... 108 14.E.5. Final Decision of the Board: ................................................................................... 108 14.E.6. Right to One Hearing and One Appeal Only: ......................................................... 109

ARTICLE 15 - CONFIDENTIALITY AND PEER REVIEW PROTECTIONS ............... 110

15.A. CONFIDENTIALITY AND REPORTING .................................................................. 110

15.B. PEER REVIEW PROTECTION ................................................................................... 110

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PART 5 – RULES AND REGULATIONS .............................................................................. 111

ARTICLE 16 .............................................................................................................................. 111

16.A. ADMISSION TO THE HOSPITAL/TREATMENT: ................................................... 111 16.A.1. Non-Discrimination: ............................................................................................... 111 16.A.2. Admission: .............................................................................................................. 111 16.A.3. Assignment of Attending Physician ........................................................................ 111 16.A.4. Attending Physician Responsibilities ..................................................................... 111

16.B. PHYSICIANS TREATING FAMILY MEMBERS ...................................................... 112

16.C. MEDICAL RECORDS ................................................................................................. 112

16.C.1. Medical Record Requirements: ............................................................................... 112 16.C.2. Failure to Complete Medical Records: ................................................................... 115

16.D. HISTORIES AND PHYSICALS .................................................................................. 116

16.D.1. Qualified Practitioners: ........................................................................................... 116 16.D.2. Requirements: ......................................................................................................... 116 16.D.3. Content: ................................................................................................................... 117

16.E. CONSULTATIONS ...................................................................................................... 119

16.E.1. Consultations Encouraged: ...................................................................................... 119 16.E.2. Attending Physician Requesting Consultation: ....................................................... 119 16.E.3. Consultant’s Responsibilities: ................................................................................. 119

16.F. SURGERY ..................................................................................................................... 120

16.F.1 Anesthesia ................................................................................................................. 120 16.F.2. Informed Consent: ................................................................................................... 121 16.F.3. Surgical Attire: ........................................................................................................ 121 16.F.4. Pregnancy Verification: ........................................................................................... 121 16.F.5. On-Time Surgery: .................................................................................................... 121 16.F.6. Pre-Op Testing: ........................................................................................................ 121 16.F.7. Visitors in the Operating Room: .............................................................................. 121 16.F.8. Surgical Assistant: ................................................................................................... 121 16.F.9. Post Operative/Post Procedure Documentation: ...................................................... 121 16.F.10. Tissue: .................................................................................................................... 122 16.F.11. Amputation: ........................................................................................................... 122 16.F.12. Safety Hazards: ...................................................................................................... 122

16.G. OBSTETRICS AND GYNECOLOGY ........................................................................ 122

16.G.1. Elective Sterilization: .............................................................................................. 122 16.G.2. Abortion: ................................................................................................................. 122 16.G.3. Personal Values: ...................................................................................................... 123

16.H. DOCUMENTATION OF ORDERS ............................................................................. 123

16.H.1. Verbal Orders – Authentication: ............................................................................. 123 16.H.2. Orders from Providers Not on Staff: ....................................................................... 123 16.H.3. Orders from Chiropractors: ..................................................................................... 124

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16.I. STANDING ORDERS ................................................................................................... 124

16.J. PHYSICIAN ROUNDS ................................................................................................. 124

16.K. AUTOPSIES ................................................................................................................. 124

16.K.1. Requirements: ......................................................................................................... 124

16.L. MASS CASUALTY ASSIGNMENTS ......................................................................... 124

16.M. QUALITY OF DRUG .................................................................................................. 125

16.N. SPECIAL CARE UNITS .............................................................................................. 125 16.N.1. Intensive Care Unit: ................................................................................................ 125 16.N.2. Inpatient Rehabilitation Department: ...................................................................... 126 16.N.3. Emergency Care: ..................................................................................................... 126 16.N.4. Responsibilities of the “On-Call” Physician: .......................................................... 126 16.N.5. Appropriate Transfers: ............................................................................................ 127

16.O. POLICIES ..................................................................................................................... 128

16.O.1. Postanesthesia Recovery: ........................................................................................ 128 16.O.2. Patient Care Policies: .............................................................................................. 128

16.P: CONFIDENTIALITY ................................................................................................... 128

16.Q: DENTAL PATIENTS: .................................................................................................. 128

16.Q.1: Dentist’s responsibilities shall include: .................................................................. 128 16.Q.2: .................................................................................................................................. 129 16.Q.3: Physician’s responsibilities shall include: .............................................................. 129

PART 6 – ALLIED HEALTH PROFESSIONAL POLICY ................................................. 130

ARTICLE 17 - GENERAL ....................................................................................................... 130

17.A. DEFINITIONS: ............................................................................................................. 130

17.B. DELEGATION OF FUNCTIONS: ............................................................................... 131

ARTICLE 18 - SCOPE AND OVERVIEW OF POLICY ..................................................... 132

18.A. SCOPE OF POLICY: .................................................................................................... 132

18.B. CATEGORIES OF ALLIED HEALTH PROFESSIONALS: ...................................... 132

18.C. PROCESS FOR DETERMINING NEED FOR A NEW CATEGORY OF ALLIED HEALTH PROFESSIONAL: .................................................................................................. 133

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ARTICLE 19 - APPLICATION ............................................................................................... 135

19.A. GENERAL QUALIFICATIONS OF APPLICANTS: ................................................. 135

19.B. WAIVER OF QUALIFICATIONS: .............................................................................. 136

19.C. NO ENTITLEMENT TO MEDICAL STAFF APPOINTMENT: ................................ 136

19.D. HEALTH SYSTEM EMPLOYEES: ............................................................................ 137

19.E. NON-DISCRIMINATION POLICY: ........................................................................... 137

19.F. ASSUMPTION OF DUTIES AND RESPONSIBILITIES: .......................................... 137

19.G. PROFESSIONAL CONDUCT: .................................................................................... 139

19.H. APPLICATION PROCESS: ......................................................................................... 140

19.I. INFORMATION TO BE SUBMITTED WITH APPLICATIONS: .............................. 140

19.J. SUBMISSION OF APPLICATION: .............................................................................. 141

19.K. BURDEN OF PROVIDING INFORMATION: ........................................................... 142

19.L. MISSTATEMENTS AND OMISSIONS: ..................................................................... 142

19.M. GRANT OF IMMUNITY AND AUTHORIZATION TO OBTAIN/RELEASE INFORMATION: ..................................................................................................................... 142

19.N. TEMPORARY PRIVILEGES OR SCOPE OF PRACTICE: ....................................... 144

19.O. LOCUM TENENS: ....................................................................................................... 144

19.P. TERMINATION OF TEMPORARY OR LOCUM TENENS SCOPE OF PRACTICE OR PRIVILEGES: ................................................................................................................... 145

ARTICLE 20 - SYSTEM CREDENTIALS COMMITTEE ................................................. 146

20.A. COMPOSITION: .......................................................................................................... 146

20.B. DUTIES: ........................................................................................................................ 146

20.C. MEETINGS, REPORTS AND RECOMMENDATIONS: ............................................ 147

ARTICLE 21 - CREDENTIALING PROCEDURES ............................................................ 148

21.A. LICENSED INDEPENDENT PRACTITIONER AND ADVANCED DEPENDENT148 PRACTITIONER CREDENTIALING: ................................................................................... 148

21.B. DEPENDENT PRACTITIONER CREDENTIALING: ............................................... 149

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21.C. CLINICAL PRIVILEGES: ........................................................................................... 151

21.D. RENEWAL OF PERMISSION TO PRACTICE: ......................................................... 152

21.E. CLINICAL PRIVILEGES/SCOPE OF PRACTICE AFTER AGE 65: ........................ 153

21.F. PROCEDURE FOR LEAVE OF ABSENCE: .............................................................. 154

ARTICLE 22 - PEER REVIEW PROCEDURES FOR QUESTIONS INVOLVING ALLIED HEALTH PROFESSIONALS ................................................................................. 156

ARTICLE 23 - HEARINGS AND APPEALS PROCEDURES FOR LICENSED INDEPENDENT PRACTITIONERS AND ADVANCED PRACTICE CLINICIANS ..... 157

ARTICLE 24 - CONDITIONS OF PRACTICE APPLICABLE TODEPENDENT PRACTITIONERS AND ADVANCED PRACTICE CLINICIANS ................................... 160

24.A. SUPERVISION BY EMPLOYING OR SUPERVISING/COLLABORATING PHYSICIAN: ........................................................................................................................... 160

24.B. QUESTIONS REGARDING AUTHORITY OF DEPENDENT PRACTITIONER: .. 160

24.C. RESPONSIBILITIES OF THE SUPERVISING/COLLABORATING PHYSICIAN: 161

APPENDIX A ............................................................................................................................. 162

APPENDIX B ............................................................................................................................. 163

APPENDIX C ............................................................................................................................. 164

PART 7 – AMENDMENTS AND ADOPTION ...................................................................... 165

ARTICLE 25 - AMENDMENTS ............................................................................................. 165

25.A. METHODS OF ADOPTION AND AMENDMENT TO BYLAWS ........................... 165

25.B. METHODS OF ADOPTION AND AMENDMENT TO MEDICAL STAFF RULES, REGULATIONS, AND POLICIES ......................................................................................... 166

25.C. CONFLICT MANAGEMENT PROCESS ................................................................... 167

25.D. UNIFIED MEDICAL STAFF PROVISIONS .............................................................. 167

25.D.1. Adoption: ................................................................................................................ 167 25.D.2. Bylaws, Policies, and Rules and Regulations of the Unified Medical Staff: .......... 168 25.D.3. Opt-Out Procedures: ............................................................................................... 168

ARTICLE 26 - ADOPTION ..................................................................................................... 169

PART 1 – ORGANIZATION AND STRUCTURE

ARTICLE 1

1.A. INTRODUCTION

This document is divided into seven parts. The definitions in Part 1 apply to all Parts. The Medical Staff Bylaws are defined as Part 1 – Organization and Structure; Part 2 – Committee and Department Structure; Part 3 – Credentialing, Privileging, and Peer Review; Part 4 – Fair Hearing and Appeal Procedures; Part 5 – Medical Staff Rules and Regulations; Part 6 – Allied Health Professionals Policy; and Part 7 – Amendments and Adoption. The process for amending any of the Parts is described in Article 25. 1.B. PURPOSE The purpose of the Medical Staff is to organize the activities of physicians and other clinical practitioners who practice at BHS Facilities to carry out, in conformity with these Bylaws, the functions delegated to the Medical Staff by the BHS Board. 1.C. AUTHORITY Subject to the authority and approval of the board, the Medical Staff will exercise such power as is reasonably necessary to discharge its responsibilities under these Bylaws and the corporate Bylaws of BHS and its subsidiary organizations.

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1.D. DEFINITIONS

The following definitions shall apply to terms used in these Bylaws:

(1) “Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) Joint Initiative” means the project undertaken by the ACGME and the ABMS that led to adoption of six core competencies for quality patient care including: • Patient Care – Provide care that is compassionate, appropriate, and effective

treatment for health problems and to promote health. • Medical Knowledge – Demonstrate knowledge about established and evolving

biomedical, clinical, and cognate sciences and their application in patient care. • Interpersonal and Communication Skills – Demonstrate skills that result in

effective information exchange and teaming with patients, their families and professional associates (e.g., fostering a therapeutic relationship that is ethically sounds, uses effective listening skills with nonverbal and verbal communication; working as both a team member and at times as a leader).

• Professionalism – Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles and sensitivity to diverse patient populations.

• Systems-based Practice – Demonstrate awareness of and responsibility to larger context and systems of healthcare. Be able to call on system resources to provide optimal care (e.g., coordinating care across sites or serving as the primary case manager when care involves multiple specialties, professions, or sites).

• Practice-based Learning and Improvement – Able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence and improve their practice of medicine.

(2) “APC Council” shall mean the leadership council consisting of the Chief Nursing

Officer and Advanced Practice Clinicians who practice in one or more BHS Facilities and are elected to a Division Lead role.

(3) “AMA PRA” means American Medical Association Physician’s Recognition

Award, which is the American Medical Association’s system for awarding continuing medical education credits.

(4) “Appointee” means any physician, dentist, or podiatrist who has been granted

Medical Staff appointment and clinical privileges by the Board to practice at a Bellin Health System facility (“BHS Facility”).

(5) “Board” means the Board of Directors of Bellin Health Systems, Inc., who have the

overall responsibility for the conduct of the BHS Facilities, including the Medical Staff.

(6) Bellin Health System (“BHS”) means Bellin Health Systems, Inc., and its subsidiaries,

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including Bellin Memorial Hospital, Inc., Oconto Hospital & Medical Center, Inc. d/b/a Bellin Health Oconto Hospital, and Bellin Psychiatric Center, Inc.

(7) “BH” means Bellin Memorial Hospital, Inc.

(8) “BHOH” means Oconto Hospital & Medical Center, Inc., d/b/a Bellin Health

Oconto Hospital.

(9) “BHS Facility” means Bellin Hospital (“BH”), Oconto Hospital & Medical Center, Inc., Bellin Psychiatric Center (“BPC”), or any medical facilities owned and operated by them.

(10) “BMG” means Bellin Medical Group, an unincorporated division of Bellin

Memorial Hospital, which operates the Bellin Family Medical Center Clinics.

(11) “Chief Executive Officer” means the Chief Executive Officer of the Bellin Health Systems, or his/her designee.

(12) “Chief Medical Officer” means the physician employed by Bellin Health to oversee

the quality management functions of Bellin Health, or during the vacancy of the Chief Medical Officer position, the President of the Medical Staff or other physician designated by the CEO shall fulfill the responsibilities of the Chief Medical Officer under these Bylaws.

(13) “Current Clinical Competence” shall be defined as an objective, evidence-based

process that is privilege-specific and can be demonstrated through activity within BHS Facility, activity at other hospitals who measure competence through a process that is consistent with BHS standards, or through submission of documentation demonstrating participation in continuing medical education programs that are privilege specific.

(14) “Dentist” shall be interpreted to include doctors of dental surgery (“D.D.S.”) and

doctors of dental medicine (“D.M.D.”).

(15) “Elective” shall mean a patient condition which requires medical attention but is not acute in nature and will not reasonably be expected to deteriorate to a more acute stage over time.

(16) “Emergency” means an acute medical condition that without immediate medical

attention, could reasonably be expected to result in serious jeopardy to the health of an individual or serious impairment or dysfunction of any bodily organ or part. In the context of psychiatric or emotional problems, an emergency condition exists when an individual presents as an immediate threat to himself or others.

(17) “Executive Committee” means the Executive Committee of the Medical Staff,

sometimes referred to as “BHS Medical Executive Committee,” unless specifically

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written “Executive Committee of the Board.”

(18) “Focused Professional Practice Evaluation” means the time limited evaluation of practitioner competence in performing a specific privilege. This process is implemented for all initially requested privileges and whenever a question arises regarding a practitioner’s ability to provide safe, high-quality patient care.

(19) “Licensure” shall mean the process by which an agency of the State of Wisconsin

and/or State of Michigan, as applicable, grants permission via a license to an individual meeting certain predetermined qualifications to engage in an occupation.

(20) “Medical Staff” means all physicians, dentists, and podiatrists who are given

privileges to treat patients in a BHS Facility.

(21) “Ongoing Professional Practice Evaluation” means a document summary of ongoing data collected for the purpose of assessing a practitioner’s clinical competence and professional behavior. The information gathered during this process is factored into decisions to maintain, revise or revoke existing privilege(s) prior to or at the end of the 2-year license and privilege renewal cycle.

(22) “Oral and Maxillofacial Surgeons” shall be interpreted to refer to licensed dentists

who have successfully completed a postgraduate program in oral surgery accredited by the American Association of Oral and Maxillofacial Surgery and/or the Commission on Dental Education of the American Dental Association.

(23) “Peer Recommendation” for purposes of reappointment shall mean a

recommendation from a doctor licensed and on the Active Medical Staff of BHS.

(24) “Physicians” shall be interpreted to include doctors of medicine (M.D.), and doctors of osteopathy (D.O.).

(25) “Qualified Medical Person” to perform an emergency medical screening for

purposes of the Emergency Medical Treatment and Active Labor Act, shall include a physician, physician assistant, nurse practitioner or registered nurse;

(26) “Urgent” shall mean a medical condition or a developing medical condition that

without medical attention within a reasonable period of time could result in a deterioration of the patient to a condition that could reasonably be expected to jeopardize the patient's life or a serious impairment or dysfunction of any bodily organ or part.

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

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ARTICLE 2

COMPLIANCE WITH POLICIES AND RULES AND REGULATIONS All Medical Staff Appointees shall abide by all bylaws and policies of BHS, and shall cooperate fully with the Corporate Compliance Program of BHS and adhere to all laws, regulations and standards of conduct applicable to their activities at BHS Facilities, the practice of their profession, and their participation in any federal health program as a condition of their continued appointment to the Medical Staff. In the event that any Medical Staff appointee has knowledge of a violation of applicable laws or regulations that could have an impact on BHS, he or she shall immediately report the same to the Chief Executive Officer, Chief Medical Officer, or the Corporate Compliance Officer. According to Medical Staff and BHS Facility policies, each Medical Staff appointee shall prepare and complete in a timely fashion the medical and other required records for all patients to whom the Medical Staff appointee provides care in the BHS Facility, or within its facilities, clinical services, or departments. (1) A medical history and physical examination, and psychiatric evaluation (when

applicable) shall be completed no more than thirty (30) days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination must be completed and documented by a physician, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with state law and the applicable BHS Facility policy.

(2) When the medical history and physical examination and psychiatric evaluation (when

applicable) is completed within thirty (30) days before admission or registration, the physician must complete and document an updated examination of the patient within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The updated examination of the patient, including any changes in the patient’s condition, must be completed and documented by a physician, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with state law and the applicable BHS Facility policy.

(3) The content of complete and focused history and physical examinations and psychiatric

examinations is delineated in the rules and regulations.

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ARTICLE 3

CATEGORIES OF THE MEDICAL STAFF An applicant may apply for either Medical Staff Appointment with Clinical Privileges or Medical Staff Appointment Without Clinical Privileges. Medical Staff appointment shall not confer any clinical privileges or the right to practice in a BHS Facility. All appointments to the Medical Staff shall be made by the Board, except as otherwise provided in this Article, and shall be to one of the following categories of the staff. Criteria for appointment shall include individual character, competence, training, experience, and judgment. All appointees shall be appointed to a specific department based upon their training, but shall be eligible for clinical privileges in other departments as applied for and recommended pursuant to these Bylaws and approved by the Board. Clinical privileges shall be granted for the specific facility where the applicant will provide services (i.e., BH, BHOH, or BPC). An applicant with inadequate clinical activity for a two (2) year period will be given the opportunity to submit evidence of adequate clinical activity from a facility which is the site of his/her primary practice. If adequate clinical activity is not documented or otherwise established to the satisfaction of the Systems Credentials Committee, the appointee will be notified that he/she has been transferred to the category of Inactive Staff, pursuant to Section 3.B.1 below, and have no right to vote, no right to hearing and appeal procedure and will not be required to reapply biennially. In the alternative, the appointee may elect to seek Active Staff without Clinical Privileges pursuant to Section 3.B.3, below, and meet the requirements stated therein. All initial appointments to the Medical Staff (regardless of the category of the staff to which the appointment is made), and all initial clinical privileges (whether for a new applicant or a current appointee) shall be provisional for a period of at least two (2) years from the date of the appointment or longer if established as part of the credentialing process. Members with provisional status shall not be entitled to hold office or serve as chair of committees, unless an exception is granted by the BHS Medical Executive Committee. They may, however, serve as members on Medical Staff committees and shall be encouraged to attend Medical Staff meetings.

3.A. MEDICAL STAFF APPOINTMENT WITH CLINICAL PRIVILEGES

3.A.1. Active Staff with Clinical Privileges: The Active Staff with Clinical Privileges shall consist of those physicians, dentists, and podiatrists who meet the criteria for clinical privileges, and who are active in the health system. “Active in the health system” shall mean those physicians who have at least six (6) patient contacts annually at the specific BHS Facility or Facilities where the physician has privileges and those dentists and podiatrists who have at least three (3) patient contacts per year at the specific BHS Facility or Facilities where the dentist or podiatrist has privileges. “Patient contacts” includes any admission, consultation, procedure, evaluation, treatment, or service performed in BHS Facilities, on an inpatient or outpatient basis, excluding laboratory and diagnostic services. One patient shall count for no more than one patient contact for each physician who provides services during any inpatient or outpatient stay.

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Only physicians under contract with Bellin shall be entitled to apply for clinical privileges at BHS clinics.

Each appointee to the Active Staff with Clinical Privileges shall agree to assume all the functions and responsibilities of appointment to the Active Staff with Clinical Privileges, including: care for unassigned patients, emergency call, committee service, accepting consultations and teaching assignments, where applicable, actively participating in the peer review and performance improvement process, and attending applicable meetings. Active Staff appointees with Clinical Privileges shall be entitled to vote, hold office, serve on Medical Staff committees, and serve as chair of such committees. They shall be encouraged to attend Medical Staff meetings as provided in Section 4.C, and departmental and committee meetings as provided in Section 4.D, of these Bylaws.

3.A.2. Courtesy Staff: The Courtesy Staff shall consist of physicians who meet the criteria for clinical privileges and who are not eligible for appointment to the Active Staff of BHS because they intend to have no more than six (6) Patient Contacts annually at BHS Facilities. The Courtesy Staff of dentists and podiatrists shall have not more than three (3) Patient Contacts annually in BHS Facilities. If a Courtesy Staff Member has not had any Patient Contacts during the two (2) year appointment period, he/she shall be moved to Inactive Staff upon reappointment unless such requirement is waived by the Board after considering the specific training, experience, and competence of the individual in question and the needs of the hospital and community (for example, the individual participates in his/her specialty’s citywide call group). Courtesy Staff Members must hold an active medical staff appointment at another accredited hospital (or provide sufficient quality data from their office practice to the Credentials Committee), must provide continuous and timely care for their inpatients and assume all functions and responsibilities assigned by the Department Chair or BHS Medical Executive Committee, including: care for unassigned patients, emergency call, and accepting consultations and teaching assignments, where applicable, and shall cooperate in the peer review and performance improvement process. Courtesy Staff appointees shall have no Staff committee responsibilities, may not vote, and may not hold office. However, they are encouraged to attend Staff and department meetings. Involvement in a greater number of patient contacts shall result in automatic transfer to the Active Staff with Clinical Privileges.

3.A.3. Consulting Staff:

The Consulting Staff shall consist of practitioners of recognized professional ability and expertise who provide a service that is not available on the Active Staff. At the time of initial appointment and each reappointment, they must provide a peer recommendation as well as such quality data and other information as may be requested to assist in an appropriate assessment of current clinical competence and overall qualifications for appointment and clinical privileges. Consulting Staff members may treat (but not admit) patients in conjunction with another physician on the Active Staff; may attend meetings of the Medical Staff and applicable department meetings (without vote) and applicable

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committee meetings (without vote); and may not hold office or serve as department or committee chairs. 3.B: MEDICAL STAFF APPOINTMENT WITHOUT CLINICAL PRIVILEGES

3.B.1. Inactive Staff:

The Inactive Medical Staff consists of those members of the medical profession qualified for Staff membership at any BHS Facility as herein provided who wish to continue Staff membership, but by reason of residence, health or other circumstances, do not wish to admit or attend patients. Persons on the Inactive Staff will not be eligible to vote, to hold office, or to serve on standing Medical Staff committees. Inactive Staff members must reapply in writing if they wish to obtain privileges and must substantiate their active status with documents as required by the Credentials Committee. The requirement of a staff physician to continuously maintain malpractice coverage would apply and continue during inactive status and can either be established: (a) through proof of an occurrence based policy that covers physician for the period when physician was engaged in the practice of medicine; or (b) through a claims made policy with tail coverage.

3.B.2. Honorary Staff:

The Honorary Staff shall consist of Medical Staff appointees who have retired from active hospital practice or nonappointees to the Medical Staff who are of outstanding reputation, not necessarily residing in the community. Persons appointed to the Honorary Staff shall not be eligible to admit or attend patients, to vote, to hold office or to serve on standing Medical Staff committees, but may be appointed to special committees. They may, but are not required to attend any Medical Staff meetings. 3.B.3. Active Staff without Clinical Privileges:

The Active Staff without Clinical Privileges shall consist of those individuals who do not have clinical privileges but who actively and productively participate in the work of the Medical Staff by serving on committees or task forces designed to improve the quality of care or the work of the Medical Staff. Persons appointed to the Active Staff without Clinical Privileges shall be entitled to vote, hold office or serve on standing Medical Staff committees. The requirement of a staff physician to continuously maintain malpractice coverage would apply and continue during the status of Active Staff without Clinical Privileges and can either be established: (a) through proof of an occurrence based policy that covers physician for the period when physician was engaged in the practice of medicine; or (b) through a claims made policy with tail coverage.

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ARTICLE 4

ORGANIZATION OF THE MEDICAL STAFF The Medical Staff is responsible to the Board of Directors of BHS for the quality of all medical care provided to patients of BHS and for the ethical and professional practices of its members.

4.A. MEDICAL STAFF YEAR

For the purpose of these Bylaws the Medical Staff year commences on the 1st day of January and ends on the 31st day of December each year.

4.B. OFFICERS OF THE MEDICAL STAFF The Officers of the Medical Staff shall be the President, Vice President, and Past President. Officers must be appointed to the Active Staff at the time of nomination and election and must continue so during their Term of Office. Failure to maintain such status shall immediately create a vacancy in the office involved. For purposes of defining the Term of Office, the Medical Staff Term of two (2) years commences after: (a) BHS Board of Directors approval (or approval by BHS Medical Executive Committee

in months when Board does not meet) of the elected officers and department/committee chairpersons; and

(b) A joint BHS Medical Executive Meeting with attendance of both incoming and

outgoing members. Only outgoing members may vote on matters presented at this joint meeting. Conclusion of this joint meeting marks the conclusion of the Medical Staff Term for outgoing members.

4.B.1. Qualifications of Officers and Chairpersons:

Only those Active Staff appointees who satisfy the following criteria, and continue to satisfy these criteria throughout their term of office, shall be eligible to serve as Medical Staff officers and committee chairs: (a) Officers must be members in good standing on the Active Staff and continue so during

their term of office. Chairpersons must be members in good standing on the Active Staff, except in the event a Medical Staff Department is newly established and all Department members have provisional status because they joined the Medical Staff at the time the Department was created or, if the Department consists of a physician group under an exclusive arrangement with BHS and a new contract results in a different physician group providing these services so all of the eligible members of the Active Staff have provisional status, in which case a member on the Active Staff with provisional status who is in good standing may serve as the Chairperson. Failure to maintain the required status shall immediately create a vacancy in the office involved;

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(b) have no pending adverse recommendations concerning staff appointment or clinical privileges; (c) not be presently serving as a Medical Staff or corporate officer, department chair or

committee chair at another hospital/health system and shall not so serve during the term of office, unless the BHS Medical Executive Committee consents to such arrangement, with approval of the Board;

(d) do not have an employment or medical director arrangement with another hospital or

health care system not affiliated with Bellin Health, unless the BHS Medical Executive Committee consents to such arrangement, with approval of the Board;

(e) have actively served on one (1) BHS committee; (f) be willing to discharge faithfully the duties and responsibilities of the position to which

they are elected or appointed; and (g) possess and have demonstrated an ability for harmonious, professional interpersonal

relationships. 4.B.2. President: The President shall: (a) act in coordination and cooperation with the Chair Executive Officer and the Chief

Medical Officer of BHS in matters of mutual concern involving Bellin Health System; (b) call, preside at and be responsible for the agenda of all general meetings of the

Medical Staff and record attendance at such meetings; (c) cause to be kept accurate and complete minutes of all BHS Medical Executive

Committee and all general meetings of the Medical Staff meetings; (d) attend to all correspondence on behalf of the Medical Staff; (e) recommend for appointment committee chair and members, in accordance with the

provisions of these Bylaws, and to all standing and special Medical Staff committees except the BHS Medical Executive Committee;

(f) serve as ex officio member of all Medical Staff committees without a vote and the BHS Medical

Executive Committee with a vote;

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

(h) provide day-to-day liaison on medical matters with the Chief Medical Officer, Chief

Executive Officer and the Board;

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(i) stand in for the Chief Medical Officer when he/she is not available in matters

concerning these Bylaws; (j) receive and interpret the policies of the Board to the Medical Staff and report to the

Board on the performance and maintenance of quality with respect to the delegated responsibility of the Medical Staff to provide quality medical care; and

(k) define the Roles, Responsibilities, Expectations and Authorities for the office of the

Vice President and the Past President.

4.B.3. Vice President: The Vice President shall: (a) assume all the duties and have the authority of the President in the event of the

President's temporary inability to perform due to illness, being out of the community or being unavailable for any other reason;

(b) be a member of the BHS Medical Executive Committee of the Medical Staff;

(c) automatically succeed the President (1) when the President fails to serve for any reason

during his/her term of office, and (2) at the conclusion of the President’s term of office;

(d) perform such duties as are assigned to him or her by the President or requested by the Chief Medical Officer, including the Roles, Responsibilities, Expectations and Authorities for the office of the Vice President, as defined by the President;

(e) call Medical Staff meetings on order of the President; and

(f) perform such other duties as ordinarily pertain to his/her office.

Should the President and Vice President be unavailable in an emergency, the authority and duties of the President will be temporarily assumed by the past President of the Medical Staff. 4.B.4. Nomination and Election of Officers: (a) At least one (1) month before the scheduled date of the next Medical Staff election, the

Nominating Committee, composed of the outgoing BHS Medical Executive Committee members, shall prepare a slate of nominees for the office of Vice President. Nominees must possess all of the qualifications set forth in Section 4.B.1. In addition, the Office of President and Vice President shall alternate between primary care and specialty care with the President and Vice President representing the alternate group (i.e., if President is a primary care physician, the Vice President shall be a specialist).

(b) The BHS Medical Executive Committee shall post the slate no later than fourteen (14)

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days prior to the annual Medical Staff meeting. Any nomination made by appointees other than the BHS Medical Executive Committee must be submitted, in writing, to the President of the Medical Staff at least three (3) days prior to the annual meeting and must be endorsed by at least five (5) Active Staff appointees who would be eligible to vote for the proposed nominee. All five (5) nominating physicians must certify that the nominee possesses all the qualifications set forth in Section 4.B.1.

(c) A final ballot shall be prepared for Vice President and may be mailed to each appointee

eligible to vote immediately following the annual meeting of the Medical Staff in alternate years, or a vote of the active staff may be taken at the annual meeting. The candidate who receives the majority vote of the Medical Staff Appointees eligible to vote, and present at the meeting (if the vote is taken at the annual meeting) or at the time the mail vote is taken, shall be elected. The election/selection of this individual shall become effective as soon as approved by the Board. The Vice President shall then serve from the conclusion of the joint BHS Medical Executive Committee Meeting referenced in Section 4.B.(2), above, for a term of two (2) years or until a successor has been elected and that election has been approved by the Board.

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

receives a majority vote, there shall then be successive balloting such that the name of the candidate receiving the fewest votes is omitted from each successive slate until a majority is obtained by one (1) candidate.

4.B.5. Removal of Officers: The BHS Medical Executive Committee, by a two-thirds majority vote and with approval of the Board, or the Board on its own motion may remove any Medical Staff officer for conduct detrimental to the interests of BHS, or if he is suffering from a physical or mental infirmity that renders him incapable of fulfilling the duties of his/her office, provided notice of the meeting at which such action takes place shall have been given in writing to such officer at least ten (10) days prior to the date of such meeting. The officer shall be afforded the opportunity to speak in his/her own behalf before the committee prior to the taking of any vote on his/her removal. Such removal will be effective when approved by the Board. 4.B.6. Vacancies in Office: If there is a vacancy in the office of the President of the Medical Staff prior to the expiration of the President’s term, the Vice President shall assume the duties and authority of the President for the remainder of the unexpired term. If there is a vacancy in the office of Vice President prior to the expiration of the Vice President’s term, the BHS Medical Executive Committee shall appoint another appointee possessing the qualifications set forth in Section 4.B.1 to serve out the remainder of the unexpired term, subject to Board approval. 4.B.7. Conflict of Interest: In any instance where an officer, committee chair, or member of any Medical Staff

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committee has a conflict of interest or is biased in any matter involving another Medical Staff appointee that comes before such individual or committee, such individual or member shall not participate in the discussion or voting on the matter and shall be excused from any meeting during that time, although that individual or committee member may be asked, and may answer, any questions concerning the matter before leaving. As a matter of procedure, the chair of that committee designated to make such a review shall inquire, prior to any discussion of the matter, whether any member has any conflict of interest or bias. The existence of a potential conflict of interest or bias on the part of any committee member may be called to the attention of the chair by any committee member with knowledge of the matter.

4.C. MEETINGS OF THE MEDICAL STAFF

4.C.1. Annual Staff Meeting:

The Medical Staff shall hold an annual meeting for the purpose of reporting the administrative and clinical progress of the hospital during the past year. Each appointee to the Active Staff shall be encouraged to attend the annual meeting.

4.C.2. Special Staff Meetings:

(a) Special meetings of the Medical Staff may be called at any time by the Board, the Chief

Executive Officer, the Chief Medical Officer, the President of the Medical Staff, a majority of the BHS Medical Executive Committee or a petition signed by not less than one fourth of the voting staff. In the event that it is necessary for the Staff to act on a question without being able to meet, the voting Staff may be presented with the question by mail, facsimile, e-mail, hand delivery, or telephone and their votes returned to the President by any of these same methods of delivery. Such a vote shall be valid so long as the question is voted on by a majority of the Staff eligible to vote.

(b) The Medical Staff appointees at BH, BHOH, and BPC may require the attendance of

the President of the Medical Staff and/or the Chief Executive Officer at a special meeting of the voting staff of the respective hospital. The petition to call the special meeting must be signed by not less than one fourth of the voting staff of the applicable BHS hospital. Any meetings called hereunder shall be held no later than two weeks after the date of the petition.

4.C.3. Quorum for Medical Staff Meeting:

Ten percent (10%) of the Staff eligible to vote shall constitute a quorum. The quorum must exist for any action to be taken.

4.D. COMMITTEE MEETINGS

4.D.1. Departmental Committee Meetings:

(a) Each departmental committee shall meet at times set by the chair of the department to

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review and evaluate the clinical work of the department and to discuss any other matters concerning the department. The agenda for the meeting and its general conduct shall be set by the chair. The Department Chair shall designate those clinical services that shall be represented at the Department meetings without a vote and shall request that the Chair of that Department designate the individual(s) from the designated clinical services.

i. Any member of the Active Medical Staff, with or without clinical privileges,

assigned to a Department committee shall be entitled to vote on matters coming before that committee.

ii. Additionally, representation from the Department of Primary Care may be

designated by the Chair of the Department of Primary Care to serve on all other Department committees without a vote. An administrative representative designated by the Chief Executive Officer shall attend all Department Committee Meetings to act as a liaison between the Department and Administration and to facilitate resolution of issues raised. The Chief Nursing Officer or Director of Nursing may attend the Department Committee Meetings without a vote.

(b) Psychologists and Advanced Practice Nurse Prescribers who meet the criteria below

shall be invited to attend the Department of Psychiatry meetings without a vote. For purposes of this Section, a Psychologist shall:

(1) Be a doctoral level licensed psychologist who is employed by, or under contract

with, Bellin Psychiatric Center to provide psychological services and be a member of the Courtesy Staff; and

(2) Perform such duties as are assigned to him or her by the Chair of the Department

of Psychiatry. The Advanced Practice Nurse Prescriber shall: (1) Be employed by, or under contract with, Bellin Psychiatric Center to provide

services; and (2) Perform such duties as are assigned to him or her by the Chair of the Department

of Psychiatry. 4.D.2. Nondepartmental Committee Meetings: All nondepartmental committees shall meet as needed, unless otherwise specified at a time set by the chair of the committee. The agenda for the meeting and its general conduct shall be set by the chair.

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4.D.3. Special Committee Meetings: (a) A special meeting of any committee may be called by the chair, the President of the

Medical Staff, the CEO, or by a petition signed by not less than one fourth of the members of the department or committee, but no less than two (2) members.

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

to meet, the voting members may be presented with the question, in person or by mail, facsimile, e-mail, hand delivery or telephone, and their vote returned to the chair of the committee, or his or her designee, within the required timeframe. Such a vote shall be binding so long as the question is voted on by a majority of the committee eligible to vote.

4.D.4. Electronic Meetings and Voting: The voting members of the Medical Staff, a department, or a committee may be presented with a question by mail, facsimile, e-mail, hand delivery, or telephone and their votes returned to the chairperson or his/her designee within the required timeframe and in accordance with the method designated in the notices. The question raised shall be determined in accordance with the vote of the majority of the responses returned within the required timeframe. 4.D.5. Quorum: Members present (either in person or through electronic participation or through voting participation under Section 4.D.4. above), but not fewer than three (3), shall constitute a quorum. The quorum must exist for any action to be taken. 4.D.6. Minutes: Minutes of each regular and special meeting of each committee shall be prepared and shall include a record of the attendance of members, of the recommendations made and of the votes taken on each matter. The minutes shall be signed by the presiding officer and copies thereof shall be sent to each department member prior to the next meeting and reported to the BHS Medical Executive Committee, and the Chief Executive Officer unless otherwise specified for certain committees elsewhere in these Bylaws. Each committee shall maintain a file of the minutes of each of its meetings and such minutes shall be retained in accordance with the BHS Record Retention Guidelines.

4. E. PROVISIONS COMMON TO ALL MEETINGS

4.E.1. Posting Notice of Meetings:

Notice of all meetings of the Medical Staff and regular meetings of committees shall be sent to each committee appointee at least five (5) days in advance of such meetings. The attendance of any individual at any meeting shall constitute a waiver of that individual's

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notice of said meeting. 4.E.2. Attendance Requirements: Appointees of the Medical Staff are encouraged to attend regular medical staff meetings and assigned committee meetings. 4.E.3. Rules of Order: Robert’s Rules of Order shall not be binding at Medical Staff meetings or elections, but may be used for reference in the discretion of the presiding officer for the meeting. Rather, specific provisions of these Bylaws, and Medical Staff, department or committee custom shall prevail at all meetings, and the department chair or committee chair shall have the authority to rule definitively on all matters of procedure. 4.E.4. Voting: Any individual who, by virtue of position, attends a meeting in more than one capacity shall be entitled to only one vote.

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PART 2 – COMMITTEE AND DEPARTMENT STRUCTURE

ARTICLE 5

CLINICAL DEPARTMENTS

5.A. LIST OF DEPARTMENTS

The following clinical departments are established. Additional departments or divisions of departments, as required from time to time, may be established by the Board after considering recommendations from the BHS Medical Executive Committee.

(a) Anesthesia and Surgery (b) Cardiovascular and Pulmonary Medicine (c) Emergency Medicine, Hospitalists, and Medical Sub-Specialty (d) Neuroscience and Orthopedic Surgery (e) Obstetrics/Gynecology and Neonatology (f) Oncology and Hematology (g) Pathology and Radiology (h) Primary Care (i) Psychiatry

All appointees of the Medical Staff shall be assigned to a department or departments and, when appropriate, to service or services.

5.B. LIST OF SERVICES WITHIN DEPARTMENTS

Medical specialties shall be called “Services” and shall function within the following specifically-assigned departments: (a) Department of Anesthesia and Surgery: Anesthesia, General Surgery, Ophthalmology,

Oral and Maxillofacial Surgery, Otolaryngology, Plastic Surgery, Podiatry, and Urology.

(b) Department of Cardiovascular and Pulmonary Medicine: Cardiac Electrophysiology,

Cardiology, Cardiothoracic Surgery, Pediatric Cardiology, Pulmonary Medicine, Sleep Medicine and Wound Care.

(c) Department of Emergency Medicine, Hospitalists, and Medical Sub-Specialty: Allergy

and Immunology, Critical Care, Critical Care/Pulmonary Disease, Dentistry, Dermatology, Emergency Medicine, Emergency Medicine/Family Medicine, Endocrinology, Gastroenterology, Infectious Disease, Internal Medicine Hospitalist, Nephrology, Occupational Medicine, and Pediatric Hospitalist.

(d) Department of Neuroscience and Orthopedic Surgery: Neurological Surgery,

Neurology, Orthopedic Surgery, Pain Medicine, Pediatric Neurology, Physical

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Medicine and Rehabilitation, Pediatric Rheumatology, and Rheumatology. (e) Department of Obstetrics/Gynecology and Neonatology: Maternal-Fetal Medicine,

Neonatal Perinatal Medicine, Obstetrics and Gynecology, and Gynecologic Oncology. A representative from Family Medicine with obstetrics privileges and a representative from Anesthesia shall attend the Department of Obstetrics/Gynecology and Neonatology meetings.

(f) Department of Oncology and Hematology: Hospice and Palliative Medicine,

Hospice/Physical Medicine and Rehabilitation, Integrative Medicine/Family Medicine, Medical Oncology, Pediatric Hematology-Oncology, Radiation Oncology. The Department of Oncology and Hematology shall have two subcommittees:

(1) The Cancer Subcommittee shall consist of at least six (6) Medical Staff appointees

including one (1) representative from each of the following specialties: Diagnostic Radiology, Pathology, General Surgery, Gynecologic Oncology, Medical Oncology, Radiation Oncology, and Palliative Care. In addition, the Cancer Committee shall include hospital representatives who serve in the roles of Cancer Program Administration, Oncology Nursing, Cancer Coach, Certified Tumor Registrar, Cancer Registry Quality Coordinator, Quality Improvement Coordinator, Clinical Research Coordinator, Cancer Program Manager, Cancer Conference Coordinator, and Community Outreach Coordinator. Additional ad hoc members may be added as needed for specific issues.

i. Duties:

The Cancer Subcommittee shall be responsible for goal setting, planning, initiating, implementing, evaluating and improving all cancer-related activities in the Cancer Program.

ii. Meetings, Reports and Recommendations: The Cancer Subcommittee shall meet as often as necessary to transact its business, but at least quarterly, shall maintain a permanent record of its findings, proceedings and actions, and shall make a report thereof after each meeting to the Department of Oncology and Hematology and the Chief Medical Officer.

(2) The Tumor Board shall be a committee of medical oncologists, general surgeons, pathologists, radiation oncologists, diagnostic and interventional radiologists and other members of the Medical Staff who have cases being presented.

(i) Duties: The Tumor Board shall be responsible for the concurrent case presentation in a

multidisciplinary approach to improve patient outcomes. (ii) Meetings, Reports and Recommendations:

This subcommittee shall meet weekly or as often as necessary to conduct its

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business and shall maintain a record of its finding, proceedings and actions, and shall make a report thereof after each meeting to the Department of Oncology and Hematology.

(g) Department of Pathology and Radiology: Diagnostic Radiology, Interventional

Radiology, and Pathology. (h) Department of Primary Care: Family Medicine, Internal Medicine, and Pediatrics. (i) Department of Psychiatry: Addiction Psychiatry, Child and Adolescent Psychiatry and

General Adult Psychiatry. A clinical service division may be formed by the majority vote of Active Staff appointees practicing medicine in the specialty, and upon approval and recommendation of the BHS Medical Executive Committee and approval by the Board. Each Department that includes multiple clinical services shall recognize a Division Lead for each clinical service. The Division Lead shall be elected by the Medical Staff members of the clinical service. The service may, upon approval and recommendation of the BHS Medical Executive Committee and Board, meet in separate meetings for the purposes of quality assurance/quality improvement and/or peer review. However, service meetings shall not take the place of the Department Meetings. A chair shall be elected by the service members. Minutes of the meetings shall be maintained.

5.C. FUNCTIONS OF DEPARTMENTS (a) Each clinical department shall recommend to the Systems Credentials Committee

written criteria for the assignment of clinical privileges within the department and each of its services. Such criteria shall be consistent with and subject to the Bylaws, policies, rules and regulations of the Medical Staff and the hospital. These criteria shall be effective when approved by the Board. Clinical privileges shall be based upon demonstrated education, training and experience, and continued clinical quality and volume standards within the specialty covered by the department.

(b) Each department or service shall conduct peer review and quality improvement in

accordance with the BHS Peer Review Policy and shall consider findings from ongoing monitoring and evaluation of the quality of care and treatment provided to patients in the credentialing and recredentialing of appointees within the department and other actions taken by the department. Records including resultant conclusions, recommendations and actions taken are maintained and reported through the quality assurance program.

(c) Each Department will participate in quality improvement utilizing improvement science

and tools to create sustainable, reliable solutions. (d) In discharging these review functions, each department and service shall report by

detailing its analysis of patient care to the BHS Medical Executive Committee whenever further investigation and appropriate action involving any individual member

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of the department is indicated. Copies of these reports shall be filed with the System Credentials Committee and the Chief Executive Officer.

(e) Each department will be given an opportunity to determine appropriate responsibilities

and limitations for graduate teaching program participants within the department. Oversight for performance is established in accordance with the “Residents, Medical Students, Nurse Practitioner Students, and/or Physician Assistant Students in Participatory Training Program Rotations” policy. Additionally, each department may recommend educational offerings through the Continuing Medical Education Committee.

(f) Each Department shall participate in BHS strategic planning and implementation

activities to achieve the strategic goals. 5.D. DEPARTMENT CHAIR (a) The chair of each department shall be an appointee to the Active Staff and hold clinical

privileges in their department. Chairs shall be certified by an appropriate specialty board or the Medical Staff affirmatively establishes comparable competence through the credentialing process. A department Chair position description is on file in the Medical Staff Services Department.

(b) The Nominating Committee described in Section 4.B.4 of these Bylaws, shall include

on their written ballot, recommendations from the hospital administration for the chair of each department (except the Department of Primary Care whose chair shall be elected by BMG) and nominations shall be received from the floor of the BHS Medical Executive Committee, provided however, that in a Department that includes multiple clinical services, the Chair of the Department shall rotate among the clinical services. A final ballot shall be prepared by the Nominating Committee and may be mailed to each appointee eligible to vote immediately following the annual meeting of the Medical Staff, or a vote of the Active Staff may be taken at the Annual meeting; provided, however, that an appointee may only be eligible to vote for the chair of the Department to which he or she is assigned. The candidate nominated for each Department who receives a majority vote of those Medical Staff appointees assigned to that Department who is otherwise eligible to vote and present at the meeting (if the vote is taken at the annual meeting) or at the time the mail vote is taken, shall be elected. The election of each chair shall become effective at the time of Board approval. The Initial term of the two-year appointment shall begin in accordance with Section 4.B, above. Each department chair is eligible to serve successive terms as long as he/she meets all other qualifications for the position. A vice-chair of each department shall be elected by the department, after receiving the recommendation of the chair. His/her tenure shall coincide with that of the chair.

(c) Removal of a chair (except the Chair of the Department of Primary Care) during his/her

term of office may be initiated by a two-thirds vote of all Active Staff appointees in the department. This removal shall be effective when it has been approved by the Board.

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5.E. FUNCTIONS OF DEPARTMENT CHAIR Each chair shall: (a) serve as a member of the BHS Medical Executive Committee and act as a liaison

between the Department and the BHS Medical Executive Committee; (b) be responsible for providing effective leadership of the Medical Staff

Department/Service; (c) be responsible for all clinically related activities of the department/service; (d) be responsible, in tandem with the department, for recommending criteria for clinical

privileges in the department; (e) be responsible to evaluate the professional performance of all individuals with clinical

privileges in the department, and make written recommendations to the Systems Credentials and BHS Medical Executive Committees as part of the appointment and reappointment process, delineation of clinical privileges for all applicants seeking clinical privileges in the department, and at such other times as may be indicated;

(f) be responsible to respond to reference requests from another facility or health plan for

verification of medical staff appointment and clinical privileges for a member of the department/service;

(g) be responsible in tandem with the department to evaluate qualifications and competence

of allied health professionals who function within the department and report and make recommendations to the Systems Credentials and BHS Medical Executive Committee;

(h) be responsible in tandem with the department for the ongoing assessment and

improvement of the quality of care and services provided; (i) provide assistance to Administration in the maintenance of quality monitoring

programs as appropriate; (j) provide assistance to Administration in the development and implementation of policies

and procedures that guide and support the provision of services; (k) provide assistance to Administration in the establishment and implementation of

orientation and continuing education of all department appointees; (l) provide assistance to Administration in administratively related activities including

departmental budget and planning, space and equipment needs, technology assessment, and other resources;

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(m) provide assistance to Administration in the comprehensive coordination and integration of interdepartmental and intradepartmental services;

(n) provide assistance to Administration in the integration of the department/services into

the hospital mission, vision, and strategic plan; (o) provide assistance to Administration in evaluating adequate numbers of qualified and

competent persons to provide care/services; (p) be responsible for assessing and recommending off-site sources of needed patient care

services not provided by the department or the hospital; (q) cooperate with Administration concerning the purchase of supplies and equipment; (r) enforce the Medical Staff Bylaws and rules within the department/service; (s) be responsible for maintaining the quality of the medical records of the department; and (t) represent the service in a medical advisory capacity to Administration and the

governing body. 5.F. VACANCIES IN OFFICE OF DEPARTMENT CHAIR In the event of a vacancy in the office of Department Chair, the Department Vice-Chair shall serve out the remainder of the unexpired term, subject to Board approval. 5.G. DEPARTMENT MEMBERS (a) Medical Staff appointees, except as otherwise provided for in these Bylaws, shall be

appointed by the President of the Medical Staff as members of appropriate departments and clinical service divisions (where appropriate) for a term commensurate with their individual Medical Staff appointment or reappointment periods and clinical privileges.

(b) The Chief Executive Officer, Chief Medical Officer, Administrative Vice President

assigned to the Department by the Chief Executive Officer, and President of the Medical Staff or their respective designees shall be members, ex officio, without a vote, on all departmental committees.

5.H. DIVISION LEADS (a) The Division Lead for each clinical service division (except those under the

Department of Primary Care, which are selected under the BMG Charter) shall be an appointee to the Active Staff and hold clinical privileges in his/her clinical service.

(b) At a meeting between sixty and thirty (30) days prior to the Annual Meeting of the Medical

Staff, each clinical service with a pending vacancy in the Division Lead position (except

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those within the Department of Primary Care) shall, with prior notice given to its members, receive nominations from its members for the Division Lead position. A vote shall be taken at that meeting to elect the Division Lead for the clinical service division. The candidate who receives a majority vote of those Medical Staff appointees eligible and present at the meeting shall be elected. The election of each Division Lead shall become effective at the time of BHS Medical Executive Committee approval. Each Division Lead is eligible to serve successive terms as long as he/she meets all other qualifications for the position.

(c) Removal of a Division Lead (except within the Department of Primary Care) during

his/her term of office may be initiated by a two-thirds vote of all Active Staff appointees in the clinical service division. This removal shall be effective when it has been approved by the BHS Medical Executive Committee.

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ARTICLE 6

NONDEPARTMENTAL COMMITTEES OF THE MEDICAL STAFF

6.A. STRUCTURE

6.A.1. Chair:

The President of the Medical Staff, in consultation with the Chief Executive Officer shall appoint all nondepartmental committee chairs and submit this recommendation to the Board for approval. The election of each nondepartmental chair shall become effective at the time of Board approval. All chairs shall be selected from the Active Staff. Appointments shall be for an initial term of two (2) years beginning according to Section 4.B., which may be renewed. Each chair is eligible to serve successive terms as long as he/she meets all other qualifications for the position.

6.A.2. Functions of Nondepartmental Committee Chair:

(a) Be responsible for identifying areas of risk, important aspects of quality care and

indicators used to monitor the care, to develop and implement the committee monitoring and evaluation process, assure committee participation in that evaluation process and report findings to the appropriate department chair and the BHS Medical Executive Committee.

(b) Provide input concerning credentials issues as requested by department chair or System

Credentials Committee. (c) Provide assistance upon request of the department chair or BHS Medical Executive

Committee. (d) At least once annually present a report to the BHS Medical Executive Committee of

actions taken by the Committee. 6.A.3. Members: (a) Members of each nondepartmental committee, except as otherwise provided for in these

Bylaws, shall be appointed for a two (2) year term by the President of the Medical Staff, in consultation with the Chief Executive Officer, with no limitation in the number of terms they may serve. All appointed members may be removed and vacancies filled by the President of the Medical Staff at his/her discretion.

(b) The Chief Executive Officer and the President of the Medical Staff or their respective

designees shall be members, ex officio without a vote, on all committees, except as otherwise provided in the Bylaws.

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6.B. BHS MEDICAL EXECUTIVE COMMITTEE 6.B.1. Composition: (a) The BHS Medical Executive Committee shall consist of the following:

� The President of the Medical Staff of BHS; � The Vice President of the Medical Staff of BHS; � The Past President of the Medical Staff of BHS; � The Chair of each Clinical Department � The President of Bellin Health Partners (previously known as Physician Partners

Limited (PPL)); � The Bellin Specialty Group President; � The Physician Lead for Bellin Health Oconto Hospital; � The Department of Primary Care Division Leads for Family Medicine, Internal

Medicine and Pediatrics; � One Advanced Practice Clinician representative (selected according to the Allied

Health Professional Policy); � The Chair of the Peer Review and Quality Committee; � The Chair of the Medical Informatics Committee; � The Chair of the System Credentials Committee; � The Chair of the Population Health Committee; � The Chair of the Medical Education Committee.

The Chairs of the Peer Review and Quality Committee, Medical Informatics Committee, Population Health Committee, Medical Education Committee and System Credentials Committee shall be members of the BHS Medical Executive Committee, but shall not vote on matters involving issues from their committees.

(b) All members of the BHS Medical Executive Committee shall be appointees of the

Active Staff of a BHS Facility or shall have a scope of practice under the BHS Allied Health Professionals Policy.

(c) The President of the Medical Staff of BHS shall be chair of the BHS Medical Executive

Committee. (d) The Chief Executive Officer or his/her designee, the Chair of the Board or his/her

designee, the Chief Medical Officer or his/her designee, the Chief Nursing Officer, and two Administrative Vice Presidents designated by the Chief Executive Officer shall attend meetings of the BHS Medical Executive Committee on an ex officio basis and participate in its discussions, but without a vote.

6.B.2. Duties: (a) The BHS Medical Executive Committee is delegated the primary authority over

activities related to the functions of the Medical Staff. The BHS Medical Executive Committee is responsible for reviewing and making any necessary recommendations to

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the Board with regard to the following:

(1) the structure of the Medical Staff; (2) the process used to review credentials and to delineate individual clinical privileges; (3) applicants for Medical Staff appointment; (4) a delineation of clinical privileges for each eligible individual; (5) the participation of the Medical Staff in performance improvement activities; (6) the process by which Medical Staff appointment may be terminated; (7) hearing procedures; (8) the sources of clinical patient care services to be provided through contracts; (9) reports and recommendations from Medical Staff committees, departments, and

other groups as appropriate; (10) the overall quality and efficiency of professional patient care services provided by

individuals with clinical privileges; (11) activities related to patient safety; (12) the process of analyzing and improving patient satisfaction; (13) continuing medical education activities and undergraduate and graduate medical

education; (14) reviewing, at least every three years, the Bylaws, policies, rules and regulations,

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

(15) identifying community health needs and participation in BHS strategic goal

setting and programs to meet those goals; and (16) performing any other functions as are assigned to it by these Bylaws, the

Credentials Policy or other applicable policies. (b) The BHS Medical Executive Committee is empowered to act on behalf of the Medical

Staff in the intervals between Medical Staff meetings (the officers are empowered to act in urgent situations between BHS Medical Executive Committee meetings) and shall serve as the final decision-making body of the Medical Staff in accordance with the Medical Staff Bylaws and provide oversight for all medical staff functions.

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(c) In addition, the duties of the BHS Medical Executive Committee shall be to:

(1) provide liaison among Medical Staff, the Chief Executive Officer and the Board;

(2) recommend action to the Chief Executive Officer on matters of hospital administration and management; and

(3) ensure that the Medical Staff is kept abreast of the CMS Conditions of Participation and the hospital accreditation standards of the BHS accreditation organization and informed of the accreditation status of the BHS hospitals; by actively involving the Medical Staff appointees in the accreditation process which shall include participation in the BHS hospital survey and final critique session.

6.B.3. Meetings, Reports, and Recommendations: The BHS Medical Executive Committee shall meet as often as necessary, but not less than quarterly, to transact pending business. The President will maintain reports of all meetings, which reports shall include the minutes of the various departmental and nondepartmental committees. The BHS Medical Executive Committee shall take actions, and evaluate the effectiveness of such actions when opportunities to improve care are identified or when important problems in patient care and clinical performance arise. Copies of all minutes and reports of the BHS Medical Executive Committee shall be transmitted to the Chief Executive Officer routinely as prepared, and important actions of the BHS Medical Executive Committee shall be reported to the Staff as a part of the BHS Medical Executive Committee’s report at Staff meetings. Recommendations of the BHS Medical Executive Committee shall be transmitted to the Board with a copy to the Chief Executive Officer. 6.B.4. Quorum: The presence of thirty-three percent (33%) of the BHS Medical Executive Committee shall constitute a quorum. This quorum must exist for any action to be taken. 6.C. BYLAWS AND GOVERNANCE The following committees shall function under the category of Bylaws and Governance and shall be represented on the BHS Medical Executive Committee through the Chair of the System Credentials Committee: 6.C.1 BYLAWS COMMITTEE

6.C.1.a. Composition: The Bylaws Committee shall consist of a minimum of five persons from the Active Staff appointed by the President of the Medical Staff, including a member of the System Credentials Committee, with a vote; at least one representative from BHOH and BPC, each

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with a vote; one representative from Administration, without a vote; and one advanced practice clinician, appointed by the APC Council, without a vote. 6.C.1.b. Duties:

The Bylaws Committee shall review the Bylaws of the Medical Staff and associated documents at least biennially and recommend amendments thereto to the BHS Medical Executive Committee. This review shall include, but not be limited to, the Medical Staff rules and regulations and appointment and reappointment application forms. In addition, the committee shall receive and consider all recommendations for changes in these Bylaws by the Board, and departmental or nondepartmental committee of the Medical Staff, the Chief Executive Officer, Chief Medical Officer and any individual appointed to the Medical Staff. 6.C.1.c. Meetings, Reports, and Recommendations: The Bylaws Committee shall meet as often as necessary to fulfill its duties, shall maintain a permanent record of its activities, and shall report its recommendations to the BHS Medical Executive Committee and the Chief Executive Officer. 6.C.2. PHYSICIAN AND APC HEALTH COMMITTEE 6.C.2.a. Composition: The Physician and APC Health Committee shall be a composed of at least five (5) Medical Staff appointees who are willing to serve and are selected for specific expertise and experience. Members shall be appointed by the President of the Medical Staff. Initial appointments are for three (3) year terms; with no restrictions on the number of terms members may serve. 6.C.2.b. Duties: In order to maintain and improve the quality of care and assist staff appointees in the maintenance of appropriate standards of personal performance, the Physician and APC Health Committee is responsible for recognizing and evaluating issues related to the health, well-being, or impairment of Medical Staff appointees and Advanced Practice Clinicians. The Physician and APC Health Committee is advisory and reports to BHS Medical Executive Committee and other appropriate Medical Staff committees as the BHS Medical Executive Committee designates. The Committee’s purpose is to attend with compassion to the needs of the Medical Staff appointee or Advanced Practice Clinician in question. The Committee has no authority to take disciplinary action. The Physician and APC Health Committee is the identified point within the BHS Facility where information and concerns about health of an individual Medical Staff appointee or Advanced Practice Clinician can be presented for consideration and evaluation.

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6.C.3. SYSTEM CREDENTIALS COMMITTEE

6.C.3.a. Composition: (a) The System Credentials Committee shall consist of at least seven (7) appointees to the

Active Staff of Bellin Hospital, Bellin Medical Group, BHOH and Bellin Psychiatric Center. There shall be at least one member from Bellin Hospital, Bellin Medical Group, BHOH and Bellin Psychiatric Center. Particular consideration is to be given to Past Presidents of the Medical Staff, past Credentials Committee members, past BHS Medical Executive Committee members, and past department chairs, and to other physicians knowledgeable in the credentialing and quality improvement processes.

(b) The Board or designee shall appoint, and may remove, the members of the System

Credentials Committee. Members shall be appointed for a term of five (5) years, provided that member terms shall be staggered such that no more than two members’ terms expire in the same year. Members may serve additional terms.

(c) Service on the System Credentials Committee shall be considered as the primary

Medical Staff obligation of each member of the System Credentials Committee.

6.C.3.b. Duties:

The System Credentials Committee shall, in accordance with these Bylaws: (a) review the credentials of applicants for appointment and reappointment to the Medical

Staff and for clinical privileges at a BHS Facility, conduct a thorough review of the applications, interview such applicants as may be necessary, and make a written report of its findings and recommendations;

(b) review, as may be requested, all information available regarding the current clinical

competence and behavior of persons currently appointed to the Medical Staff and, as a result of such review, make a written report of its findings and recommendations;

(c) review, consider, and make recommendations regarding appropriate threshold

eligibility criteria for clinical privileges within BHS, including specifically as set forth in Section 9.A.3 (“Clinical Privileges for New Procedures”) and Section 9.A.8 (“Clinical Privileges that Cross Specialty Lines”); and

(d) review, consider, and make recommendations regarding allied health professionals, as

set forth in the Allied Health Professionals Policy.

6.C.3.c. Meetings, Reports, and Recommendations: (a) The System Credentials Committee shall meet as often as necessary, but at least

quarterly, to accomplish its duties. The System Credentials Committee shall maintain a permanent record of its proceedings and actions and shall report its recommendations to

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the BHS Medical Executive Committee, the Chief Executive Officer, and the Board. (b) For any regular or special meeting of the System Credentials Committee, the presence

of at least three of the persons eligible to vote shall constitute a quorum, provided that a representative of the BHS Facility where the applicant has applied for privileges is present and votes. Where necessary, in order to meet the quorum requirement, members of the Committee may appear by telephone provided there is a speaker phone available that allows the member to participate in the discussion and the member is provided with any documents prior to the meeting.

(c) The Chair of the System Credentials Committee shall be available to meet with the

Chief Executive Officer and the Board (or its designated committee) on all recommendations made by the System Credentials Committee.

6.C.4. UTILIZATION REVIEW COMMITTEE The Utilization Review Committee shall adhere to the Conditions of Participation for Hospitals according to the Code of Federal Regulations-42 CFR 482.30 Utilization Review.

6.C.4.a. Composition: The Utilization Review Committee shall consist of at least two (2) Medical Staff appointees serving as medical advisors, of which one (1) is designated Chair, one (1) representative from each of BMH, BPC, and BHOH one (1) Revenue Audit Coordinator, one (1) representative from the clinical documentation resource team, and one (1) representative from the health system leadership team. Additional ad hoc members may be added as needed to represent specific areas of expertise.

6.C.4.b. Duties: The Committee shall: (a) review and recommend practices, protocols, and utilization of clinical resources within

the health system in order to understand and improve resource utilization and assure compliance in all aspects of care at BHS Facilities;

(b) review and recommend opportunities to create system-wide utilization management policies to improve compliance and financial stewardship in the patient care environment;

(c) identify processes or patient care situations requiring closer study and understanding in

order to address opportunities for improvement in the healthcare environment, or refer matters to secondary review when necessary or appropriate in the committee’s opinion;

(d) assist the Utilization Management teams in identifying circumstances requiring

physician peer assessment and intervention related to regulatory or compliance situations;

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(e) perform periodic performance review as required by the regulatory and accrediting bodies.

(f) serve as a resource to members of the Medical Staff, Utilization Management teams, case managers and Administration on utilization management issues;

(g) develop and implement policies which serve to clarify and direct practices and

protocols related to utilization management and processes; (h) coordinate data reporting with other quality committees, as appropriate; and (i) review and approve Utilization Management Plan. 6.D. MEDICAL EDUCATION

The following committees shall function under the category of Medical Education. The Chair of the Medical Education Committee shall represent medical education at the BHS Medical Executive Committee on an ad hoc basis.

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6.D.1 CONTINUING MEDICAL EDUCATION COMMITTEE 6.D.1.a. Composition: The Continuing Medical Education Committee shall consist of at least three (3) Active or Provisional Staff appointees (including the Physician Education Coordinator), a representative of Nursing Service, a representative of System Quality, a representative of the Allied Health Professionals Staff, the health science librarian, a health system administrative representative, and others as appointed by the Chief Executive Officer. The Chair of the Continuing Medical Education Committee shall hold a three (3) year term. The Continuing Medical Education Committee shall review and recommend system needs from other hospital committees and departments that address staff education throughout BHS. 6.D.1.b. Duties: The Continuing Medical Education Committee shall advance and support the mission of the BHS Continuing Medical Education program by: (a) coordinating continuing medical education activities to align with the BHS Strategic

and quality initiatives which address the improvement of patient care; (b) offering educational opportunities for the Medical Staff and other providers affiliated

with BHS, with the objective of improving healthcare services provided throughout the Northeastern Wisconsin region;

(c) providing educational activities for all specialties of the Medical Staff utilizing various

teaching and learning modalities such as seminars, lectures, workshops, self-study opportunities, etc.;

(d) developing and planning, or participating in, activities of continuing medical education

that are designed to keep the Medical Staff informed of significant new developments and new skills in medicine and that are responsive to feedback from our target audience;

(e) identifying the educational needs and interests of the Medical Staff and planning and

providing, where appropriate, learning experiences in response to identified needs and interests; (f) evaluating the satisfaction of the participants of the educational activities by inquiring if

the objectives of the programs were met according to their expectations and eliciting opportunities for improvement;

(g) analyzing, on a continuing basis, the professional library needs of the organization; (h) acting upon continuing medical education recommendations from the BHS Medical

Executive Committee, the departments or other committees; and

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(i) cooperating, where appropriate, with universities and other institutions in postgraduate

and Medical Staff continuing education. 6.D.1.c. Meetings, Reports, and Recommendations: The Continuing Medical Education Committee shall meet at least four (4) times per annum, shall maintain a permanent record of its findings, proceedings and actions, and shall make a report thereof to the BHS Medical Executive Committee, the Chair of the Medical Education Committee and the Chief Executive Officer. 6.D.2 MEDICAL EDUCATION COMMITTEE (for Undergraduate and Graduate Medical Education) 6.D.2.a. Composition:

The Medical Education Committee shall consist of at least ten (10) physician members and one (1) Advance Practice Clinician who are actively teaching and represent the medical specialties involved in teaching in BHS Facilities. Members shall be appointed by the Chief Executive Officer, including at least one representative from BPC.

6.D.2.b. Duties: The scope of the Medical Education Committee shall be to expand and enhance the delivery Medical Education within Bellin Health System by: (a) providing overall vision for the program in collaboration with faculty, Administration,

and the University-based directors;

(b) managing balance between capacity and demand for medical education at Bellin Health;

(c) prioritizing relationships with educational institutions with which Bellin Health collaborates;

(d) educating leadership and providers on requirements for successful medical education at Bellin Health;

(e) assuring compliance with requirements for medical education;

(f) serving as ambassadors for Bellin’s Medical Education Program and participating in the

program’s teaching opportunities;

(g) actively working with the Physician Education Coordinator to maintain ongoing affiliations as well as recruit new teaching sites/affiliates;

(h) motivating, supporting, and mentoring colleagues in their teaching;

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(i) participating in curriculum development when needed;

(j) attending clerkship/preceptorship meetings when applicable to specialty; and

(k) being responsible for working with the University-based Clerkship Directors, fellow Medical Education Committee members, and the Physician Education Coordinator to facilitate the instruction of third and fourth year medical students, nurse practitioner students and physician assistant students, as well as residents.

6.D.2.c. Meetings, Reports, and Recommendations: The Medical Education Committee will meet at least quarterly. Records of meetings shall be kept by the Physician Education Coordinator and the Committee shall make a report thereof to the BHS Medical Executive Committee and the Chief Executive Officer. 6.E. CLINICAL QUALITY The following committees shall function under the category of Clinical Quality and shall be represented on the BHS Medical Executive Committee through the Chair of the Peer Review and Quality Committee:

6.E.1. INSTITUTIONAL REVIEW BOARD The Institutional Review Board functions independently of, but in coordination with, other committees within Bellin Health System. The Institutional Review Board makes its independent determination whether to approve or disapprove research protocols based upon whether or not human subjects are adequately protected. The Institutional Review Board reports to the BHS Medical Executive Committee for informational purposes and receives its authority from the Health System Board. 6.E.2. INFECTION PREVENTION COMMITTEE 6.E.2.a. Composition:

The Infection Prevention Committee shall be a System committee responsible to the Medical Staff. Representation from the following clinical services shall be appointed: Surgery, Internal Medicine, Infectious Diseases, Pediatrics, and Pathology. Representatives from Administration, Nursing Division Quality Assurance, Pharmacy, Microbiology, the operating suites, Employee Health, and the Infection Prevention practitioner shall attend on a regular basis, including at least one representative from each of the BHS hospitals. Other Medical Staff and hospital department representatives shall attend on a consultative basis. 6.E.2.b. Duties: The Infection Prevention Committee shall be responsible for the surveillance of inadvertent hospital infection potentials, the review and analysis of actual infections, the promotion of a

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preventive and corrective program designed to minimize infection hazards, and the supervision of infection control in all phases of the hospital's activities. The Infection Prevention Committee through its chairperson is vested with the authority to institute surveillance activities and any appropriate infection prevention measures or studies when there is reasonably felt to be a danger to any patient or personnel. The committee shall: (a) provide standard criteria for reporting all types of infections occurring in patients with

no evidence of infection upon admission. These nosocomial infections may include clean surgical wounds (category A), respiratory infections postop, and septicemias related to the use of intravascular catheters;

(b) investigate any occurrence of nosocomial infections that exceed usual base line or

threshold levels, sentinel cases of unusual nosocomial infections, and infections due to unusual pathogens;

(c) focus their review on those infections that present the potential for prevention or

intervention to reduce the risk of future occurrence; (d) review and approve annually, all policies and procedures related to infection prevention

and document in committee minutes; and (e) provide or assist in employee health activity and in-service education on infection prevention. 6.E.2.c. Meetings, Reports, and Recommendations: The Infection Prevention Committee shall meet at least quarterly, shall maintain a permanent record of its findings, proceedings and actions, and forward minutes to the Medical Staff through the BHS Medical Executive Committee, to the Chief Executive Officer, the Chief Nursing Officer and the Performance Plan Steering Team.

6.E.3. PHARMACY AND THERAPEUTICS COMMITTEE

6.E.3.a. Composition:

The Pharmacy and Therapeutics Committee shall consist of at least six (6) Medical Staff appointees and shall include representation from the adult hospitalist service, the intensivist service, the Department of Anesthesia and Surgery, the Department of Oncology and Hematology, and the Department of Primary Care, including at least one representative from each of the BHS hospitals. In addition, the Pharmacy and Therapeutics Committee shall include one (1) representative each from Nursing Service, Pharmacy Services, and System Administration. Additional ad hoc members from the Infectious Disease service and from Nutrition Services, as well as the Medication Safety Officer, may be added as needed for special issues. The Pharmacy Services representative will serve as coordinator of the committee.

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6.E.3.b. Duties:

The Committee shall be responsible for: (a) the review of the appropriateness of empiric and therapeutic use of drugs through the

analysis of individual or aggregate patterns of drug practice; (b) the development of policies and procedures relating to the selection,

prescribing/transcription, dispensing, administration, monitoring and outcomes of drugs and diagnostic testing materials;

(c) the review of significant preventable drug reactions and medication errors; (d) the maintenance of a formulary or drug list; (e) the evaluation and, if appropriate, the approval of protocols concerned with the use of

investigational or experimental drugs; (f) the review of the appropriateness (safety, cost and effectiveness) of the prophylactic,

empiric and therapeutic use of major drug classes in the hospital; and (g) making recommendations to improve patient safety in connection with the

administration of drugs. 6.E.3.c. Meetings, Reports, and Recommendations: (a) The Pharmacy and Therapeutics Committee shall meet at least every other month to

transact its business. It shall maintain a permanent record of its findings, proceedings and actions, and shall make a report thereof after each meeting to the BHS Medical Executive Committee and the Chief Executive Officer.

(b) The committee shall make recommendations and report to the BHS Medical Executive

Committee for its consideration and appropriate action, any situation involving questions of the clinical competence, professional ethics, patient care, infraction of system or Medical Staff Bylaws or rules or unacceptable conduct on the part of any individual appointed to the Medical Staff.

6.E.4. TRANSFUSION COMMITTEE ON BLOOD USAGE

6.E.4.a Composition:

The Transfusion Committee on Blood Usage shall consist of at least four (4) Medical Staff appointees, the Blood Bank Manager and representation from the Nursing Service Administration and Surgery.

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6.E.4.b. Duties:

The Committee shall perform comprehensive reviews of all blood components including albumin. Each confirmed transfusion reaction shall be evaluated. The Committee shall also develop or approve those policies and procedures relating to the distribution, handling, use and administration of blood and blood products. A review is made of the ordering practices and adequacy of transfusion services to meet patient needs. For known or suspected problem identification, a screening mechanism may be used with clinically valid criteria.

6.E.4.c. Meetings, Reports, and Recommendations:

(a) The Transfusion Committee on Blood Usage shall meet as often as necessary to transact its

business, but at least quarterly, shall maintain a permanent record of its findings, proceedings and actions, and shall make a report thereof after each meeting to the BHS Medical Executive Committee and the Chief Executive Officer.

(b) The committee shall make recommendations and report to the BHS Medical Executive

Committee for its consideration and appropriate action, any situation involving questions of the clinical competence, professional ethics, patient care, infraction of hospital or Medical Staff Bylaws or rules of unacceptable conduct on the part of any individual appointed to the Medical Staff.

6.E.5. PEER REVIEW AND QUALITY COMMITTEE 6.E.5.a. Composition: The Peer Review and Quality Committee shall consist of the CMO, or President of the Medical Staff in the absence of a CMO, Chair of the Peer Review and Quality Committee, two (2) additional physicians, one (1) Advanced Practice Clinician, Director of System Quality, Medication Safety Officer, Risk Manager, Director of Nursing, Senior Vice President of Quality, and two (2) peer review coordinators. Additional ad hoc members may be added as needed for specific issues. 6.E.5.b. Duties: The Committee shall be responsible for: (a) evaluation of clinical cases within the health system that cross departments in a

significant manner in order to improve the quality of care provided in BHS Facilities; (b) evaluation of opportunities to create hospital-wide clinical policies to improve care and

patient safety; (c) selecting a peer review panel with expertise in a given subject or in a specific medical

specialty, or referral of matters to external review, when necessary or appropriate in the committee’s opinion;

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(d) assisting Departments in identifying circumstances requiring peer review within the

Department; (e) performing the periodic performance review required by the regulatory and accrediting

bodies. 6.E.5.c. Meetings, Reports, and Recommendations: (a) The Peer Review and Quality Committee shall meet as often as necessary to transact its

business, but at least quarterly, shall maintain a permanent record of its findings, proceedings and actions, and shall make a report thereof after each meeting to the BHS Medical Executive Committee and the Chief Medical Officer.

(b) The committee shall make a recommendation and referral to the appropriate Medical

Staff Departments for its consideration and appropriate action, any situation involving questions of the clinical competence, professional ethics, patient care, infraction of hospital or Medical Staff Bylaws or rules or unacceptable conduct on the part of any individual appointed to the Medical Staff.

(c) The committee shall make recommendations and report to the BHS Medical Executive

Committee for its consideration and appropriate action, any issues involving system changes that do not relate to an individual appointee.

(d) The committee minutes, reports, and recommendations shall be deemed protected by

the peer review privilege under the Health Care Quality Improvement Act, and Wisconsin Statutes.

6.E.5.d. Quorum The presence of at least three (3) members of the Peer Review and Quality Committee, consisting of at least two (2) physicians and one (1) representative from Administration, shall constitute a quorum. 6.F. MEDICAL INFORMATICS COMMITTEE 6.F.1. Composition: The Medical Informatics Committee shall consist of physicians or Advanced Practice Clinicians representing the following clinical services, as needed: Primary Care, Hospitalists, Obstetrics and Gynecology, Emergency Medicine, Surgery, Cardiovascular Medicine, Neurology, Oncology, Ophthalmology and Otolaryngology, Cardiothoracic Surgery, Critical Care, Physical Medicine and Rehabilitation, Endocrinology, Pulmonology, Radiology, Pathology, Psychiatry and Orthopedics, which shall include at least one representative from BHOH. The Chief Executive Officer shall appoint the Chair of the Medical Informatics Committee, who will serve on the BHS Medical Executive Committee.

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In addition, the Medical Informatics Committee shall include individuals representing Administration, Information Technology Clinical Leaders, Information Technology Clinical Analysts, Information Technology Training and Optimization, and Zone Leaders. 6.F.2. Duties: The Medical Informatics Committee shall guide the configuration of the patient’s electronic health record and the clinical workflows that support improvement in clinical quality, reduced variation, and increased efficiency of information collection and use. The committee shall be responsible for: (a) identifying and facilitating innovation and spreading best practice; (b) providing communication and change management support to physicians and advanced

practice providers as Bellin plans, designs and optimizes the patient’s electronic medical record;

(c) reviewing/creating order sets; (d) reviewing changes to the patient’s electronic medical record; (e) reviewing new clinical decision-support tools; (f) assessing and approving hardware to support clinical practice; (g) providing feedback on electronic health record training, optimization and orientation

processes; (h) updating policies and procedures related to electronic health record use; and (i) reviewing proposed upgrades; and (j) approving and reviewing Best Practice Alerts for BHS. 6.F.3. Meetings, Reports, and Recommendations: The Medical Informatics Committee shall meet at least monthly to transact its business. It shall maintain a record of its findings, proceedings and actions, and shall make a report thereof to the BHS Medical Executive Committee and the Chief Medical Officer as necessary.

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6.G. POPULATION HEALTH COMMITTEE 6.G.1. Composition: The Population Health Committee shall consist of at least three (3) members, including, the Chair of Population Health Committee and at least one representative from Bellin Health Partners Clinical Integration Committee, at least one member of the Department of Primary Care, the Vice President of Business Health, the Team Leader of Redesign, and others assigned by the Chair of the Population Health Committee, to include representation from each population segment (panel, condition, employer, payer, and community). 6.G.2. Duties: The Population Health Committee shall advance and support the Population Health strategies for individuals in all population segments. The committee shall be responsible for: (a) guiding the development and maintaining the ongoing integrity of the standardized

Population Health framework; (b) providing the overall vision for the Population Health strategy; (c) building knowledge of the Population Health framework and competencies throughout

the entire system; and

(d) serving as ambassadors for Bellin Health Population Health work.

6.G.3. Meetings, Reports, and Recommendations: (a) The Population Health Committee shall meet as often as necessary, but not less than quarterly. (b) The Population Health Committee shall maintain a permanent record of its activities,

and shall make a report thereof to the BHS Medical Executive Committee and the Chief Executive Officer.

6.H. CREATION OF STANDING COMMITTEES The BHS Medical Executive Committee may, by resolution, and upon approval of the Board, without amendment of these Bylaws, establish additional committees to perform one or more Staff functions. In the same manner, the BHS Medical Executive Committee may by resolution and upon approval by the Board dissolve or rearrange committee structure, duties or composition as needed, to better perform the Medical Staff functions. Any function required to be performed by these Bylaws which is not assigned to a standing or special committee shall be performed by the BHS Medical Executive Committee.

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6.I. SPECIAL COMMITTEES Special committees shall be created and their members and chair shall be appointed by the President of the Medical Staff with the approval of the Board as required. Such committees shall confine their activities to the purpose for which they were appointed, and shall report to the BHS Medical Executive Committee.

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PART 3 – CREDENTIALING, PRIVILEGING, AND PEER REVIEW

INTRODUCTION This part describes the credentialing and peer review processes for physicians, dentists, and podiatrists who desire to practice within Bellin Health System (“BHS”). It outlines the procedure for assessing an individual’s qualifications to provide patient care services, the manner in which that individual is authorized to provide those services, and the process for limiting or revoking that authorization based on concerns with clinical competence and/or professional conduct. All credentialing and peer review processes described in these Bylaws shall be subject to the confidentiality provisions described in Section 15.A. Qualified physicians, dentists, and podiatrists shall be appointed to the Medical Staff and shall be granted clinical privileges at one or more facilities that comprise Bellin Health System (individually, “BHS Facility” or collectively, “BHS Facilities”), provided they meet the criteria for the exercise of clinical privileges at that particular BHS Facility. The granting of clinical privileges at any particular BHS Facility does not permit an individual to exercise those clinical privileges at any other BHS Facility unless the individual has formally requested, and has been granted permission to do so, in accordance with the terms of these Bylaws.

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ARTICLE 7

APPOINTMENT TO THE MEDICAL STAFF

7.A. QUALIFICATIONS FOR APPOINTMENT

7.A.1. General:

Appointment to the Medical Staff is a privilege which shall be extended only to professionally competent individuals who continuously meet the qualifications, standards, and requirements set forth in these Bylaws and in such policies as may be adopted by the Board (or its designated committee). All individuals practicing medicine, dentistry, or podiatry at a BHS Facility, unless excepted by specific provisions of these Bylaws, must first have been appointed to the Medical Staff. Except where otherwise noted, these Bylaws applies to members of the Medical Staff at all BHS Facilities.

7.A.2. Specific Qualifications:

Only physicians, dentists, and podiatrists who satisfy the following conditions shall be eligible for appointment to the Medical Staff: (a) have a current, unrestricted license to practice in the State of Wisconsin; (b) where applicable, have current, unrestricted Drug Enforcement Administration and

State of Wisconsin controlled substance certificates; (c) be located close enough to provide a physical response time of less than 30 minutes

when on call for the BHS hospital and to fulfill their Medical Staff responsibilities;

(d) provide timely and continuous care for their patients in the BHS Facility in which they practice;

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

amounts satisfactory to BHS; (f) have not been convicted of Medicare, Medicaid or other governmental or private third-

party payer fraud or program abuse, nor have been required to pay civil penalties for the same;

(g) have not been excluded from participation in Medicare, Medicaid or other federal

health program; (h) have not been convicted of, or entered a plea of guilty or no contest to, any felony (no

time limitation), or to any misdemeanor (during the previous 10-year period) relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, or violence;

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(i) where applicable, have successfully completed a residency training program approved by the Accreditation Council for Graduate Medical Education (“ACGME”) or the American Osteopathic Association (“AOA”) in the specialty in which the applicant seeks clinical privileges. Oral and Maxillofacial Surgeons shall have completed a postgraduate program in oral surgery accredited by the American Association of Oral and Maxillofacial Surgery and/or the Commission on Dental Education of the American Dental Association. Podiatrists shall have completed a residency training program of a duration commensurate with that required by the privileges requested. (This requirement shall be applicable only to those individuals who apply for initial staff appointment and clinical privileges on or after the date these Bylaws are adopted.) The Board may grant exceptions when the applicant is enrolled in an approved residency program or fellowship program;

(j) where applicable, are actively participating in the examination process or board certified

within five (5) years of completion of a training program (i.e. the residency or fellowship program in the specialty for which the applicant is requesting privileges as described on the BHS delineation of privileges form) by the appropriate specialty board of the American Board of Medical Specialties, the Bureau for Osteopathic Specialists, or by a podiatric specialty board recognized by the Council on Podiatric Medical Education of the American Podiatric Medical Association, and satisfy maintenance of certification / recertification requirements of the applicable specialty board. Failure to satisfy these requirements after three consecutive testing cycles shall be deemed a failure to meet eligibility criteria for Medical Staff appointment and shall be deemed an automatic relinquishment of the appointment unless such requirement is waived or extended by the Board of Directors after considering the specific education, training, experience, and competence of the individual in question and the needs of the hospital and community. (Relinquishment of the appointment is not reportable to the National Practitioner Data Bank when a healthcare organization's medical staff policy requires board certification.);

(k) are eligible for clinical privileges at a BHS Facility; (l) agree to fulfill all responsibilities regarding emergency call; (m) have never had Medical Staff appointment or clinical privileges denied, revoked,

resigned, relinquished, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct;

(n) any appointees seeking clinical privileges in a BHS clinic should have a current

contract to provide professional medical services for patients of BHS; and (o) can document their: (1) background, experience, relevant training, judgment and demonstrated competence

as defined by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative, including assessment of patient care, interpersonal and communication skills, professionalism,

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medical knowledge, practice-based learning and improvement and systems-based practice; (2) adherence to the ethics of their profession; (3) good reputation and character; (4) ability to perform the clinical privileges requested safely and competently; and (5) ability to work harmoniously with others sufficiently to convince BHS that all

patients treated by them at a BHS Facility will receive quality care and that the BHS Facility and Medical Staff will be able to operate in an orderly manner.

The qualifications set forth in paragraphs (a) through (o) above are deemed to be threshold criteria for appointment to the Medical Staff.

7.A.3. Waiver of Criteria:

(a) Any individual who does not satisfy a criterion may request that it be waived. The

individual requesting the waiver bears the burden of demonstrating that his or her qualifications are equivalent to, or exceed, the criterion in question.

(b) The Board may grant waivers in exceptional cases after considering the findings of the

Credentials Committee, BHS Medical Executive Committee, Committee on Health System Performance, or other committee designated by the Board, the specific qualifications of the individual in question, and the best interests of BHS and the community it services. The granting of a waiver in a particular care is not intended to set a precedent for any other individual or group of individuals.

(c) No individual is entitled to a waiver or to a hearing if the Board determines not to grant

a waiver. (d) A determination that an individual is not entitled to a waiver is not a “denial” of

appointment or clinical privileges.

7.A.4. No Entitlement to Appointment:

No individual shall be entitled to appointment to the Medical Staff or to the exercise of particular clinical privileges at any BHS Facility merely by virtue of the fact that such individual: (a) is licensed to practice a profession in the State of Wisconsin or any other state, (b) is a member of any particular professional organization, (c) has had in the past, or currently has, medical staff appointment or clinical privileges at

any hospital or health care facility,

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(d) resides in the geographic service area of a BHS Facility, or (e) is a participating provider in Medicare, Medicaid, any managed care plan, insurance

plan, HMO, PPO, or other entity. 7.A.5. Nondiscrimination Policy: No individual shall be denied medical staff membership, appointment, or clinical privileges on the basis of gender, race, creed, religion, color, or national origin, or on the basis of any criteria unrelated to the delivery of quality patient care at a BHS Facility, to professional qualifications, or to the purposes, needs, and capabilities of a BHS Facility. 7.A.6. Professional Conduct: Individuals appointed to the Medical Staff are expected to relate in a positive and professional manner to other health care professionals, and to cooperate and work collegially with the Medical Staff leadership, management and personnel. Disruptive conduct and behavior, specifically including threatening or abusive language and actions, is unacceptable and below the standard expected of appointees to the Medical Staff. 7.A.7. Participation in Organized Health Care Arrangement: Bellin Health System is a clinically integrated care setting where patients receive health care services from more than one provider. As such, BHS and its Medical Staff operate as an Organized Health Care Arrangement (as that term is defined by the Health Insurance Portability and Accountability Act (“HIPAA”)). Participation in this Organized Health Care Arrangement is an essential requirement for Medical Staff appointment. In order to comply with the Privacy Notice requirements of the Health Insurance Portability and Accountability Act, Bellin and its Medical Staff will adopt a single Privacy Notice for patients receiving services at a BHS Facility which will allow Bellin and the Medical Staff Appointees involved in the patient’s care to share protected health information with each other as necessary to carry out treatment, payment, or health care operations relating to the Organized Health Care Arrangement. Except for the joint Privacy Notice, individual Medical Staff Appointees and Bellin are separate entities and responsible for their own HIPAA compliance efforts. Therefore, treatment provided in a Medical Staff Appointee’s office or outside of BHS Facilities is outside the Organized Health Care Arrangement and requires the Medical Staff Appointee to provide the patient with a Privacy Notice and otherwise comply with HIPAA. 7.B. GENERAL CONDITIONS OF APPOINTMENT AND REAPPOINTMENT 7.B.1. Basic Responsibilities and Requirements for Applicants and Appointees: As a condition of consideration of an application for Medical Staff appointment or reappointment, and as a condition of continued Medical Staff appointment, if granted, every applicant and appointee shall specifically agree to the following:

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(a) to provide appropriate continuous and timely care and supervision to all patients within a BHS Facility for whom the individual has responsibility;

(b) to abide by all bylaws, policies, and rules and regulations of BHS, the Medical Staff,

and the BHS Facility in which they practice as shall be in force during the time the individual is appointed to the Medical Staff;

(c) to accept committee assignments, emergency service call obligations, and such other

reasonable Medical Staff duties and responsibilities as shall be assigned; (d) to provide, with or without request, new or updated information to BHS, as it occurs,

that is pertinent to any question on the application form including, but not limited to, changes in professional liability insurance coverage, the filing of a lawsuit, changes in medical staff status at any other hospital or health care facility, and any change in eligibility for participation in the Medicare, Medicaid or other federal health program, 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;

(e) to immediately report to BHS any change in health status, including specifically,

impairment due to addiction, that could be considered to adversely affect the individual’s ability to safely and competently exercise clinical privileges or perform the duties and responsibilities of appointment to the Medical Staff;

(f) to attest that the applicant has had an opportunity to read a copy of this policy, and any

other applicable Bylaws, rules and regulations of the Medical Staff as are in force at the time of application, and to agree to be bound by the terms thereof in all matters relating to appointment, reappointment, and clinical privileges, without regard to whether the same are granted;

(g) to appear, if requested, for personal interviews in regard to an application for initial

appointment or reappointment, or regarding questions of clinical competence or professional behavior. Failure to appear will be deemed to constitute automatic relinquishment of clinical privileges and Medical Staff appointment, without any hearing or appeal rights as set forth in these Bylaws;

(h) to agree that any misrepresentation or misstatement in, or omission from the

application, whether intentional or not, shall constitute cause for immediate cessation of the processing of the application and no further processing shall occur. In the event that an appointment has been granted prior to the discovery of such misrepresentation, misstatement or omission, such discovery may be deemed to constitute automatic relinquishment of clinical privileges and Medical Staff appointment. In either situation, there shall be no entitlement to any hearing or appeal rights as set forth in these Bylaws;

(i) to use the BHS Facility at which they practice sufficiently to allow BHS, through

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assessment by appropriate committees, department chairs and individuals, to evaluate in a continuing manner the current competence of the appointee;

(j) to refrain from illegal fee splitting or other illegal inducements relating to patient referral; (k) to refrain from delegating responsibility for diagnoses or care of hospitalized patients to

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

(l) to refrain from deceiving patients as to the identity of an operating surgeon or any other

individual providing treatment or services; (m) to seek consultation whenever necessary; (n) to abide by generally recognized ethical principles applicable to the applicant’s or

appointee’s profession; (o) to comply with current OSHA and CDC recommendations for health care providers

concerning immunizations and communicable disease testing; (p) to participate in the monitoring and evaluation activities of clinical departments and committees; (q) to complete in a timely manner the medical and other required records for all patients as

required by the applicable Medical Staff Bylaws, rules and regulations, this policy, and other applicable policies of BHS;

(r) to work cooperatively and professionally with Medical Staff appointees, Medical Staff

leadership, management, allied health professionals, nurses, and other personnel sufficiently to convince BHS that all patients treated by them will receive quality care and that BHS and its Medical Staff will be able to operate in an orderly manner;

(s) to promptly pay any applicable Medical Staff dues and assessments; (t) to participate in continuing education programs (both for his or her own benefit and for

the benefit of other professionals and personnel); (u) to complete the required continuing medical education credits required by the Medical

Staff appointee’s governing licensing board; (v) to authorize the release of all information necessary for an evaluation of the

individual’s qualifications for initial or continued appointment, reappointment, and/or clinical privileges;

(w) to agree to a criminal background check; (x) to agree that the hearing and appeal procedures set forth in these Bylaws shall be the

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sole and exclusive remedy with respect to any professional review action taken; (y) to agree not to sue BHS, the BHS Facilities, the Medical Staff, or anyone acting by or

for BHS and/or its Medical Staff for any matter relating to the application for appointment, reappointment, or clinical privileges, or relating to the evaluation of the applicant’s qualifications on any matter related to appointment, reappointment, or clinical privileges;

(z) to extend absolute immunity to BHS, the BHS Facilities, the Medical Staff, and all

individuals acting by or for BHS and/or its Medical Staff for all matters relating to appointment, reappointment, and clinical privileges or the individual’s qualifications for the same; and

(aa) if the individual institutes legal action notwithstanding the provisions of subparagraphs

(x), (y) and (z), and does not prevail, he or she shall reimburse BHS, the BHS Facilities, and any Medical Staff members named in the action for all costs incurred in defending such legal action, including reasonable attorney’s fees.

(bb) to maintain and monitor a current email address with the Medical Staff Services

Department, which will be the primary mechanism used to communicate relevant information to the individual.

7.B.2. Burden of Providing Information: (a) Applicants for appointment or reappointment shall have the burden of producing

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

(b) Applicants for appointment or reappointment shall have the burden of providing

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

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

form have been answered, all supporting documentation has been supplied, and all information verified. If at any time during the evaluation, the need arises for new, additional, or clarifying information, the application shall be considered incomplete. Any application that continues to be incomplete sixty (60) days after the applicant has been notified of the additional information required may be deemed to be withdrawn upon notice to the applicant.

(d) Should information provided in an application for appointment or reappointment

change during the course of an appointment year, the appointee has the burden to provide information about such change to BHS sufficient for review and assessment.

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7.B.3. Grant of Immunity and Authorization to Obtain/Release Information: The following statements, which shall be included on the application form for initial appointment and reappointment, and which form a part of these Bylaws, are express conditions applicable to any Medical Staff applicant, any appointee to the Medical Staff, and to all others having or seeking clinical privileges at a BHS Facility. By applying for appointment, reappointment, or clinical privileges, the applicant expressly accepts these conditions during the processing and consideration of the application, whether or not appointment or clinical privileges are granted. This acceptance also applies throughout all terms of appointment or reappointment.

(a) Immunity: To the fullest extent permitted by law, the applicant or appointee releases from any and all

liability, extends absolute immunity to, and agrees not to sue BHS, the BHS Facilities or the Board, any member of the Medical Staff or Board, their authorized representatives, and third parties who provide information for any matter relating to appointment, reappointment, clinical privileges, or the applicant’s/appointee’s qualifications for the same. This immunity covers any actions, recommendations, reports, statements, communications, or disclosures that are made, taken, or received by BHS, the BHS Facilities, their representatives, or third parties in the course of credentialing and peer review activities. Nothing herein shall be deemed to waive any other immunity or privilege provided by federal or state law.

(b) Authorization to Obtain Information from Third Parties: The applicant or appointee specifically authorizes BHS, the BHS Facilities, Medical Staff

leaders, and their representatives (1) to consult with any third party who may have information bearing on the individual’s qualifications, and (2) to obtain any and all information from third parties that may be relevant. The applicant authorizes third parties to release this information to BHS, the BHS Facilities, and their representatives upon request.

(c) Authorization to Release Information to Third Parties: The applicant/appointee also authorizes BHS, the BHS Facilities, the Medical Staff, and

their representatives to release information to other hospitals, health care facilities, managed care organizations, government regulatory and licensure boards or agencies, and their representatives when information is requested in order to evaluate his or her qualifications.

(d) Hearing and Appeal Procedures:

The applicant/appointee agrees that the hearing and appeal procedures set forth in these Bylaws will be the sole and exclusive remedy with respect to any professional review action taken by BHS.

(e) Legal Actions:

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If an applicant/appointee institutes legal action challenging any professional review action and does not prevail, he or she will reimburse the BHS Facility and any appointee of the Medical Staff or Board involved in the action for all costs incurred in defending such legal action, including reasonable attorney’s fees.

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ARTICLE 8

INITIAL APPOINTMENT

8.A. APPLICATION FORM (a) Applications for appointment to the Medical Staff shall be in writing, and shall be

submitted on forms approved by the Board upon recommendation of the System Credentials Committee. These forms shall be obtained from the Chief Executive Officer, in accordance with the procedure set forth in Section 8.B.1.

(b) The application shall contain a request for specific clinical privileges desired by the

applicant and shall require detailed information concerning the applicant’s professional qualifications, including:

(1) the names and complete addresses of at least two (2) physicians, dentists,

podiatrists, or other practitioners, as appropriate, who have had recent extensive experience in observing and working with the applicant, and who can provide adequate information pertaining to the applicant’s present professional competence and character. These references may not be from individuals personally related to the applicant. At least one (1) reference shall be from an individual who practices in the same specialty area as the applicant;

(2) the names and complete addresses of the chairs of the applicant’s department at

any and all hospitals or other institutions at which the applicant has worked or trained (i.e., the individuals who served as chairs at the time the applicant worked in the particular department);

(3) information as to whether the applicant’s medical staff appointment or clinical

privileges have ever been voluntarily or involuntarily relinquished, withdrawn, denied, revoked, suspended, subjected to probationary or other conditions, reduced, or not renewed at any other hospital or health care facility;

(4) information as to whether the applicant has ever voluntarily or involuntarily

withdrawn his/her application for appointment, reappointment, and clinical privileges, or resigned from the medical staff before a final decision by a hospital’s or health care facility’s governing board;

(5) information as to whether the applicant’s license to practice any profession in any

state, or Drug Enforcement Administration license is or has ever been voluntarily or involuntarily relinquished, suspended, modified, terminated, restricted, or is currently being challenged. (The submitted application shall include a copy of the applicant’s current Drug Enforcement Administration license. The original source, or an approved agent of that source who can verify the accuracy, will be contacted by BHS to confirm the licensure, education and post graduate training reported by the applicant);

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(6) information as to whether the applicant currently meets or exceeds BHS’s

minimum requirements for professional liability insurance coverage, the name of the insurance company, and the amount and classification of such coverage, and whether said insurance coverage covers the clinical privileges the applicant or appointee seeks to exercise at a BHS Facility;

(7) information concerning the applicant’s professional liability litigation experience,

specifically information concerning pending matters, final judgments, or settlements: (i) the substance of the allegations, (ii) the findings, (iii) the ultimate disposition, and (iv) any additional information concerning such proceedings or actions as may be requested as part of the credentialing process;

(8) a consent to the release of information from the applicant’s present and past

professional liability insurance carriers; (9) information concerning any professional misconduct proceedings involving the

applicant in the State of Wisconsin or any other state, whether such proceedings are closed or still pending;

(10) information concerning the suspension or termination for any period of time of

the right or privilege to participate in Medicare, Medicaid, or other federal health program or any private or public medical insurance program and information as to whether the applicant is currently under investigation;

(11) current information regarding the applicant’s ability to safely and competently

exercise the privileges requested and to perform the duties and responsibilities of appointment;

(12) information as to whether the applicant has ever been named as a defendant in a

criminal action and/or convicted of a crime with details about any such instance; (13) a complete chronological listing of the applicant’s professional, medical staff and

educational appointments, employment, or positions; (14) information on the citizenship and/or visa status of the applicant; (15) the applicant’s signature; and (16) such other information as may be required as part of the credentialing process.

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(c) The history of malpractice verdicts and the settlement of malpractice claims, as well as pending claims, will be evaluated as a criteria for appointment, reappointment, and the granting of clinical privileges. However, the mere presence of verdicts, settlements, or claims shall not, in and of themselves, be sufficient to deny appointment or particular clinical privileges. The evaluation shall consider the extent to which verdicts, settlements, or claims evidence a pattern of care that raises questions concerning the individual’s clinical competence, or whether a verdict, settlement, or claim in and of itself, represents such deviation from standard medical practice as to raise overall questions regarding the applicant’s clinical competence, skill in the particular clinical privilege, or general behavior.

8.B. PROCEDURE FOR INITIAL APPOINTMENT 8.B.1. Application Review Process: (a) An application for appointment to the Medical Staff shall be processed only for those

individuals who, according to the Medical Staff Bylaws and this policy (1) meet the threshold criteria for appointment to the Medical Staff set forth in Section 7.A.2 of these Bylaws; (2) desire to provide care and treatment to patients for conditions and diseases for which BHS has facilities and personnel; (3) indicate an intention to utilize a BHS Facility; and (4) If privileges requested are part of an exclusive contract, approval of those privileges would be subject to the approval of the exclusive contract holders.

(b) An individual requesting appointment shall be sent a letter that outlines the threshold

criteria for appointment and the applicable clinical privileges and which explains the review process along with the application form.

(c) A completed application form with copies of all required documents must be returned

to the Chief Executive Officer within sixty (60) days after receipt of same if the individual desires further consideration.

8.B.2. Submission of Application: (a) As a preliminary step, the completed application form shall be reviewed by the Chief

Executive Officer to determine whether the individual satisfies the threshold criteria. Individuals who fail to meet the threshold criteria shall be notified that they are not eligible for appointment and that their application will not be processed. Such individuals shall also be notified that they do not have a right to request a hearing. After collecting references and all other information or materials deemed pertinent, the Chief Executive Officer shall, after reviewing the application to determine that all questions have been answered, and after reviewing all references and other information or materials deemed pertinent, and after verifying the information provided in the application with the primary sources, transmit the complete application and all supporting materials to the appropriate department chair, or his/her designee. It is the responsibility of the applicant to provide a complete application, including adequate

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responses from references. An incomplete application shall not be processed. (b) As part of the process of reviewing the application, the Chief Executive Officer shall

determine whether the application should be processed in accordance with Section 8.B.4. Thereafter, the Chief Executive Officer shall transmit the complete application and all supporting materials to the appropriate department chair.

(c) Except for Applications that are processed in accordance with Section 8.B.4,

applications to practice at a BHS Facility shall be processed as set forth in Section 8.B.5 through 8.B.8.

(d) In addition to comprehensive inquiries to the agencies, organizations, and individuals

identified in the application, the review and verification of the application by the Chief Executive Officer shall specifically include the following:

(1) a copy of the list of clinical privileges requested by the applicant shall be sent to

the applicant’s most recent affiliations, along with a request for specific information concerning the applicant’s experience and competence in exercising each of the privileges requested;

(2) a query shall be sent to the National Practitioner Data Bank regarding the

applicant pursuant to the Health Care Quality Improvement Act of 1986; (3) the Cumulative Sanctions Report shall be checked to determine if the applicant

has been excluded from Medicare or Medicaid; and (4) a criminal background check. (e) The President of BHS (or designee) shall post or circulate the name of the applicant so

that each Medical Staff appointee may have an opportunity to submit, in writing, information bearing on the applicant’s qualifications for appointment or clinical privileges.

8.B.3. Department Chair Review Procedure: (a) For individuals applying for appointment and clinical privileges at a BHS Facility the

initial evaluation of the application shall be performed by the appropriate department chair.

(b) The appropriate department chair shall evaluate the applicant’s education, training, and

experience, and make inquiries with respect to the same to the applicant’s past or current department chair(s), residency training director(s), and others who may have knowledge about the applicant’s education, training, experience, and ability to work with others.

(c) As part of the process of performing this evaluation, the department chair has the right

to meet with the applicant to discuss any aspect of the application, qualifications, and

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requested clinical privileges. (d) The department chair shall prepare a written report concerning the applicant’s

qualifications for appointment and for the requested clinical privileges. This report shall be prepared no later than thirty (30) days from the time the department chair received the completed application.

(e) The department chair shall be available to answer any questions that may be raised with

respect to that individual’s report and findings.

8.B.4. Processing Applications with No Questions or Discrepancies:

(a) Applications shall be processed as set forth in this Section so long as they meet the following conditions:

(1) where applicable, the applicant has a consistent and successful residency training

program record (in the specialty for which the applicant is requesting privileges); (2) the applicant has not changed practice locations more than three times in the past

10 years; (3) all reference evaluations are completed, and received within a reasonable time of

the initial request; (4) all references contain only favorable evaluations, including unqualified

recommendations for appointment and clinical privileges; (5) the applicant’s claims activity (including past malpractice claims settlements, or

judgments) is reasonable in light of his or her specialty (according to maximum claims established by the System Credentials Committee for each specialty);

(6) the applicant was not subject to any disciplinary action or conditions during

residency training; (7) there are no pending or past investigations or reports of disciplinary action from

any hospital or licensing agency; (8) no member of the Medical Staff has raised a question about the applicant’s

qualifications for appointment or clinical privileges; (9) no questions have been raised about the applicant by the department chair; and (10) the department chair recommends a streamlined review of the application. (b) The Chair of the System Credentials Committee, acting for the System Credentials

Committee as a whole, shall review the report from each appropriate department chair,

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and the information contained in references given by the applicant and from other available sources. The System Credentials Committee Chair shall examine evidence of the applicant’s character, professional competence, qualifications, prior behavior, and ethical standing and shall determine whether the applicant has established and satisfied all of the necessary qualifications for appointment and for the clinical privileges requested.

(c) As part of the process of making a recommendation, the System Credentials Committee

Chair shall have the right to meet with the applicant to discuss the applicant’s application, qualifications, and clinical privileges requested. The appropriate department chair may participate in this interview. The Chair of the System Credentials Committee shall then prepare a report and forward the same to the BHS Medical Executive Committee. The report shall recommend the clinical privileges to be granted and, if applicable, provisional department assignment.

(d) The BHS Medical Executive Committee shall review the recommendation made by the

Chair of the System Credentials Committee and shall then make its recommendation to the voting members of the Board who have been delegated by the Board with the authority to render such decisions, and who shall take final action on the application for appointment and grant of clinical privileges, subject to approval by the Board (the Board has designated this authority to the President of the Medical Staff, Past President of the Medical Staff, Chair of the Department of Primary Care, President of Bellin Specialty Group, and the Chief Executive Officer; approval by three of the five appointed governing body members shall be considered a quorum).

(e) In the event the department chair, the Chair of the System Credentials Committee or the

BHS Medical Executive Committee has any questions about the applicant, the questions shall be noted and the matter shall be referred to the entire System Credentials Committee for further action in accordance with Section 8.B.5 through 8.B.8 of these Bylaws.

(f) A report regarding all applicants appointed through this process shall be forwarded to

the BHS Medical Executive Committee, the System Credentials Committee, and the Board (or its designated committee).

8.B.5. System Credentials Committee Procedure: (a) Except as expressly provided in Section 8.B.4, all other Applications for initial appointment

and clinical privileges shall be processed as set forth in Sections 8.B.5 through 8.B.8. (b) The System Credentials Committee shall examine evidence of the applicant’s character,

professional competence, qualifications, prior behavior, and ethical standing and shall determine, through information contained in references given by the applicant and from other sources available to the System Credentials Committee, including the report and findings from the appropriate department chair, whether the applicant has established and satisfied all of the necessary qualifications for appointment and for the clinical privileges requested.

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(c) As part of the process of making its recommendation, the System Credentials

Committee shall have the right to meet with the applicant to discuss the applicant’s application, qualifications, and clinical privileges requested. The appropriate department chair may participate in this interview. At this interview, the applicant may be requested to produce certain documentation for review by the System Credentials Committee, such as documentation of particular procedures performed, medical record documentation from the applicant’s private office, or any other information that may be necessary to address questions or concerns with the applicant’s qualifications for appointment and/or privileges. In addition, in the discretion of the System Credentials Committee, the System Credentials Committee may designate one or more of its members and/or the department chair to conduct personal interviews with the applicant’s past or current department chair(s), residency training program director(s) or residency supervising physicians, or others who may have knowledge about the applicant’s education, training, experience, and ability to work with others.

(d) The System Credentials Committee may use the expertise of the department chair, any

member of the Medical Staff, or an outside consultant, if additional information is required regarding the applicant’s qualifications.

(e) After determining that the applicant is qualified for appointment and privileges, the

System Credentials Committee may require the applicant to undergo a physical and/or mental examination, including diagnostic testing and testing of blood and/or urine by a physician or physicians satisfactory to the System Credentials Committee if there is any question about the applicant’s ability to perform the privileges requested and the responsibilities of appointment. The results of any such examination shall be made available to the System Credentials Committee for its consideration. Failure of an applicant to undergo such an examination within a reasonable time after being requested to do so in writing by the System Credentials Committee shall constitute a voluntary withdrawal of the application for appointment and clinical privileges, and all processing of the application shall cease.

(f) If the System Credentials Committee’s recommendation for appointment is favorable,

the System Credentials Committee shall recommend, if applicable, provisional department assignment. All recommendations to appoint, including provisional appointment, must specifically recommend the clinical privileges to be granted, which may be qualified by any probationary or other conditions or restrictions as deemed appropriate by the System Credentials Committee.

(g) If the recommendation of the System Credentials Committee is delayed longer than

sixty (60) days after receipt of the department chair’s report, the Chair of the System Credentials Committee shall send a letter to the applicant, with a copy to the Chief Executive Officer, explaining the reasons for the delay.

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8.B.6. System Credentials Committee Report: (a) Not later than sixty (60) days from its receipt of the application and all required and

requested information, the System Credentials Committee shall send its recommendation and written findings to the BHS Medical Executive Committee. The completed application and all supporting documentation, including the department chair’s report, shall accompany the System Credentials Committee’s findings and recommendation.

(b) The Chair of the System Credentials Committee or his/her designee shall be available

to the BHS Medical Executive Committee (and to the Board) to answer any questions that may be raised with respect to the System Credentials Committee’s findings and recommendation.

8.B.7. BHS Medical Executive Committee Procedure: (a) At its next regular meeting after receipt of the written findings and recommendation of the

System Credentials Committee, the BHS Medical Executive Committee shall: (1) adopt the findings and recommendation of the System Credentials Committee; or (2) refer the matter back to the System Credentials Committee for further consideration

and preparation of responses to specific questions raised by the BHS Medical Executive Committee prior to its final recommendation, in which case, no further action will be taken until the System Credentials Committee has responded; or

(3) set forth in its report and recommendation clear and convincing reasons, along

with supporting information, for its disagreement with the System Credentials Committee’s recommendation.

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

applicant, it shall be transmitted along with the report of the System Credentials Committee to the Board (or its designated committee) for final action. All recommendations to appoint must also specifically recommend the clinical privileges to be granted, which may be qualified by any probationary or other conditions or restrictions relating to such clinical privileges.

(c) If the recommendation of the BHS Medical Executive Committee would entitle the

applicant to request a hearing pursuant to these Bylaws, it shall be forwarded to the Chief Executive Officer who shall promptly notify the applicant in writing, certified mail, return receipt requested. The Chief Executive Officer shall then hold the application until after the applicant has exercised or waived the right to a hearing as provided in these Bylaws, after which the Chief Executive Officer shall forward the recommendation, together with the complete application and all supporting documentation, to the Board (or its designated committee) for further action.

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8.B.8. Action of the Board: Upon receipt of a favorable recommendation from the BHS Medical Executive Committee that the applicant be granted appointment and the requested clinical privileges, the Board (or its designated committee) may: (a) appoint the applicant and grant clinical privileges as recommended; or (b) refer the matter back to the BHS Medical Executive Committee or to another source

inside or outside BHS for additional research or information; or (c) reject the recommendation. If the Board determines to reject the favorable

recommendation, it should first discuss the matter with the President of the Medical Staff. If the Board’s determination remains unfavorable to the applicant, that determination and the reasons in support thereof, shall be sent to the Chief Executive Officer, who shall promptly notify the applicant in writing, certified mail, return receipt requested. The Board shall make no final decision until the applicant has exercised or waived the right to a hearing and appeal as outlined in these Bylaws.

The applicant will be notified of the Board’s decision within one week of the decision. 8.C. PROVISIONAL STATUS 8.C.1. Duration of Provisional Appointment: (a) All initial appointments to the Medical Staff (regardless of the category of the staff to

which the appointment is made), and all initial clinical privileges (whether for a new applicant or a current appointee) shall be provisional for a period of at least two (2) years from the date of the appointment or longer if established as part of the credentialing process.

(b) All grants of increased clinical privileges to existing Medical Staff appointees for

purposes of performing new procedures not previously performed at a BHS Facility are also provisional for a period of at least two (2) years.

(c) During the provisional period, a professional practice evaluation shall be conducted for

all initially requested privileges, and the individual shall be evaluated by the chair of the appropriate department or his/her designee and by the relevant committees of the Medical Staff as to the individual’s clinical competence and general behavior and conduct.

(d) Provisional clinical privileges shall be adjusted to reflect clinical competence at the end

of the provisional period, or sooner if warranted. (e) Continued appointment and/or clinical privileges after the provisional period shall be

conditioned on an evaluation of the factors to be considered for reappointment as set

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forth in Section 10.A.2 of these Bylaws. (f) Under no circumstances may a provisional period for a Medical Staff appointment

and/or clinical privileges be extended for a period longer than three (3) years. Failure to conclude the provisional period within this time frame shall render the provisional appointee ineligible to apply for reappointment and/or the clinical privileges at issue.

8.C.2. Duties of Provisional Appointees: (a) During the provisional period, a provisional appointee must demonstrate all of the

qualifications and must fulfill all of the obligations attendant to his or her staff category, as applicable. A provisional appointee’s exercise of clinical privileges during the provisional period is subject to any conditions and/or limitations imposed as part of the appointment to the Medical Staff or grant of clinical privileges.

(b) Each provisional appointee must arrange, or cooperate in the arrangement of the required

numbers and types of cases to be reviewed/observed by the department chair and/or designated proctors. This shall be done within a time frame that results in the required cases being monitored/reviewed prior to the proposed end of the provisional period.

(c) During the provisional period the provisional appointee must: (1) admit, treat, or attend a

sufficient number of patients to permit observation and assessment; (2) fulfill all requirements of appointment relating to completion of medical records and other citizenship requirements; and (3) cooperate with any required monitoring or proctoring conditions.

(d) Failure of the provisional appointee to meet the conditions set forth in subparagraph (c)

shall render the provisional appointee ineligible to apply for reappointment. In that event, at the expiration of provisional appointment, all clinical privileges shall be relinquished. This provision may be waived, at the discretion of the System Credentials Committee, BHS Medical Executive Committee, and the Board for appointees in specialties that do not require use of hospital facilities or treatment of hospitalized patients.

(e) Whenever provisional appointment or provisional clinical privileges are terminated,

revoked, or restricted for reasons other than those set forth in subparagraph (c), the provisional appointee shall be entitled to the hearing and appeals procedures set forth in these Bylaws.

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ARTICLE 9

CLINICAL PRIVILEGES 9.A. CLINICAL PRIVILEGES 9.A.1. General: (a) Medical Staff appointment or reappointment as such shall not confer any clinical

privileges or right to practice at any BHS Facility. (b) Each individual who has been appointed to the Medical Staff shall be entitled to

exercise only those clinical privileges specifically granted pursuant to these Bylaws. All clinical privileges shall be BHS Facility-specific.

(c) The granting of clinical privileges shall carry with it acceptance of the obligations of

such privileges, including consultations, emergency service and other rotational obligations established to fulfill BHS’s responsibilities under the Emergency Medical Treatment and Active Labor Act and/or other applicable requirements or standards.

(d) The applicant shall have the burden of establishing qualifications for and competence to

exercise the clinical privileges requested. (e) The clinical privileges granted for any BHS Facility shall be based upon consideration

of the following: (1) the applicant’s ability to meet all current criteria for the requested clinical

privileges at the BHS Facility where privileges are sought; (2) the applicant’s education, training, experience, and demonstrated current

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

(3) appropriateness of utilization patterns;

(4) ability to exercise the privileges requested safely and competently;

(5) information resulting from ongoing and professional practice evaluation and other

performance improvement activities, as applicable: (6) availability of qualified physicians or other appropriate appointees to provide

medical coverage for the applicant in case of the applicant’s illness or unavailability;

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(7) adequate levels of professional liability insurance coverage with respect to the clinical privileges requested;

(8) the available resources and personnel at the applicable BHS Facility; (9) any previously successful or currently pending challenges to any licensure or registration,

or the voluntary or involuntary relinquishment of such licensure or registration; (10) any information concerning professional review actions, voluntary or involuntary

termination, limitation, reduction, or loss of appointment or clinical privileges at another hospital or healthcare entity;

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

(12) morbidity and mortality data, when available;

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

pattern or number of actions; and

(14) other relevant information, including a written report and findings by the appropriate department chair/committee/individual at the BHS Facility where such privileges are sought.

(f) The reports of the appropriate department chair/committee/individual shall be

forwarded to the System Credentials Committee Chair and processed as a part of the application for appointment.

9.A.2. Additional Clinical Privileges for Procedures Currently Available at a BHS Facility: (a) Whenever, during the term of appointment, additional clinical privileges are desired,

the appointee requesting increased privileges shall apply in writing to the Chief Executive Officer on a form approved by the System Credentials Committee. The application shall state in detail the specific additional clinical privileges desired and the appointee’s relevant recent training and experience which justify the additional privileges.

(b) After verification of the information provided, primary source verification of current

licensure, and querying the National Practitioner Data Bank, this application shall be transmitted to the appropriate department chair. Thereafter, it shall be processed in the same manner as an application for initial clinical privileges.

(c) The recommendation for such increased privileges may carry with it such requirements

for supervision or consultation or other conditions, for such periods of time as are thought necessary.

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9.A.3. Clinical Privileges for New Procedures: Whenever a Medical Staff appointee requests clinical privileges to perform a procedure or service not currently being performed at a BHS Facility (or a significant new technique to perform an existing procedure), the process outlined in this Section shall be followed: (a) The appointee shall first be informed by the Chief Executive Officer that his/her request

will not be processed until (1) a determination has been made regarding whether the procedure or service will be offered by the BHS Facility and, if so, until (2) minimum threshold criteria to be eligible to request the clinical privileges in question have been established.

(b) Upon request by the Chief Executive Officer, the appropriate Medical Staff committee

shall make a preliminary recommendation as to whether the procedure or service (or technique) is one that should be offered to patients. The appropriate Medical Staff committee shall forward its recommendation to the System Credentials Committee. The System Credentials Committee shall adopt the findings of the appropriate Medical Staff committee, refer the matter back to the appropriate Medical Staff committee, or set forth its reasons for its disagreement with the appropriate Medical Staff committee. One factor to be considered in reaching this recommendation is whether the applicable BHS Facility has the capabilities, including support services, to perform the procedure or service in question.

(c) If the preliminary recommendation is favorable, the BHS Medical Executive

Committee, either on its own or by appointment of an ad hoc committee, shall then develop threshold credentialing criteria to determine those individuals who are eligible to request the clinical privileges at the BHS Facility. In developing the criteria, the BHS Medical Executive Committee or ad hoc committee shall conduct research and may consult with experts -- either on the Medical Staff or those outside BHS -- and develop recommendations regarding (1) the minimum education, training, and experience necessary to perform the procedure or service, and (2) the extent of monitoring and supervision that should occur if the privileges are granted. The BHS Medical Executive Committee may also, as it deems necessary or appropriate, develop criteria and/or indications for when the procedure or service is appropriate. The BHS Medical Executive Committee shall forward its recommendations to the Board (or its designated committee) for final action.

(d) After receiving the recommendations from the BHS Medical Executive Committee, the

Board (or its designated committee) shall make a determination as to whether the new procedure or service will be offered to patients. If the Board (or its designated committee) determines to offer the procedure or service, it shall then establish the minimum threshold qualifications that an individual must demonstrate in order to be eligible to request the clinical privileges in question.

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(e) Once the foregoing steps are completed, specific requests from eligible Medical Staff appointees who wish to perform the procedure or service shall be handled as set forth above.

9.A.4. Clinical Privileges for Dentists and Oral and Maxillofacial Surgeons: (a) For any patient who meets the classifications of ASA 1 (normal, healthy patients) or

ASA 2 (patients with mild systemic disease with no functional limitations), dentists and oral and maxillofacial surgeons may admit the patient and perform a complete admission history and physical examination, and assess the medical risks of the procedure on the patient, if they are deemed qualified to do so by the System Credentials Committee and BHS Medical Executive Committee. The Hospitalist Service will respond in the event any medical issue arises with the patient.

(b) For any patient who meets ASA 3 or ASA 4 classifications, a medical history and

physical examination of the patient will be made and recorded by a physician who is a member of the Medical Staff before dental or oral surgery may be performed. In addition, the Hospitalist shall be responsible for the medical care of the patient throughout the period of hospitalization.

(c) The dentist or oral and maxillofacial surgeon will be responsible for the oral surgery

care of the patient, including the appropriate history and physical examination, as well as all other appropriate elements of the patient’s record. Dentists and oral and maxillofacial surgeons may write orders within the scope of their licenses and consistent with relevant hospital policies and rules and regulations.

9.A.5. Clinical Privileges for Podiatrists:

(a) Podiatrists who have successfully completed a PSR 24 or 36 residency program will

have H&P privileges for admissions or procedures granted as part of their core privileges.

(b) Podiatrists who have not completed a PSR 24 or 36 residency program may request H&P privileges for admission or procedures with any type of anesthesia, if they are deemed qualified to do so by the System Credentials Committee and BHS Medical Executive Committee.

(c) The podiatrist will be responsible for the podiatric care of the patient, including the

podiatric history and the podiatric physical examination, as well as all appropriate elements of the patient’s record. Podiatrists may write orders which are within the scope of their license and consistent with relevant hospital policies and rules and regulations.

9.A.6. Physician in Training: Physicians in training at a BHS Facility will not be granted appointment to the Medical Staff

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or clinical privileges. The program director, clinical faculty, or attending staff member will be responsible for the direction and supervision of the on-site or day to day patient care activities of each trainee, who will be permitted to perform only those clinical functions set out in curriculum requirements, affiliation agreements, or training protocols approved by the BHS Medical Executive Committee or its designee, and the Medical Education Committee of BHS. The applicable program director will be responsible for verifying and evaluating the qualifications of each physician in training. 9.A.7. Clinical Privileges After Age 65: (a) The System Credentials Committee shall specifically consider the mental and physical

capabilities of each appointee who has attained the age of 65 years and who has clinical privileges at a BHS Facility on an annual basis. Recommendations by the System Credentials Committee and the BHS Medical Executive Committee for continued clinical privileges for appointees between the ages 65 and 75 shall be based upon an evaluation of the individual’s current knowledge, skills, conduct, and ability to perform the privileges requested safely and competently.

(b) Upon reappointment following age 75 and every year thereafter: (1) The appointee shall undergo a physical examination, the cost of which is absorbed

by the appointee, that is performed by one of the professionals identified by Bellin Health System, and the examining physician shall complete a physical examination form indicating either a) the appointee is mentally and physically competent to continue to perform the privileges requested, b) the appointee is able to perform these privileges but with some restrictions, or c) the appointee is not currently able to safely perform these privileges; the form must be returned by the examining practitioner directly to the Medical Staff Services Department;

(2) the appointee shall undergo a neuropsychological assessment, performed by one

of the professionals identified by Bellin Health System, the cost of which is absorbed by the appointee; the examination results must be returned by the examining practitioner directly to the Medical Staff Services Department;

(3) a chart review shall be conducted by the BHS department to verify current

practice patterns and clinical competence. 9.A.8. Clinical Privileges that Cross Specialty Lines:

Whenever a Medical Staff appointee requests clinical privileges that traditionally have been exercised at a BHS Facility only by individuals from another specialty, the process outlined below shall be followed: (a) The individual shall first be informed by the Chief Executive Officer that his/her

request will not be processed until the steps outlined in this Section have been completed and a determination has been made regarding the individual’s eligibility to

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request the clinical privileges in question. (b) The System Credentials Committee shall then investigate the matter and prepare a report

and recommendation for the BHS Medical Executive Committee and the Board (or its designated committee). Specifically, the System Credentials Committee shall conduct research and consult with experts, both those on the Medical Staff (e.g., appropriate department chairs, President of the Medical Staff, individuals on the Medical Staff with special interest and/or expertise in the privileges in question) and those outside BHS (e.g., other hospitals, residency training programs, specialty societies).

(c) The System Credentials Committee shall then develop recommendations regarding (1) the

minimum education, training, and experience necessary to perform the clinical privileges in question, and (2) the extent of monitoring and supervision that should occur. These recommendations may or may not permit individuals from different specialties to request the privileges at issue. The System Credentials Committee shall forward its recommendations to the BHS Medical Executive Committee, which shall review the matter and forward its recommendations to the Board (or its designated committee) for final action.

(d) The Board (or its designated committee) shall then establish the minimum threshold

qualifications that an individual must demonstrate in order to be eligible to request the clinical privileges in question.

(e) Once the foregoing steps are completed, specific requests from eligible Medical Staff

members who wish to exercise the privileges in question shall be handled as set forth above. 9.A.9. Telemedicine Privileges:

(a) Telemedicine is the exchange of medical information from one site to another via

electronic communications for the purpose of providing patient care, treatment, and services. The Board will determine the clinical services to be provided through telemedicine after considering the recommendations of the appropriate department chair, the System Credentials Committee and the BHS Medical Executive Committee.

(b) Individuals applying for telemedicine privileges must meet the qualifications for Medical

Staff appointment outlined in these Bylaws, except for those requirements relating to geographic residency, coverage arrangements, and emergency call responsibilities.

(c) Qualified applicants may be granted telemedicine privileges but will not be appointed

to the Medical Staff. Telemedicine privileges granted in conjunction with a contractual agreement will be incident to and coterminous with the agreement.

(d) Applications for telemedicine privileges will be processed in accordance with the

provisions of these Bylaws in the same manner as for any other applicant, except that BHS may use the credentialing information provided by the applicant’s primary hospital if that hospital is a Medicare-participating hospital and provides: (1) a list of

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all privileges granted to the practitioner; (2) information indicating that the applicant has exercised such privileges in a competent manner; and (3) a signed attestation that the information is complete, accurate, and up-to-date.

(e) Telemedicine privileges, if granted, will be for a period of not more than two years.

Individuals seeking to renew telemedicine privileges will be required to complete an application and, upon request, provide BHS with evidence of current clinical competence. This information may include, but is not limited to, a quality profile from the applicant’s primary practice affiliation and an evaluation form(s) from a qualified supervisor(s). If all requested information is not received by dates established by BHS, the individual’s telemedicine privileges will expire at the end of the current term. Once all information is received and verified, an application to renew telemedicine privileges will be processed as set forth above.

(f) Individuals granted telemedicine privileges will be subject to the BHS Facility’s

performance improvement, ongoing and peer review activities. 9.B. PROCEDURE FOR TEMPORARY AND LOCUM TENENS CLINICAL PRIVILEGES 9.B.1. Temporary Clinical Privileges for Applicants: (a) Temporary privileges may be granted by the Chief Executive Officer or designee, after

consultation with the appropriate department chair, and the System Credentials Chair following their review of the application and related documentation, including: (i) completed application; (ii) primary source verification of current State professional licensure; (iii) demonstration of current competence and receipt of professional references attesting to current competence; (iv) relevant training/experience through receipt of an American Medical Association (AMA) or American Osteopathic Association (AOA) database profile and primary source verification of education if not listed on the AMA/AOA profile; (v) ability to perform the privilege requested; (vi) Office of Inspector General Medicare/Medicaid Exclusions profile; (vii) satisfactory NPDB query; and (viii) where applicable, a current, unrestricted Drug Enforcement Administration controlled substance certificate, only:

(1) for up to one hundred twenty (120) days when there is an important patient care

need that requires immediate authorization to practice. Specifically, temporary privileges may be granted for: (i) the care of a specific patient; or (ii) the purpose of proctoring or teaching; or

(2) for up to one hundred twenty (120) days when an applicant for initial appointment

is awaiting review by the BHS Medical Executive Committee and Board following a favorable recommendation of the System Credentials Committee, has no current or previously successful challenges to his or her licensure or registration, and has not been subject to involuntary termination of medical staff membership, or involuntary limitation, reduction, denial, or loss of clinical privileges,

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at another health care facility.

9.B.2. Locum Tenens: (a) The Chief Executive Officer may grant an individual serving as a locum tenens for an

appointee of the Medical Staff temporary admitting and clinical privileges to attend patients of that appointee for a period not to exceed six (6) months. The Chief Executive Officer may grant such privileges:

(1) after receiving a completed locum tenens application and a request for clinical

privileges form; (2) after making inquiry to the National Practitioner Data Bank, obtaining an

American Medical Association (AMA) or American Osteopathic Association (AOA) database profile and primary source verification of education if not listed on the AMA/AOA profile, determining through primary source verification the applicant’s current State licensure, DEA certification where applicable, Medicare and Medicaid participation status, and professional liability insurance coverage, and verifying competence, character, ethical standing, and ability to perform the privileges requested by querying the previous 3 practice sites or all practice sites within the immediately preceding two (2) years, whichever spans the longest period, as well as obtaining two peer recommendations/professional references; and

(3) after obtaining the written concurrence of the appropriate department chair and

the Chair of the System Credentials Committee. The Chief Executive Officer shall also obtain such individual’s signed acknowledgment

that the individual has had an opportunity to read copies of this policy, the Medical Staff Bylaws, and rules and regulations which are then in force, and agrees to be bound by the terms thereof.

(b) The individual serving as a locum tenens must have in force and effect a current license

to practice in this state, a DEA license where applicable, professional liability insurance in an amount and terms acceptable to BHS, and must be a participating provider in the Medicare and Medicaid programs.

9.B.3. Special Requirements: Special requirements of supervision and reporting may be imposed by the appropriate department chair on any individual granted temporary or locum tenens clinical privileges. Temporary or locum tenens privileges shall be immediately terminated by the Chief Executive Officer or a designee upon notice of any failure by the individual to comply with such special conditions.

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9.B.4. Termination of Temporary or Locum Tenens Clinical Privileges: (a) The Chief Executive Officer may, at any time after consulting with the appropriate

department chair responsible for the individual’s supervision, terminate temporary or locum tenens admitting privileges. Clinical privileges shall then be terminated when the individual’s inpatients are discharged from the BHS Facility. However, where it is determined that the care or safety of such patients would be endangered by continued treatment by the individual granted interim, temporary, or locum tenens privileges, a termination of those clinical privileges may be imposed by the Chief Executive Officer, or the appropriate department chair, and such termination shall be immediately effective.

(b) For those terminations that are immediately effective, the appropriate department chair

shall assign to a Medical Staff appointee responsibility for the care of such terminated individual’s patients until they are discharged from the BHS Facility, giving consideration wherever possible to the wishes of the patient in the selection of the substitute.

(c) The granting of any temporary or locum tenens admitting and clinical privileges is a

courtesy on the part of the BHS Facility and any or all may be terminated if a clinical and/or behavioral question or concern has been raised. Neither the granting, denial, or termination of such privileges shall entitle the individual concerned to any of the procedural rights provided in these Bylaws.

9.C. EMERGENCY CLINICAL PRIVILEGES (a) For the purpose of this Section, an “emergency” is defined as a condition which could

result in serious or permanent harm to a patient(s) and in which any delay in administering treatment would add to that harm or danger.

(b) In an emergency, a physician currently appointed to the Medical Staff may exercise

clinical privileges to the extent permitted by his or her license, regardless of that individual’s department status or specific grant of clinical privileges. When the emergency situation no longer exists, the patient shall be assigned by the appropriate department chair to an appointee with appropriate clinical privileges. The wishes of the patient shall be considered in the selection of a substitute physician.

(c) If the BHS disaster plan has been activated and BHS is unable to meet immediate patient needs, the individual identified in the BHS’s disaster plan with such authority may decide to assign disaster responsibilities to volunteer practitioners based on the specific circumstances of the disaster event and the related needs of BHS and its patients, as well as the qualifications of the volunteer practitioners. At minimum, these practitioners must present valid government-issued photo identification (e.g., driver’s license or passport) and at least one of the following: • A current picture hospital identification card that clearly identifies professional

designation; • A current license, certification, or registration;

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• Primary source verification of licensure, certification, or registration (if required by law and regulation to practice a profession);

• Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), Medical Reserve Corps (MRC), Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), or other recognized state or federal organizations or groups;

• Identification indicating that the individual has been granted authority to render patient care, treatment, and services in disaster circumstances (such authority having been granted by a federal, state, or municipal entity);

• Identification by a current BHS member(s) who possesses personal knowledge regarding the volunteer practitioner’s qualifications.

Each emergency credentialed physician shall be supervised by a member of the Medical Staff in the same specialty as the visiting physician. Oversight shall be conducted through direct observation, mentoring, clinical record review, or other appropriate mechanisms developed by the Medical Staff and BHS. Based on information obtained regarding the professional practice of the volunteer practitioner, a decision will be made within 72 hours related to the continuation of the disaster responsibilities initially assigned. Primary source verification of licensure shall begin as soon as the immediate situation is under control, and shall be completed within 72 hours from the time the volunteer practitioner presents to BHS. In extraordinary circumstances when primary source verification cannot be completed within 72 hours, it shall be completed as soon as possible. In these situations, there shall be documentation of the following: (a) the reason primary source verification could not be performed in the required time frame; (b) evidence of the volunteer’s demonstrated ability to continue to provide adequate care; and (c) an attempt to obtain primary source verification as soon as possible. If a volunteer has not provided care, then primary source verification is not required. Once the immediate situation has passed and such determination has been made consistent with BHS’s disaster plan, the practitioner’s disaster privileges will terminate immediately. Any individual identified in BHS’s disaster plan with the authority to grant disaster privileges shall also have the authority to terminate disaster privileges. Such authority may be exercised in the sole discretion of BHS and will not give rise to a right to a fair hearing or an appeal.

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ARTICLE 10

REAPPOINTMENT 10.A. PROCEDURE FOR REAPPOINTMENT All terms, conditions, and procedures relating to initial appointment shall apply to continued appointment and clinical privileges and to reappointment. If an appointee provides notice that he/she is voluntarily relinquishing his/her Medical Staff appointment and clinical privileges, BHS will hold the notice of relinquishment for ten (10) days to allow the appointee to reconsider. If the appointee withdraws the notice of relinquishment within the 10-day period, the appointee shall be reinstated as if the notice of relinquishment had never been issued. If within 6 months of a voluntary relinquishment of Medical Staff appointment and clinical privileges, an applicant reapplies for Medical Staff appointment and clinical privileges, the application shall be processed under this Article 10. Applications that are received by Bellin more than 6 months after the appointee has relinquished his/her privileges shall be processed as an Application for Initial Appointment. 10.A.1. Application: (a) Each current appointee who is eligible to be reappointed to the Medical Staff shall be

responsible for completing a reappointment application form and for paying a reappointment processing fee in an amount determined by the System Credentials Committee and approved by the Board (or its designated committee). The reappointment processing fee shall be waived if the complete reappointment application (with all required documentation) is submitted to the Chief Executive Officer within the time frame set forth in subparagraph (b).

(b) The reappointment application shall be furnished to the appointee by the Chief

Executive Officer at least four (4) months prior to the expiration of the appointee’s current appointment period. In order for the reappointment processing fee to be waived, the completed reappointment application shall be submitted to the Chief Executive Officer at least three (3) months prior to the expiration of the appointee’s current appointment period. In addition, failure to submit an application at least two (2) months prior to the expiration of the appointee’s current term may result in automatic expiration of the appointee’s appointment and clinical privileges at the end of the then current term of appointment.

(c) The reappointment application shall be considered incomplete and shall not be

processed unless the applicant is current with respect to the payment of Medical Staff dues and assessments.

(d) Reappointment, if granted, shall be for a period of not more than two (2) years. The

specific staggering of reappointments shall be in a manner established by the Chief Executive Officer.

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10.A.2. Factors to be Considered: (a) Each recommendation concerning reappointment of an individual currently appointed

to the Medical Staff shall be based upon such appointee’s: (1) current clinical competence, clinical judgment in the treatment of patients,

technical skill, ethical behavior, and conduct; (2) participation in Medical Staff duties and responsibilities, such as committee

assignments and emergency service call rotations; (3) compliance with this policy and any applicable Bylaws, policies, and rules and

regulations of BHS; (4) behavior at BHS, including cooperation with Medical Staff and personnel as it

relates to patient care, the orderly operation of BHS, and general attitude toward patients, BHS and its personnel;

(5) use of the BHS Facilities for patients, taking into consideration the individual’s

comparative utilization patterns; (6) current information regarding the applicant’s ability to exercise the privileges

requested competently and safely, including review of ongoing professional practice evaluation data, for making decisions to continue, limit or revoke any existing privilege(s) and to perform the duties and responsibilities of appointment;

(7) capacity to satisfactorily treat patients as indicated by the results of medical

records review, performance improvement activities, or other reasonable indicators of continuing qualifications;

(8) completion of the required continuing medical education credits required by the

Medical Staff appointee’s governing licensing board; (9) current professional liability insurance status and pending malpractice challenges,

including claims, lawsuits, judgments, and settlements; (10) current licensure, including currently pending challenges to any license or registration; (11) voluntary or involuntary termination of Medical Staff appointment or voluntary or

involuntary limitation, reduction, or loss of clinical privileges at another hospital or health care facility;

(12) complaints received from patients and/or personnel; and (13) other reasonable indicators of continuing qualifications.

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(b) To be eligible to apply for renewal of clinical privileges, the appointee must submit to

the Medical Staff Services Department the names of two peers (defined as appropriate practitioners in the same professional discipline as the appointee who have personal knowledge of the appointee), one of whom is not a practice partner whenever possible, recognizing there are situations where practice partners may be the only peers available, for example, in the case of pathologists or other hospital-based specialties. Upon receipt of the names of these peers, the Medical Staff Services Department shall send peer reference forms to these individuals for completion. The forms shall be returned directly to the Medical Staff Services Department, that is, the forms shall not be viewed by the appointee and shall be considered confidential, as are all other peer references in the appointee’s credentials file. In the event that the appointee has not had sufficient patient contacts to enable the assessment of current clinical judgment and competence for the privileges requested, the appointee shall be instructed to provide additional information (such as a copy of his/her confidential quality profile from his/her primary hospital, clinical information from the individual’s private office practice, and/or a quality profile from a managed care organization), before the application will be considered complete and processed further.

10.A.3. Department Chair Procedure: (a) For individuals applying for clinical privileges, the initial evaluation of the application

at the time of reappointment shall be performed by the appropriate department chair. For individuals applying for clinical privileges at BPC, the initial evaluation shall be performed by the Chair of the Department of Psychiatry.

(b) No later than three (3) months prior to the end of the individual’s current appointment period,

the Chief Executive Officer shall send to the appropriate department chair, the individual’s application for reappointment and a description of the individual’s clinical privileges.

(c) No later than fifteen (15) days after receipt of the application, the department chair shall

prepare a written report concerning the individual seeking reappointment. The department chair shall include in each written report, when applicable, the reasons for any changes recommended in staff category, in clinical privileges, or for non-reappointment.

(d) As part of the process of preparing this report, the department chair has the right to

meet with the applicant to discuss any aspect of the application, qualifications, and requested clinical privileges.

(e) The department chair shall be available to answer any questions that may be raised with

respect to any such report. 10.A.4. Processing Applications with No Questions or Discrepancies: (a) Applications from individuals seeking reappointment and renewal of clinical privileges

shall be processed as set forth in this Section so long as they meet the following conditions:

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(1) The applicant has a current, unrestricted State of Wisconsin license and, where applicable, a current, unrestricted DEA certificate;

(2) the applicant’s claims activity (including past malpractice claims settlements, or

judgments) during the previous appointment period, is reasonable in light of his or her specialty (according to maximum claims established by the System Credentials Committee for each specialty);

(3) there are no pending or past investigations or reports of disciplinary action from

any medical facility or licensing agency; (4) no member of the Medical Staff has raised a question about the applicant’s

qualifications for reappointment or renewal of clinical privileges; (5) no quality or performance concerns have been raised about the applicant during

the previous appointment term; (6) no valid complaint from patients or their families, nursing personnel, or any other

member of the Medical Staff has been raised about the applicant during the previous appointment term;

(7) no questions have been raised about the applicant by the department chair; and (8) the department chair recommends a streamlined review of the application. (b) The Chair of the System Credentials Committee, acting for the System Credentials

Committee as a whole, shall review the report from each appropriate department chair, review all pertinent information available, including all information provided from other committees of the Medical Staff and from management, for the purpose of making a recommendation for reappointment, for change in staff category, and for the granting of clinical privileges for the ensuing appointment period. The Chair of the System Credentials Committee shall have the right to require any appointee to meet with him or her to discuss any aspect of the individual’s reappointment application, qualifications, or clinical privileges requested.

(c) The Chair of the System Credentials Committee shall prepare a report and forward the

same to the BHS Medical Executive Committee. The report, if favorable, shall recommend reappointment and the specific clinical privileges to be granted.

(d) The BHS Medical Executive Committee shall review the recommendation made by the

Chair of the System Credentials Committee and shall then make its recommendation to the voting members of the Board who have been delegated by the Board with the authority to render such decisions, and who shall take final action on the application for reappointment and grant of clinical privileges, subject to approval by the Board (the Board has designated this authority to the President of the Medical Staff, Past President of the Medical Staff, Chair of the Department of Primary Care, President of Bellin

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Specialty Group, and the CEO; approval by three of the five appointed governing body members shall be considered a quorum).

(e) In the event the department chair, the Chair of the System Credentials Committee or the

BHS Medical Executive Committee has any questions about the applicant, the questions shall be noted and the matter shall be referred to the entire System Credentials Committee for further action in accordance with Section 10.A.5 through 10.A.7 of this Article.

(f) A report regarding all applicants appointed through this process shall be forwarded to

the BHS Medical Executive Committee, the System Credentials Committee, and the Board (or its designated committee).

10.A.5. System Credentials Committee Procedure: (a) Except as expressly provided in Section 10.A.4, all other Applications for

reappointment and clinical privileges shall be processed as set forth in Sections 10.A.5 through 10.A.7.

(b) The System Credentials Committee, after receiving the reports from each appropriate

department chair, shall review all pertinent information available, including all information provided from other committees of the Medical Staff and from Administration, for the purpose of determining its recommendations for reappointment, for change in staff category, and for the granting of clinical privileges for the ensuing appointment period.

(c) The System Credentials Committee shall have the right to require the appointee to meet

with it to discuss any aspect of the individual’s reappointment application, qualifications, or clinical privileges requested.

(d) The System Credentials Committee may use the expertise of the department chair, any

member of the Medical Staff, or an outside consultant, if additional information is required regarding the appointee’s qualifications for reappointment or for any of the clinical privileges requested.

(e) After determining that the applicant is qualified for reappointment and renewed clinical

privileges, the System Credentials Committee may require the applicant to undergo a physical and/or mental examination, including diagnostic testing and testing of blood and/or urine, by a physician or physicians satisfactory to the System Credentials Committee if there is any question about the applicant’s ability to perform the privileges requested or the responsibilities of appointment. The results of any such examination shall be made available to the System Credentials Committee for its consideration. Failure of an applicant to undergo such an examination within a reasonable time after being requested to do so in writing by the System Credentials Committee shall constitute a voluntary withdrawal of the application for reappointment and clinical privileges, and all processing of the application shall cease.

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(f) If, after considering the report of the appropriate department chair, the System

Credentials Committee’s recommendation is favorable, it shall recommend reappointment and the specific clinical privileges to be granted, which may be qualified by any probationary or other conditions or restrictions, as appropriate.

(g) If, during the processing of an individual’s reappointment, it becomes apparent to the

System Credentials Committee or its Chair that the System Credentials Committee is considering a recommendation that would deny reappointment, deny a requested change in staff category or clinical privileges, or reduce clinical privileges, the Chair of the System Credentials Committee may notify the individual of the general tenor of the possible recommendation and ask if the individual desires to meet with the System Credentials Committee prior to any final recommendation by the System Credentials Committee. At such meeting, the affected individual shall be informed of the general nature of the evidence supporting the action contemplated, and shall be invited to discuss, explain or refute it. This interview shall not constitute a hearing and none of the procedural rules provided in these Bylaws with respect to hearings shall apply. Minutes of the discussion in the meeting shall not be kept. However, the committee shall indicate as part of its report to the BHS Medical Executive Committee and the Board whether such a meeting occurred, and shall include a summary of the meeting.

(h) The System Credentials Committee shall forward its written findings and recommendations

to the BHS Medical Executive Committee. This shall be done in time for the BHS Medical Executive Committee to consider the individual’s reappointment at its regularly scheduled meeting before the expiration of the applicant’s appointment period. The completed application and all supporting documentation shall accompany the System Credentials Committee’s findings and recommendation. Where non-reappointment, non-promotion, or a change in clinical privileges is recommended, the reasons for such recommendation shall be stated. The Chair of the System Credentials Committee shall be available to the BHS Medical Executive Committee (or to the Board) to answer any questions that may be raised with respect to the recommendation.

10.A.6. BHS Medical Executive Committee Procedure: (a) At its next regular meeting after receipt of the written findings and recommendation of the

System Credentials Committee, the BHS Medical Executive Committee shall: (1) adopt the findings and recommendation of the System Credentials Committee; or (2) refer the matter back to the System Credentials Committee for further

consideration and preparation of responses to specific questions raised by the BHS Medical Executive Committee prior to its final recommendation; or

(3) set forth in its report and recommendation clear and convincing reasons, along

with supporting information, for its disagreement with the System Credentials Committee’s recommendation.

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(b) If the recommendation of the BHS Medical Executive Committee is favorable, it shall

transmit its recommendation, together with all supporting documentation, to the Chief Executive Officer for action on behalf of the Board (or its designated committee). All recommendations for reappointment must also specifically recommend the clinical privileges to be granted, which may be qualified by any probationary or other conditions or restrictions relating to such clinical privileges. A report regarding all applicants reappointed by the Chief Executive Officer shall be forwarded to the BHS Medical Executive Committee and to the Board (or its designated committee).

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

affected individual to the procedural rights provided in these Bylaws shall be forwarded to the Chief Executive Officer who shall promptly notify the affected individual by certified mail, return receipt requested. The Chief Executive Officer shall then hold the recommendation until after the individual has exercised or has waived the right to a hearing as provided in these Bylaws, after which time, the Chief Executive Officer shall forward the recommendation of the BHS Medical Executive Committee, together with all supporting documentation to the Board (or its designated committee). The Chair of the BHS Medical Executive Committee shall be available to the Board to answer any questions that may be raised with respect to the recommendation.

10.A.7. Action of the Board: (a) All recommendations referenced in Section 10.A.6.(b) shall be forwarded to the Board

(or its designated committee) for final action. (b) If the Board (or its designated committee) determines to reject a favorable

reappointment determination that has been reported to it, it should first discuss the matter with the President of the Medical Staff and/or the Chief Executive Officer. If the Board’s determination remains unfavorable to the individual, that determination and the reasons in support thereof, shall be sent to the Chief Executive Officer, who shall promptly notify the individual in writing, certified mail, return receipt requested. The Board shall make no final decision until the individual has exercised or waived the right to a hearing and appeal as outlined in these Bylaws.

(c) The applicant will be notified of the Board’s decision within one week of the decision. 10.A.8. Conditional Reappointments: (a) Consistent with the intention of Article 11, which encourages collegial and educational

efforts to address concerns with an individual’s clinical practice and/or conduct at BHS, recommendations for reappointment and renewed privileges may be contingent upon an individual’s compliance with certain specific conditions. These conditions may relate to concerns with behavior or to concerns with clinical competence. Unless they involve the matters set forth in Section 14.A.1, the imposition of such conditions does not entitle an individual to request the procedural rights set forth in Article 14.

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(b) In addition, in the event the application for reappointment is the subject of an

investigation or hearing at the time reappointment is being considered, a conditional reappointment may be recommended for periods of less than two years in order to emphasize the seriousness of the matter and to permit closer monitoring of an individual’s compliance with any conditions that may be imposed, or pending the completion of the investigation or hearing. A recommendation for reappointment for a period of less than two years does not, in and of itself, entitle an individual to the procedural rights set forth in Article 14.

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ARTICLE 11

COLLEGIAL, EDUCATIONAL, AND/OR INFORMAL PROCEEDINGS (a) Nothing in these Bylaws shall preclude collegial, educational, and/or informal efforts to

address questions or concerns relating to an individual’s practice and conduct at BHS. These Bylaws specifically encourage such efforts where there is a reasonable likelihood that such steps may correct a pattern/concern before it requires formal investigation. The goal of such efforts is to arrive at voluntary, responsive actions by the individual.

(b) All efforts of Medical Staff leaders and Administration in this regard are intended to be,

and are, part of BHS’s performance improvement and professional review activities. (c) These efforts involve counseling and educating colleagues when questions arise

concerning their clinical practice or professional conduct and include, but are not limited to:

(1) educating and advising colleagues of all applicable policies, such as policies

regarding appropriate behavior, emergency call obligations, and the timely and adequate completion of medical records;

(2) proctoring, monitoring, consultation, and letters of guidance; and (3) sharing with individuals comparative quality, utilization, and other relevant

information in order to assist those individuals to conform their practices to appropriate norms within BHS.

(d) The affected individual shall be provided an opportunity to respond in writing to any

written communications and the response shall be maintained in the individual’s file along with the original communication. Such collegial and educational efforts are encouraged, but are not mandatory, and shall be within the discretion of the appropriate Medical Staff leaders depending on the circumstances. Such efforts shall be considered to be confidential peer review activities, but shall not in and of themselves give rise to any procedural rights.

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ARTICLE 12

QUESTIONS INVOLVING MEDICAL STAFF APPOINTEES 12.A. OVERVIEW AND GENERAL PRINCIPLES OF PEER REVIEW RELATED ACTIVITIES 12.A.1. Options Available to Medical Staff Leaders and Administration: (a) This Article empowers Medical Staff leaders and Administration to use various options

to address and resolve questions that may be raised about members of the Medical Staff. The various options available to Medical Staff leaders and Administration and the mechanisms they may use when questions pertaining to competence, health or behavior are raised are outlined below and include, but are not limited to, the following:

(1) collegial intervention and progressive steps; (2) ongoing and focused professional practice evaluations; (3) mandatory meeting; (4) fitness for practice evaluation (including blood and/or urine test); (5) competency assessment; (6) automatic relinquishment of appointment and clinical privileges; (7) leaves of absence; (8) precautionary suspension; and (9) formal investigation.

(b) In addition to these options, Medical Staff leaders and Administration also have the

discretion to determine whether a matter should be handled in accordance with another policy (e.g., code of conduct, practitioner health, peer review policies) or should be referred to the BHS Medical Executive Committee for further action.

12.A.2. Documentation: (a) Except as otherwise expressly provided, Medical Staff leaders and Administration may

use their discretion to decide whether to document any meeting with an individual that may take place pursuant to the processes and procedures outlined in this Article.

(b) Any documentation of the meeting that is prepared will be shared with the individual.

The individual will have an opportunity to review the documentation and respond to it.

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That documentation, along with any response, will be maintained in the individual’s confidential file.

12.A.3. No Recordings of Meetings: It is the policy of BHS to maintain the confidentiality of all medical staff meetings, including, but not limited to, discussions relating to credentialing, quality assessment, performance improvement, and peer review activities. The discussions that take place at such meetings are private conversations that occur in a private place. In addition to existing bylaws and policies governing confidentiality, individuals in attendance at such meetings are prohibited from making audio or video recordings at such meetings unless authorized to do so in writing by the individual chairing the meeting or by the CEO. 12.A.4. No Right to Counsel: (a) The processes and procedures outlined in this Article are designed to be carried out in

an informal manner. Therefore, lawyers will not be present for any meeting that takes place pursuant to this Article. By agreement of the President of the Medical Staff and CEO, an exception may be made to this general rule.

(b) If the individual refuses to meet without his or her lawyer present, the meeting will be

canceled and it will be reported to the BHS Medical Executive Committee that the individual declined to attend the meeting.

12.A.5. No Right to the Presence of Others:

Peer review activities are confidential and privileged to the fullest extent permitted by law. Accordingly, the individual may not be accompanied by friends, relatives or colleagues when attending a meeting that takes place pursuant to this Article. 12.B. COLLEGIAL INTERVENTION AND PROGRESSIVE STEPS (a) The use of collegial intervention efforts and progressive steps by Medical Staff leaders

and Administration is encouraged. (b) The goal of those efforts is to arrive at voluntary, responsive actions by the individual

to resolve an issue that has been raised. Collegial efforts and progressive steps may be carried out, within the discretion of Medical Staff leaders and Administration, but are not mandatory.

(c) Collegial intervention efforts and progressive steps are part of BHS’s ongoing and

focused professional practice evaluation activities and may include, but are not limited to, the following:

(1) sharing and discussing applicable policies, such as policies regarding appropriate

behavior, emergency call obligations, and the timely and adequate completion of

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medical records; (2) counseling, mentoring, monitoring, proctoring, consultation, and education; (3) sharing comparative quality, utilization, and other relevant information, including

any variations from clinical protocols or guidelines, in order to assist an individual to conform his or her practice to appropriate norms;

(4) communicating expectations for professionalism and behaviors that promote a

culture of safety; (5) providing informational letters of guidance, education, or counseling; and (6) performance improvement plans.

12.C. AUTOMATIC RELINQUISHMENT Any of the occurrences described in this Section will constitute grounds for the automatic relinquishment of an individual’s appointment and clinical privileges. An automatic relinquishment is considered an administrative action and, as such, it does not trigger an obligation on the part of BHS to file a report with the National Practitioner Data Bank. Except as otherwise provided below, an automatic relinquishment of appointment and privileges will be effective immediately upon actual or special notice to the individual. 12.C.1. Failure to Complete Medical Records: Failure of an individual to complete medical records, after notification by the Health Information Management & Services Department of delinquency in accordance with applicable policies and rules and regulations, may result in automatic relinquishment of all clinical privileges. 12.C.2. Failure to Satisfy Eligibility Criteria: Failure of an individual to continuously evidence satisfaction of any of the criteria set forth in Article 7.A.2 of these Bylaws will result in automatic relinquishment of appointment and clinical privileges. In the event any information provided by the individual in an application for appointment or reappointment changes during the term of any appointment, the individual shall promptly provide information about any such change(s) to BHS for review and assessment. 12.C.3. Criminal Activity: The occurrence of specific criminal actions will result in the automatic relinquishment of appointment and clinical privileges. Specifically, an arrest, indictment, conviction, plea of guilty or plea of no contest pertaining to any felony or misdemeanor involving the following

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will result in an automatic relinquishment: (a) Medicare, Medicaid, or other federal or state governmental or private third-party payer fraud or program abuse; (b) controlled substances; (c) illegal drugs; (d) violent act, unless upon review the BHS Medical Executive Committee determined that such act was necessary in the defense of the physician or other; (e) sexual misconduct; (f) moral turpitude; or (g) child or elder abuse. 12.C.4. Failure to Provide Information: (a) Failure of an individual to notify the President of the Medical Staff or CEO of any

change in any information provided on an application for initial appointment or reappointment may, as determined by the BHS Medical Executive Committee, result in the automatic relinquishment of appointment and clinical privileges.

(b) Failure of an individual to provide information pertaining to an individual’s

qualifications for appointment or clinical privileges in response to a written request from the System Credentials Committee, the BHS Medical Executive Committee, or any other authorized committee may, as determined by the BHS Medical Executive Committee, result in the automatic relinquishment of appointment and clinical privileges until the information is provided to the satisfaction of the requesting party.

12.C.5. Failure to Attend a Mandatory Meeting: Failure to attend a mandatory meeting requested by the Medical Staff leaders or Administration, after appropriate notice has been given, may, as determined by the BHS Medical Executive Committee, result in the automatic relinquishment of appointment and clinical privileges. The relinquishment will remain in effect until the individual attends the mandatory meeting and reinstatement is granted as set forth below. 12.C.6. Failure to Complete or Comply with Training or Educational Requirements: Failure of an individual to complete or comply with training and educational requirements that are adopted by the BHS Medical Executive Committee and/or required by the Board, including, but not limited to, those pertinent to electronic medical records or patient safety, will result in the automatic relinquishment of clinical privileges. 12.C.7. Failure to Comply with Request for Fitness for Practice Evaluation: (a) Failure of an applicant to undergo a requested fitness for practice evaluation or to

execute any of the required releases (i.e., to allow the Medical Staff leaders, or the relevant committee, to discuss with the health care professional(s) the reasons for the evaluation and to allow the health care professional to report the results to the Medical Staff leaders or relevant committee) will be considered a voluntary withdrawal of the application.

(b) Failure of an Appointee to undergo a requested fitness for practice evaluation or to

execute any of the required releases (i.e., to allow the Medical Staff leaders, or the

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relevant committee, to discuss with the health care professional(s) the reasons for the evaluation and to allow the health care professional to report the results to the Medical Staff leaders or relevant committee) will result in the automatic relinquishment of appointment and privileges.

12.C.8 Action at Another BHS Facility: Any suspension, restriction, limitation, or condition imposed upon an individual in one BHS Facility shall automatically and immediately be effective in all BHS Facilities in which the individual has been granted clinical privileges, without recourse to any additional hearing or appeal. 12.C.9. Reinstatement from Automatic Relinquishment and Automatic Resignation: (a) If an individual believes that the matter leading to the automatic relinquishment of

appointment and privileges has been resolved within ninety (90) days of the relinquishment, the individual may request to be reinstated.

(b) A request for reinstatement from an automatic relinquishment following completion of

all delinquent records will be processed in accordance with applicable policies and rules and regulations. Failure to complete the medical records that caused relinquishment within the time required will result in automatic resignation from the Medical Staff.

(c) Requests for reinstatement from an automatic relinquishment following the expiration

or lapse of a license, controlled substance authorization, or insurance coverage will be processed by the Medical Staff Services Department. If any questions or concerns are noted, the Medical Staff Services Department will refer the matter for further review in accordance with (d) below.

(d) All other requests for reinstatement from an automatic relinquishment will be reviewed

by the relevant department chair, the chair of the System Credentials Committee, the President of the Medical Staff, the CMO, and the CEO. If all these individuals make a favorable recommendation on reinstatement, the individual may immediately resume clinical practice at the applicable BHS Facility. This determination will then be forwarded to the System Credentials Committee, the BHS Medical Executive Committee, and the Board for ratification. If, however, any of the individuals reviewing the request have any questions or concerns, those questions will be noted and the reinstatement request will be forwarded to the System Credentials Committee, BHS Medical Executive Committee and Board for review and recommendation.

(e) Failure to resolve a matter leading to an automatic relinquishment within ninety (90)

days of the relinquishment, and to be reinstated as set forth above, will result in an automatic resignation from the Medical Staff.

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12.C.10 Voluntary Relinquishment: Appointees may voluntarily resign from the Medical Staff and relinquish their clinical privileges at any time by providing written notice to Medical Staff Services at least 90 days prior to the effective date of their resignation. In the event that the appointee fails to provide such notice and continue to practice in Bellin’s geographic service area, the appointee will be required to satisfy his/her call obligations. Failure to satisfy call obligations may result in formal action by the BHS Medical Executive Committee and the Board, including revocation of privileges. 12.D. PROCEDURE FOR LEAVE OF ABSENCE (a) Individuals appointed to the Medical Staff may request a leave of absence by

submitting a written request to the Chief Executive Officer. The request must state the beginning and ending dates of the leave, which shall not exceed one year, and the reasons for the leave, such as military duty, additional training, family matters, or personal health condition. Absence from Medical Staff and patient care responsibilities for longer than sixty (60) days shall require an individual to request a leave of absence. The foregoing notwithstanding, an individual taking a leave of absence for the birth or adoption of his/her natural or adoptive child shall not be required to request a leave of absence under this Section 12.D.a. The granting of a leave of absence or reinstatement hereunder may be conditioned upon the individual’s completion of all medical records.

(b) The Board delegates to the Chief Executive Officer the authority to make

determinations in connection with requests for leaves of absence, provided that the Board reserves the right to make final determinations, in its discretion. In determining whether to grant a request, the Chief Executive Officer may consult with the President of the Medical Staff, department chief, or the System Credentials Chair and use his or her best efforts to render a determination within thirty (30) days of the receipt of the written request and of any clarifying information that the Chief Executive Officer may request.

(c) No later than thirty (30) days prior to the conclusion of the leave of absence, the

individual may request reinstatement by filing a written statement with the Chief Executive Officer summarizing the professional activities undertaken during the leave of absence. The Chief Executive Officer shall refer the matter to the System Credentials Committee for a recommendation. The individual bears the burden of providing information and documentation sufficient to demonstrate current competence and all other applicable qualifications. The individual shall provide such other information as may be requested by the Chief Executive Officer or the System Credentials Committee at that time, including executing any releases that may be necessary to cause third parties, including the individual’s physician, to respond to any requests for information or clarification.

(d) If the leave of absence was for health reasons, the request for reinstatement must be

accompanied by a report from the individual’s physician indicating that the individual

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is physically and/or mentally capable of resuming patient care responsibilities and safely exercising the clinical privileges requested.

(e) Individuals must report to the CEO any time they are away from medical staff or

patient care responsibilities for longer than thirty (30) days and the reason for such absence is related to their physical or mental health or otherwise to their ability to care for patients safely and competently. Upon becoming aware of such circumstances, the CEO, in consultation with the President of the Medical Staff, may trigger an automatic medical leave of absence at any point after becoming aware of the individual’s absence from patient care.

(f) In acting upon the request for reinstatement, the Chief Executive Officer shall consider

the recommendations of the System Credentials Committee and others, as deemed appropriate, and may approve reinstatement either to the same or a different staff category and may limit or modify the clinical privileges to be extended to the individual upon reinstatement or impose conditions for the individual’s practice deemed reasonably necessary for patient safety or the effective operation of the BHS Facility. In the event that the Chief Executive Officer determines that such modifications or conditions would require a report to the National Practitioner Data Bank, the individual shall be given written notice and the opportunity to request a hearing within thirty (30) days pursuant to the procedures set forth in Article 14.

(g) Absence for longer than one (1) year shall constitute automatic lapse of Medical Staff

appointment and clinical privileges unless an extension is requested in writing and granted by the Board. Extensions will be considered only in extraordinary cases of hardship and where extension of a leave is found to be in the best interest of BHS or a BHS Facility.

(h) Leaves of absence and reinstatement are matters of courtesy, not of right. In the event

that it is determined that an individual has not demonstrated good cause for a leave or for reinstatement, or where a request for extension is not granted, the determination shall be final, with no recourse to the hearing and appeal procedures set forth in these Bylaws (except for those limited circumstances outlined in subparagraph (e)).

12.E. PROCEDURE FOR INVESTIGATING QUESTIONS INVOLVING MEDICAL STAFF APPOINTEES 12.E.1. Initial Procedure: Whenever a concern or question has been raised, or where collegial efforts have not resolved an issue regarding the following: (a) the clinical competence or clinical practice of any Medical Staff appointee; (b) the care or treatment of a patient or patients or management of a case by any Medical

Staff appointee;

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(c) the known or suspected violation by any Medical Staff appointee of applicable ethical

standards or the Bylaws, policies, rules or regulations of BHS or its Medical Staff, including, but not limited to BHS’s performance improvement, risk management, and utilization review programs; and/or

(d) behavior or conduct on the part of any Medical Staff appointee that is considered lower

than the standards of BHS or disruptive to the orderly operation of BHS or its Medical Staff, including the inability of the appointee to work harmoniously with others;

The appropriate department chair, System Credentials Chair, Medical Staff Officer, or Chief Executive Officer shall make sufficient inquiry to satisfy themselves that the concern or question raised is credible, after which it shall be submitted in writing to the BHS Medical Executive Committee. If any of the inquiring individuals set forth in this provision believe it to be in the best interest of BHS and the appointee concerned, they may, but are not required to, discuss the matter with the affected appointee. No action taken pursuant to this Section shall constitute an investigation. 12.E.2. Initiation of Investigation: (a) When a concern or question involving clinical competence or behavior/conduct has

been referred to the BHS Medical Executive Committee which shall review the question, may discuss the matter with the individual, and determine whether to conduct an investigation or direct that the question be handled pursuant to another policy. An investigation shall begin only after a formal resolution of the BHS Medical Executive Committee to that effect. The BHS Medical Executive Committee may also, by formal resolution, initiate an investigation on its own motion. If the Board (or its designated committee) wishes to begin such an investigation, it shall also formally resolve to do so, but may delegate the actual investigation.

(b) Should the BHS Medical Executive Committee determine to conduct an investigation,

it shall promptly notify the individual in question and explain the manner in which the investigation will be conducted.

(c) The BHS Medical Executive Committee shall also promptly notify the Chief Executive

Officer and the President of the Medical Staff in writing of all such requests and investigations, and shall keep these individuals fully informed of all action taken in connection therewith.

12.E.3. Investigative Procedure: Upon resolving to initiate an investigation, the BHS Medical Executive Committee shall meet as soon as possible and: (a) If the concern contains sufficient information to warrant a recommendation, the BHS

Medical Executive Committee, at its discretion, may make such a recommendation,

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with or without a personal interview with the individual being investigated. (b) If the concern does not contain sufficient information to warrant a recommendation, the

BHS Medical Executive Committee shall immediately investigate the matter, request the System Credentials Committee to investigate, appoint a subcommittee to do so, or appoint an ad hoc investigating committee consisting of up to three (3) persons, who may or may not hold appointments to the Medical Staff (“Investigating Committee”). The Investigating Committee shall not include any individual who:

(1) is in direct economic competition with the individual being investigated; (2) is professionally associated with, a relative of, or involved in a referral

relationship with, the individual being investigated; (3) has an actual bias, prejudice, or conflict of interest that would prevent the

individual from fairly and impartially considering the matter; or (4) actively participated in the matter at any previous level.

(c) The individual will be notified of the composition of the Investigating Committee.

Within five (5) days of receipt of this notice, the individual must submit any reasonable objections to the service of any Investigating Committee member to the CEO or the CMO. The objections must be in writing. The CEO or the CMO will review the objection and determine whether another Member should be selected to serve on the Investigating Committee.

(d) The Investigating Committee shall have the authority to review relevant documents and

interview individuals with relevant information. It shall also have available to it the full resources of the Medical Staff and BHS, as well as the authority to use outside consultants, if needed. The Investigating Committee may also require a physical and mental examination, including diagnostic testing and testing of blood and/or urine, of the individual being investigated. The examination shall be made by a physician or physicians satisfactory to the Investigating Committee, and the Investigating Committee shall require that the results of such examination be made available for its consideration.

(e) The Investigating Committee shall make a reasonable effort to complete the

investigation and issue its report within thirty (30) days, provided that an outside review is not necessary. When an outside review is used, the Investigating Committee shall make a reasonable effort to complete the investigation and issue its report within fifteen (15) days of receiving the results of the outside review. These time frames are intended to serve as guidelines and, as such, shall not be deemed to create any right for an individual to have an investigation completed within such time periods.

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

Investigating Committee before it makes its report. Prior to this meeting, the individual

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shall be informed of the general nature of the evidence supporting the question being investigated and shall be invited to discuss, explain, or refute it. The individual being investigated shall not have the right to be represented by legal counsel at this meeting. This interview shall not constitute a hearing, and none of the procedural rules provided in these Bylaws with respect to hearings shall apply. A summary of such interview shall be made by the Investigating Committee and included with its report to the BHS Medical Executive Committee.

(g) If an Investigating Committee is used, the BHS Medical Executive Committee may

accept, modify, or reject the recommendation received from the Investigating Committee.

12.E.4. Procedure Thereafter: (a) Upon completion of the investigation, the BHS Medical Executive Committee may:

(1) determine that no action is justified; (2) issue a letter of guidance or counsel; (3) issue a written warning/reprimand; (4) impose conditions for continued appointment; (5) impose a requirement for monitoring, proctoring or consultation; (6) require additional training or education; (7) recommend reduction of clinical privileges; (8) recommend suspension of clinical privileges for a term; (9) recommend revocation of Medical Staff appointment or clinical privileges; or (10) make such other recommendations as it deems necessary or appropriate.

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

individual being investigated to the procedural rights provided in these Bylaws shall be forwarded to the Chief Executive Officer who shall promptly notify the affected individual by certified mail, return receipt requested. The Chief Executive Officer shall then hold the recommendation until after the individual has exercised or has waived the right to a hearing, after which the Chief Executive Officer shall forward the recommendation of the BHS Medical Executive Committee, together with all supporting information, to the Board (or its designated committee). The President of the Medical Staff shall be available to the Board (or its designated committee) to answer any questions that may be raised with respect to the recommendation.

(c) If the action of the BHS Medical Executive Committee does not entitle the individual to

a hearing, the action shall take effect immediately without action of the Board and without the right of appeal to the Board. A report of the action taken and reasons therefore shall be made to the Board (or its designated committee) through the Chief Executive Officer, and the action shall stand unless modified by the Board (or its designated committee).

(d) In the event the Board (or its designated committee) determines to consider

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modification of the action of the BHS Medical Executive Committee and such modification would entitle the individual to a hearing in accordance with these Bylaws, it shall so notify the affected individual, through the Chief Executive Officer, and shall take no final action thereon until the individual has had an opportunity to exercise the right to a hearing and appeal as provided in these Bylaws.

12.F. PRECAUTIONARY SUSPENSION OF CLINICAL PRIVILEGES 12.F.1. Grounds for Precautionary Suspension: (a) The President of the Medical Staff, the appropriate department chair, the System

Credentials Committee Chair, Chief Executive Officer, or the Board Chair shall each have the authority to suspend all or any portion of the clinical privileges of a Medical Staff appointee or other individual whenever failure to take such action may result in an imminent danger to the health and/or safety of any individual. Such precautionary suspension shall be deemed an interim step in the professional review activity related to the ultimate professional review action that may be taken with respect to the suspended individual, but is not a complete professional review action in and of itself. It shall not imply any final finding of responsibility for the situation that caused the suspension.

(b) A precautionary suspension can be imposed at any time, including after a specific

event, a pattern of events, or a recommendation by the BHS Medical Executive Committee that would entitle the individual to request a hearing. When possible, prior to the imposition of a precautionary suspension, the person(s) considering the suspension will meet with the individual and review the concerns that support the suspension and afford the individual an opportunity to respond.

(c) Such precautionary suspension shall become effective immediately upon imposition,

shall immediately be reported in writing to the Chief Executive Officer and the President of the Medical Staff and the BHS Medical Executive Committee and shall remain in effect unless or until modified by the BHS Medical Executive Committee.

(d) Within three (3) days of the imposition of a suspension, a brief written description of

the reason(s) for the action, including the names and medical record numbers of the patient(s) involved (if any), will be provided to the individual.

12.F.2. BHS Medical Executive Committee Procedure: (a) Any individual who exercises authority under Section 12.F.1 to suspend clinical

privileges as a precaution shall immediately report this action to the BHS Medical Executive Committee to take further action in the manner specified in Section 12.E of these Bylaws.

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

BHS Medical Executive Committee within fifteen (15) days of the imposition of the suspension.

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(c) As part of this review, the individual will be invited to meet with the BHS Medical

Executive Committee. In advance of the meeting, the individual may submit a written statement and other information to the BHS Medical Executive Committee.

(d) At the meeting, the individual may provide information to the BHS Medical Executive

Committee and should respond to questions that may be raised by committee members. The individual may also propose ways, other than precautionary suspension, to protect patients, employees or others while an investigation is conducted.

(e) The individual may be accompanied by counsel at this meeting. The role of counsel

will be limited to providing advice to the individual subject to the suspension. Counsel may not make a presentation to or question members of the BHS Medical Executive Committee or anyone else attending the meeting. The BHS Medical Executive Committee may also have counsel present subject to the same conditions that counsel may not question the individual. A record of this meeting will be maintained by a stenographic reporter.

(f) After considering the reasons for the suspension and the individual’s response, if any,

the BHS Medical Executive Committee will determine whether the precautionary suspension should be continued, modified, or lifted. The BHS Medical Executive Committee will also determine whether to begin an investigation.

(g) If the BHS Medical Executive Committee decides to continue the suspension, it will

send the individual written notice of its decision, including the basis for it and that suspensions lasting longer than thirty (30) days must be reported to the National Practitioner Data Bank.

(h) There is no right to a hearing based on the imposition or continuation of a precautionary

suspension. The procedures outlined above are deemed to be fair under the circumstances.

(i) Upon the imposition of a precautionary suspension, the President of the Medical Staff

will assign responsibility for the care of any hospitalized patients to another individual with appropriate clinical privileges. Whenever possible, consideration will be given to the wishes of the patient in the selection of a covering physician.

12.F.3. Care of Suspended Individual’s Patients: (a) Immediately upon the imposition of a precautionary suspension, the appropriate

department chair or the President of the Medical Staff shall assign to another individual with appropriate clinical privileges responsibility for care of the suspended individual’s patients still in the BHS Facility. The assignment shall be effective until such time as the patients are discharged. The wishes of the patient shall be considered in the selection of the assigned appointee.

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(b) It shall be the duty of all Medical Staff appointees to cooperate with the President of the Medical Staff, the department chair, the BHS Medical Executive Committee, and the Chief Executive Officer in enforcing all suspensions.

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ARTICLE 13

PHYSICIANS UNDER CONTRACT WITH BHS (a) From time to time, BHS may enter into contracts or employment relationships with

physicians or a physician group for the performance of certain services, including those in administrative positions. All physicians functioning pursuant to such contracts or employment relationships and who provide clinical services shall obtain and maintain Medical Staff appointment and clinical privileges, in accordance with the provisions of the applicable Medical Staff Bylaws regarding qualifications for appointment and clinical privileges.

(b) The effect of the expiration or other termination of a contract/employment upon the

appointee’s Medical Staff appointment and clinical privileges and the hearing and appeal pursuant thereto shall be governed by the terms of the appointee’s contract/employment with BHS. If the contract/employment arrangement is silent on the matter, then the clinical privileges of an appointee who has an exclusive contract with BHS, or who is employed by a group with an exclusive contract, shall be coterminous with the exclusive contract, or with the appointee’s termination of employment with the group holding an exclusive contract, which ever shall occur first. Any such reduction in term shall not be deemed an Adverse Recommendation as defined in these Bylaws and shall not entitle the individual to a fair hearing on the matter.

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PART 4 – FAIR HEARING AND APPEAL PROCEDURES

ARTICLE 14

FAIR HEARING AND APPEAL PROCEDURES 14.A. INITIATION OF HEARING 14.A.1. Grounds for Hearing: (a) An applicant or an individual holding a Medical Staff appointment shall be entitled to

request a hearing whenever the BHS Medical Executive Committee makes one of the following adverse recommendations (“Adverse Recommendations”):

(1) denial of initial Medical Staff appointment; (2) denial of Medical Staff reappointment; (3) revocation of Medical Staff appointment; (4) denial or restriction of requested clinical privileges for more than thirty (30) days,

excluding routine proctoring requirements and precautionary suspension; (5) denial of requested additional clinical privileges; (6) decrease of clinical privileges; (7) suspension of clinical privileges for more than thirty (30) days (unless the

suspension is for failure to complete medical records or any other reason unrelated to clinical competence or professional conduct);

(8) restriction of current clinical privileges, meaning the imposition of a mandatory

concurring consultation requirement (i.e., the individual must obtain a consult and must reach agreement with the consult as to the course of treatment before that treatment can be pursued) if the requirement only applies to an individual medical staff member and is imposed for more than 14 calendar days; or

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

professional competence or conduct. (b) No other recommendations except those enumerated in subparagraph (a) shall entitle

the individual to request a hearing. (c) The affected individual shall also be entitled to request a hearing before the Board

enters a final decision, in the event the Board should determine, without a similar recommendation from the BHS Medical Executive Committee, to take any action on an

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Adverse Recommendation. (d) The hearing shall be conducted in as informal a manner as possible, subject to the rules

and procedures set forth in these Bylaws.

14.A.2. Actions Not Grounds for Hearing: None of the following actions shall constitute grounds for a hearing, and shall take effect without hearing or appeal: (a) the issue of a letter of warning, counsel, admonition, guidance, or reprimand; (b) the imposition of terms of conditions, probation, monitoring, proctoring, or a general

consultation requirement (i.e., the individual must obtain a consult but need not reach agreement with the consult before the treatment is pursued);

(c) a lapse or failure to renew temporary or locum tenens privileges; (d) the automatic relinquishment of clinical privileges as provided in these Bylaws; (e) the imposition of a requirement for additional training or continuing education; (f) a precautionary suspension that does not exceed thirty (30) days; (g) denial of a request for leave of absence, for an extension of a leave or for reinstatement

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

omission; (j) removal from the on-call roster or any reading or rotational panel; (k) the voluntary acceptance of a performance improvement plan option; (l) determination of ineligibility based on a failure to meet threshold eligibility criteria, a

lack of need or resources, or because of an exclusive contract; (m) any actions related to the clinical practice of BHS employees at a BHS clinic

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14.A.3. Employment and Exclusive Arrangements: (a) From time to time, BHS may enter into employment agreements or exclusive contracts or

arrangements (“exclusive arrangements”) with practitioners and/or groups of practitioners for the performance of clinical and administrative services at a BHS Clinic or other facility. All individuals providing clinical services pursuant to such arrangements will obtain and maintain clinical privileges in accordance with the terms of these Bylaws.

(b) To the extent that:

(1) any such arrangement confers the exclusive right to perform specified services to one or more practitioners or groups of practitioners, or

(2) the Board by employment, resolution, or other exclusive arrangement limits the

practitioners who may exercise specific clinical privileges or services to employees of the hospitals or their affiliates, no practitioner except those authorized by or pursuant to the exclusive arrangement may exercise clinical privileges to perform the specified services. Only practitioners so authorized are eligible to apply the clinical privileges included in the exclusive arrangement.

(c) Prior to any BHS hospital entering into any exclusive arrangement in a clinical service that

has not previously been subject to such arrangement, the Board will request the BHS Medical Executive Committee (or a subcommittee of its members appointed by the Chairperson of the BHS Medical Executive Committee) to review the proposal developed by the Board and comment on the quality of care and service implications of the proposed arrangement.

(d) After receiving the BHS Medical Executive Committee’s comments, the Board will

consider whether or not to proceed with the employment or exclusive arrangement. If the Board makes a preliminary determination to proceed with an exclusive arrangement that would have the effect of preventing a practitioner from exercising clinical privileges that had previously been granted, the affected practitioner is entitled to the following notice and review procedures:

(1) Notice of the proposed exclusive arrangement and the right to request to meet with

the Board to discuss the matter prior to the proposed effective date of such arrangement.

(2) At the meeting, the affected member will be entitled to present information relevant

to the decision to enter into the arrangement. (3) If, following this meeting, the Board determines to enter into the exclusive

arrangement, the affected member will be notified that he or she is ineligible to continue to exercise the clinical privileges covered by the exclusivity. The ineligibility begins as of the effective date of the exclusive arrangement.

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(4) The procedural rights outlined above will be the member’s exclusive remedy (5) The inability of a member to exercise clinical privileges because of an exclusive

contract or arrangement is not a matter that requires a report to the state licensure board or to the National Practitioner Data Bank.

(e) Except as provided in paragraph (a), in the event of any conflict between these Medical

Staff Bylaws and the terms of any contract or arrangement, the terms of the contract or arrangement will control.

(f) Practitioners holding employment or other exclusive arrangements shall be governed by the

terms of their employment or other contracts or arrangements and shall not be entitled to any of the procedural rights provided by these Bylaws.

14.B. THE HEARING 14.B.1. Notice of Recommendation: When a recommendation is made which, according to these Bylaws entitles an individual to request a hearing prior to a final decision of the Board, the affected individual shall promptly be given notice by the Chief Executive Officer, in writing, certified mail, return receipt requested. The Chief Executive Officer shall provide this notice to the individual within ten (10) days from the date the recommendation was made. This notice shall contain: (a) a statement of the recommendation made and the general reasons for it; (b) notice that the individual has the right to request a hearing on the recommendation

within thirty (30) days of receipt of this notice; and (c) a copy of this Article outlining the rights in the hearing as provided for in these Bylaws. 14.B.2. Request for Hearing: An individual shall have thirty (30) days following the date of the receipt of such notice within which to request the hearing. The request shall be in writing to the Chief Executive Officer and shall include the name, address, and telephone number of the individual’s counsel, if any. In the event the individual does not request a hearing within the time and in the manner required by these Bylaws, the individual shall be deemed to have waived the right to the hearing and to have accepted the action involved. That action shall become effective immediately upon final Board action. 14.B.3. Notice of Hearing and Statement of Reasons: (a) The Chief Executive Officer shall schedule the hearing and shall give written notice,

certified mail, return receipt requested, to the person who requested the hearing. The notice shall include:

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(1) the time, place, and date of the hearing; (2) a proposed list of witnesses, as known at that time, but which may be modified,

who will give testimony or present evidence at the hearing in support of the BHS Medical Executive Committee or the Board and a brief summary of the anticipated testimony;

(3) the names of the Hearing Panel members and Presiding Officer (or Hearing

Officer) if known; and (4) a statement of the specific reasons for the recommendation, as well as the list of

patient records and information supporting the recommendation. This statement, and the list of supporting patient record numbers and other supporting information, may be revised or amended at any time, even during the hearing, so long as the additional material is relevant to the continued appointment or clinical privileges of the individual requesting the hearing. The individual and counsel shall have sufficient time, up to thirty (30) days, to study this additional information and rebut it.

(b) The hearing shall begin as soon as practicable, but no sooner than thirty (30) days after

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

14.B.4. Witness List: (a) At least fifteen (15) days before the pre-hearing conference, the individual requesting

the hearing shall provide a written list of the names and addresses of the individuals expected to offer testimony or present evidence on his or her behalf.

(b) The affected individual’s witness list, as well as the witness list of the BHS Medical

Executive Committee or the Board, shall include a brief summary of the nature of the anticipated testimony. Both lists shall be finalized at the pre-hearing conference. However, the witness list of either party may, thereafter, in the discretion of the Presiding Officer or Hearing Panel Chair, be supplemented or amended at any time during the course of the hearing, provided that notice of the change is given to the other party. The Presiding Officer shall have the authority to limit the number of witnesses, especially character witnesses or witnesses whose testimony is merely cumulative, as set forth in Section 14.B.5.

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14.B.5. Hearing Panel, Presiding Officer, and Hearing Officer: (a) Hearing Panel: (1) When a hearing is requested, the Chief Executive Officer, acting for the Board

and after considering the recommendations of the President of the Medical Staff (and that of the Board Chair, if the hearing is occasioned by a Board determination), shall appoint a Hearing Panel which shall be composed of not less than three (3) members. The Hearing Panel shall be composed of Medical Staff appointees who shall not have actively participated in the consideration of the matter involved at any previous level, or of physicians or laypersons not connected with BHS, or a combination of such persons. Knowledge of the matter involved shall not preclude any individual from serving as a member of the Hearing Panel. Employment by or other contractual arrangement with BHS or an affiliate will not preclude an individual from serving on the Hearing Panel.

(2) The Hearing Panel shall not include any individual who is (i) in direct economic

competition with the affected person, (ii) professionally associated with, related to, or involved in a referral relationship with the affected individual; (iii) demonstrated to have an actual bias, prejudice, or conflict of interest that would prevent the individual from fairly and impartially considering the matter; or (iv) actively participated in the matter at any previous level. Employment by, or other contractual arrangement with, BHS or an affiliate will not preclude an individual from serving on the Hearing Panel.

(3) In addition to the appointment of a Hearing Panel, the Chief Executive Officer

shall appoint a Presiding Officer or a Hearing Panel Chair.

(b) Presiding Officer: (1) The Chief Executive Officer will appoint a Presiding Officer who may be an

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

(2) The Presiding Officer shall: (i) schedule and conduct a pre-hearing conference; (ii) act to insure that all participants in the hearing have a reasonable

opportunity to be heard and to present oral and documentary evidence subject to reasonable limits on the number of witnesses and duration of direct and cross examination, applicable to both sides, as may be necessary to avoid cumulative or irrelevant testimony or to prevent abuse of the hearing process;

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(iii) prohibit conduct or presentation of evidence that is cumulative, excessive,

irrelevant, abusive, or that causes undue delay; (iv) maintain decorum throughout the hearing; (v) determine the order of procedure throughout the hearing; (vi) have the authority and discretion, in accordance with these Bylaws, to make

rulings on all questions which pertain to matters of procedure and to the admissibility of evidence;

(vii) act in such a way that all information relevant to the continued appointment

or clinical privileges of the individual requesting the hearing is considered by the Hearing Panel in formulating its recommendations; and

(viii) conduct argument by counsel on procedural points outside the presence of

the Hearing Panel unless the panel wishes to be present. (3) The Presiding Officer may be advised by legal counsel to BHS with regard to the

hearing procedure.

(c) Hearing Officer: (1) As an alternative to the Hearing Panel described in Section 14.B.5(a), the Chief

Executive Officer, after consulting with the President of the Medical Staff (and Board Chair if the hearing was occasioned by a Board determination), may instead appoint a Hearing Officer to perform the functions that would otherwise be carried out by the Hearing Panel. The Hearing Officer shall preferably be an attorney at law.

(2) The Hearing Officer may not be in direct economic competition with the individual

requesting the hearing, and shall not act as a prosecuting officer or as an advocate to either side at the hearing. If the Hearing Officer is an attorney, he/she shall not represent clients in direct economic competition with the affected individual.

(3) In the event a Hearing Officer is appointed instead of a Hearing Panel, all

references in this Article to the “Hearing Panel” or “Presiding Officer” shall be deemed to refer instead to the Hearing Officer, unless the context would clearly otherwise require.

(d) Objections:

Any objection to any member of the Hearing Panel, the Hearing Officer, or the Presiding Officer shall be made in writing, within ten (10) days of receipt of notice, to the Chief Executive Officer. A copy of such written objection must be provided

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President of the Medical Staff and must include the basis for the objection. The President of the Medical Staff shall be given a reasonable opportunity to comment. The Chief Executive Officer may request that the Presiding Officer make a recommendation as to the validity of the objection.

(e) Members of the Hearing Panel, the Hearing Officer, or the Presiding Officer may be compensated for their service. The individual requesting the hearing may be responsible for that compensation. Compensation will not constitute grounds for challenging the impartiality of the Hearing Panel members.

14.C. PRE-HEARING AND HEARING PROCEDURE 14.C.1. General Provisions: The pre-hearing and hearing processes will be conducted in an informal manner. Formal rules of evidence or procedure will not apply. 14.C.2. Time Frames: The following time frames, unless modified by mutual written agreement of the parties, will govern the timing of pre-hearing procedures: (a) the pre-hearing conference will be scheduled at least fourteen (14) days prior to the

hearing; (b) the parties will exchange witness lists and proposed exhibits at least ten (10) days prior

to the pre-hearing conference; and (c) any objections to witnesses and/or proposed exhibits must be provided at least five (5)

days prior to the pre-hearing conference. 14.C.3. Provision of Relevant Information: (a) Prior to receiving any confidential documents, the individual requesting the hearing

must agree that all documents and information will be maintained as confidential and will not be disclosed or used for any purpose outside of the hearing. The individual must also provide a written representation that his or her counsel and any expert(s) have executed Business Associate agreements in connection with any patient Protected Health Information contained in any documents provided.

(b) Upon receipt of the above agreement and representation, the individual requesting the

hearing will be provided with a copy of the following: (1) copies of, or reasonable access to, all patient medical records referred to in the

statement of reasons, at the individual’s expense;

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(2) reports of experts relied upon by the BHS Medical Executive Committee; (3) copies of relevant minutes (with portions regarding other physicians and unrelated

matters deleted); and (4) copies of any other documents relied upon by the BHS Medical Executive Committee. The provision of this information is not intended to waive any privilege.

(c) The individual will have no right to discovery beyond the above information. No

information will be provided regarding other practitioners on the Medical Staff. In addition, there is no right to depose, interrogate, or interview witnesses or other individuals prior to the hearing.

(d) Ten (10) days prior to the pre-hearing conference, or on dates set by the Presiding

Officer or agreed upon by both sides, each party will provide the other party with its proposed exhibits.

(e) Neither the individual, nor any other person acting on behalf of the individual, may

contact BHS employees or Medical Staff Members whose names appear on the BHS Medical Executive Committee’s witness list or in documents provided pursuant to this Section concerning the subject matter of the hearing, until BHS has been notified and has contacted the individuals about their willingness to be interviewed. BHS will advise the individual who requested the hearing once it has contacted such employees or Medical Staff Members or confirmed their willingness to meet. Any employee or Medical Staff Member may agree or decline to be interviewed by or on behalf of the individual who requested a hearing.

14.C.4. Pre-Hearing Conference: The Presiding Officer shall require counsel for the individual and for the BHS Medical Executive Committee or the Board to participate in a pre-hearing conference for purposes of resolving all procedural questions in advance of the hearing. The Presiding Officer shall specifically require that: (a) all documentary evidence/exhibits to be submitted by the parties be presented to each

other at least three (3) days prior to this conference; (b) evidence unrelated to the reasons for the unfavorable recommendation or unrelated to

the individual’s qualifications for appointment or the relevant clinical privileges be excluded;

(c) the names of all witnesses and a brief statement of their anticipated testimony be

exchanged by the parties at least three (3) days prior to this conference. All objections to Exhibits or witnesses will be submitted in writing five (5) days in advance of the pre-hearing conference;

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(d) the time granted to each witness’ testimony and cross-examination be agreed upon, or

determined by the Presiding Officer, in advance; (e) witnesses and documentation not provided and agreed upon in advance of the hearing

may be excluded from the hearing; (f) At the pre-hearing conference, the Presiding Officer will resolve all procedural

questions, including any objections to exhibits or witnesses; (g) Evidence unrelated to the reasons for the recommendation or to the individual’s

qualifications for appointment or the relevant clinical privileges will be excluded; and (h) The Presiding Officer will establish the time to be allotted to each witness’s testimony

and cross-examination.

14.C.5. Provision of Information to the Hearing Panel:

The following documents shall be provided to the Hearing Panel (or Hearing Officer) in advance of the hearing:

(a) a pre-hearing statement that either party may choose to submit; (b) exhibits offered by the parties following the pre-hearing conference (without the need

for authentication); and (c) stipulations agreed to by the parties. 14.C.6. Failure to Appear: Failure, without good cause, of the individual requesting the hearing to appear and proceed at such a hearing shall be deemed to constitute voluntary acceptance of the pending recommendations or actions, which shall then be forwarded to the Board for final action. 14.C.7. Record of Hearing: The Hearing Panel shall maintain a record of the hearing by a stenographic reporter. The cost of such reporter shall be borne by BHS, but copies of the transcript shall be provided to the individual requesting the hearing at that individual’s expense. Oral evidence shall be taken only on oath or affirmation administered by any person designated by such body and entitled to notarize documents in this State. 14.C.8. Rights of Both Sides and the Hearing Panel at the Hearing: (a) At a hearing both sides shall have the following rights, subject to reasonable limits

determined by the Presiding Officer:

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(1) to call and examine witnesses to the extent they are available and willing to testify; (2) to introduce exhibits; (3) to cross-examine any witness on any matter relevant to the issues and to rebut any

evidence; (4) representation by counsel who may call, examine, and cross-examine witnesses

and present the case. Both sides shall notify the other of the name of that counsel at least ten (10) days prior to the pre-hearing conference; and

(5) to submit a written statement at the close of the hearing. (b) Any individual requesting a hearing who does not testify in his or her own behalf may

be called and examined as if under cross-examination. (c) The Hearing Panel may question the witnesses, call additional witnesses, and/or request

documentary evidence. (d) It is expected that the hearing shall last no more than 15 hours, with each side being

afforded approximately seven and a half hours to present its case, in terms of both direct and cross-examination of witnesses. Both parties are required to prepare their case so that a hearing shall be concluded after a maximum of 15 hours. The Presiding Officer may, after considering any objections, grant limited extensions upon a demonstration of good cause and to the extent compelled by fundamental fairness.

14.C.9. Admissibility of Evidence: The hearing shall not be conducted according to rules of evidence. Hearsay evidence shall not be excluded merely because it constitutes hearsay. Any relevant evidence shall be admitted if it is the sort of evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of such evidence in a court of law. The guiding principle shall be that the Board, which must ultimately decide about the affected physician’s appointment and clinical privileges, shall have before it all information relevant to the physician’s qualifications for the appointment and/or clinical privileges. 14.C.10. Persons to Be Present: The hearing will be restricted to those individuals involved in the proceeding. Administrative personnel may be present as requested by the CEO or the President of the Medical Staff. 14.C.11. Official Notice: The Presiding Officer shall have the discretion to take official notice of any matters, either

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technical or scientific, relating to the issues under consideration that could have been judicially noticed by the courts of this State. Participants in the hearing shall be informed of the matters to be officially noticed and such matters shall be noted in the record of the hearing. Either party shall have the opportunity to request that a matter be officially noticed or to refute the noticed matter by evidence or by written or oral presentation of authority. Reasonable additional time shall be granted, if requested, to present written rebuttal of any evidence admitted on official notice. 14.C.12. Postponements and Extensions: Postponements and extensions of time beyond any time limit set forth in these Bylaws may be requested by anyone but shall be permitted only by the Presiding Officer or the Chief Executive Officer on a showing of good cause. 14.C.13. Presence of Hearing Panel Members:

A majority of the Hearing Panel will be present throughout the hearing. In unusual circumstances when a Hearing Panel member must be absent from any part of the hearing, he or she will read the entire transcript of the portion of the hearing from which he or she was absent. 14.C.14. Post-Hearing Memoranda of Points and Authorities: Each party shall have the right to submit a memorandum of points and authorities, and the Hearing Panel may request such a memorandum to be filed, following the close of the hearing. 14.D. HEARING CONCLUSION, DELIBERATIONS, AND RECOMMENDATIONS 14.D.1. Order of Presentation: The BHS Medical Executive Committee or the Board, depending on whose recommendation prompted the hearing initially, shall first present evidence in support of its recommendation. Thereafter, the burden shall shift to the individual who requested the hearing to present evidence. 14.D.2. Basis of Decision: (a) Consistent with the burden on the individual to demonstrate that he or she satisfies, on a

continuing basis, all criteria for initial appointment, reappointment and clinical privileges, the Hearing Panel shall recommend in favor of the BHS Medical Executive Committee or the Board unless it finds that the individual who requested the hearing has proved that the recommendation that prompted the hearing was arbitrary, capricious, or not supported by substantial evidence.

(b) The recommendation of the Hearing Panel shall be based on the evidence produced at

the hearing. This evidence may consist of the following:

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(1) oral testimony of witnesses; (2) memorandum of points and authorities presented in connection with the hearing; (3) any information regarding the individual who requested the hearing so long as

that information has been admitted into evidence at the hearing and the person who requested the hearing had the opportunity to comment on and, by other evidence, refute it;

(4) any and all applications, references, and accompanying documents; (5) other documented evidence, including medical records; and (6) any other evidence that has been presented at the hearing. 14.D.3. Adjournment and Conclusion: The Presiding Officer may, without special notice, adjourn the hearing and reconvene the same at the convenience and with the agreement of the participants. Upon conclusion of the presentation of evidence by the parties and/or questions by the Hearing Panel, the hearing shall be closed. 14.D.4. Deliberations and Recommendation of the Hearing Panel: Within twenty (20) days after final adjournment of the hearing (which may be designated as the time the Hearing Panel receives the hearing transcript or any post-hearing memoranda, whichever is later), the Hearing Panel shall conduct its deliberations outside the presence of any other person except the Presiding Officer, and shall render a recommendation, accompanied by a report, which shall contain a concise statement of the reasons for the Hearing Panel’s recommendation. 14.D.5. Disposition of Hearing Panel Report: The Hearing Panel shall deliver its report and recommendation to the Chief Executive Officer who shall forward it, along with all supporting documentation, to the Board for further action. The Chief Executive Officer shall also send a copy of the report and recommendation, certified mail, return receipt requested, to the individual who requested the hearing. The Chief Executive Officer shall also provide a copy to the Executive Committee. 14.E. APPEAL PROCEDURE 14.E.1. Time for Appeal: Within ten (10) days after notice of the Hearing Panel’s recommendation, either party may request an appellate review. The request shall be in writing, and shall be delivered to the Chief Executive Officer either in person or by certified mail, return receipt requested, and must include a statement of the reasons for appeal and the specific facts or circumstances

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which justify further review. If such appellate review is not requested within ten (10) days as provided herein, both parties shall be deemed to have waived appellate review, and the Hearing Panel’s report and recommendation shall be forwarded to the Board for final action. 14.E.2. Grounds for Appeal: The grounds for appeal shall be limited to the following: (a) there was substantial failure to comply with these Bylaws and/or the applicable Medical

Staff Bylaws during or prior to the hearing, so as to deny a fair hearing; and/or (b) the recommendations of the Hearing Panel were made arbitrarily, capriciously, or with

prejudice; and/or (c) the recommendations of the Hearing Panel were not supported by substantial evidence.

14.E.3. Time, Place, and Notice:

Whenever an appeal is requested as set forth in the preceding Sections, the Board Chair shall schedule and arrange for an appellate review. The affected individual shall be given notice of the time, place, and date of the appellate review. The appellate review shall be held as soon as arrangements can reasonably be made, taking into account the schedules of all the individuals involved.

14.E.4. Nature of Appellate Review: (a) The Board Chair shall appoint a Review Panel composed of not less than three (3)

persons, either members of the Board or others, including but not limited to reputable persons outside BHS, to consider the record upon which the recommendation before it was made, or the Board may hear the appeal as a whole body.

(b) The Review Panel may in its discretion accept additional oral or written evidence

subject to the same rights of cross-examination or confrontation provided at the Hearing Panel proceedings. Such additional evidence shall be accepted only if the party seeking to admit it can demonstrate that it is new, relevant evidence or that any opportunity to admit it at the hearing was improperly denied, and then only at the discretion of the Review Panel.

(c) Each party shall have the right to present a written statement in support of its position

on appeal. In its sole discretion, the Review Panel may allow each party or its representative to appear personally and make oral argument not to exceed thirty (30) minutes. The Review Panel shall recommend final action to the Board.

14.E.5. Final Decision of the Board: (a) The Board shall take final action within thirty (30) days after it (i) considers the appeal

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as a Review Panel, (ii) receives a recommendation from a separate Review Panel, or (iii) receives the Hearing Panel’s report when no appeal has been requested.

(b) Consistent with its ultimate legal authority for the operation of BHS and the quality of

care provided, the Board may adopt, modify, or reverse any recommendation that it receives or refer the matter for further review.

(c) The Board will render its final decision in writing, including the basis for its decision,

and will send special notice to the individual. A copy will also be provided to the President of the Medical Staff.

14.E.6. Right to One Hearing and One Appeal Only:

No applicant or Medical Staff appointee shall be entitled to more than one (1) hearing and one (1) appellate review on any matter which may be the subject of an appeal. If the board decides to deny initial Medical Staff appointment or reappointment to an applicant, or to revoke or terminate the Medical Staff appointment and/or clinical privileges of a current appointee, that individual may not apply for staff appointment or for those clinical privileges for a period of five (5) years unless the Board provides otherwise.

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ARTICLE 15

CONFIDENTIALITY AND PEER REVIEW PROTECTIONS

15.A. CONFIDENTIALITY AND REPORTING (a) Actions taken and recommendations made pursuant to these Bylaws shall be treated as

confidential in accordance with applicable legal requirements and such policies regarding confidentiality as may be adopted by BHS, the BHS Facilities, and the Medical Staff. In addition, reports of actions taken pursuant to these Bylaws shall be made by the Chief Executive Officer to such governmental agencies as may be required by law.

(b) All records and other information generated in connection with and/or as a result of

professional review activities shall be confidential, and each individual or committee member participating in such review activities shall agree to make no disclosures of any such information except as authorized, in writing, by the Chief Executive Officer or by legal counsel to BHS. Any breach of confidentiality by an individual or committee member may result in a professional review action, and/or may result in appropriate legal action to ensure that confidentiality is preserved, including application to a court of law for injunctive or other relief.

15.B. PEER REVIEW PROTECTION All minutes, reports, recommendations, communications, and actions made or taken pursuant to these Bylaws are deemed to be covered by the provisions of Wis. Stat. Ann. §146.37 and §146.38, or the corresponding provisions of any subsequent federal or state statute providing protection to peer review or related activities. Furthermore, the committees and/or panels charged with making reports, findings, recommendations, or investigations pursuant to these Bylaws shall be considered to be acting on behalf of the BHS Facilities and Board when engaged in such professional review activities and thus shall be deemed to be “professional review bodies” as that term is defined in the Health Care Quality Improvement Act of 1986.

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PART 5 – RULES AND REGULATIONS

ARTICLE 16

16.A. ADMISSION TO THE HOSPITAL/TREATMENT: 16.A.1. Non-Discrimination: Patients who have been admitted to the hospital (whether as an inpatient or outpatient) shall receive care regardless of race, color, national origin, age, sex, sexual identity, sexual orientation, religion, political beliefs, disability, or ability to pay the costs. 16.A.2. Admission: Admission to the hospital and discharges from the hospital may be done only by qualified Staff appointees. Staff appointees having admitting privileges are those who are appointees to the Medical Staff or who have been granted temporary privileges. The attending physician is a member of the Medical Staff who directs and coordinates patient care. 16.A.3. Assignment of Attending Physician (a) Upon admission, the admitting physician is designated as the Attending Physician (b) Transfer of Attending Physician responsibilities may be performed only on the basis of

direct communication with another physician (face-to-face, by telephone or by BHS approved electronic communication). Following such direct communication, the Attending Physician shall document an order in the chart for “transfer Attending Physician responsibility to.” The original attending shall remain on the case until such time as there is chart documentation of the acceptance of the transfer of responsibility by the other physician.

16.A.4. Attending Physician Responsibilities (a) The Attending Physician, or appropriately credentialed designee, will (1) provide a documented order for admission to the appropriate level of care; (2) be responsible for completing or arranging for the completion of a history and

physical examination in a timely manner as required by these Rules and Regulations; and

(3) record daily progress notes in the medical record. (b) The Attending Physician is responsible to oversee coordination of medical information

that is provided to the family.

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(c) The Attending Physician is responsible for working with hospital staff to meet family requests for family meetings.

(d) The Attending Physician is responsible for discussing code status with the patient

and/or designee and documenting the appropriate order in the patient’s chart. (e) The Attending Physician is responsible for coordinating physician consultations. This

shall include personally contacting the consultant, when appropriate, and providing him/her with pertinent information.

(f) The Attending Physician is responsible for any required documentation necessary for

transfer and/or discharge of a patient. (g) The Attending Physician shall be responsible to provide the hospital staff with such

information as may be necessary for the protection of staff and other patients from those who are a source of danger from any cause and for protection of patients from self-harm.

16.B. PHYSICIANS TREATING FAMILY MEMBERS Physicians shall not treat immediate members of their families or themselves when inpatients or surgical patients at BH (immediate family members are defined as parents, spouse, children, siblings or in-laws or step relationships in the same categories). This policy is based on the concern that professional objectivity may be compromised when a family member or the physician is the patient. Concerns regarding patient autonomy and informed consent are also relevant when physicians attempt to treat members of their family. In emergency situations, physicians may treat family members until another physician becomes available. 16.C. MEDICAL RECORDS 16.C.1. Medical Record Requirements: (a) Inpatient/Outpatient Hospital Records.

(1) There shall be a medical record maintained for every patient admitted to the

hospital. (2) The Medical Record must contain sufficient information to justify the admission

and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services.

(3) Except as otherwise provided in Section 16.C.1(a)(4) below, the

inpatient/outpatient hospital Medical Records shall contain the following

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information as applicable:

(i) Identification data (ii) Advance Directives (iii) Complaint (iv) Present illness (v) Past history (vi) Family history (vii) Physical examination (viii) Relevant inventory of body systems (ix) Provisional or admitting diagnosis (x) Goals of Treatment/Treatment Plan (xi) Orders (xii) Medications and Adverse Drug Reactions (xiii) Clinical laboratory reports (xiv) Radiology reports (xv) Consultation records (xvi) Informed Consent (xvii) Treatment: Medical and Surgical (xviii) Tissue reports (xix) Progress notes (xx) Final Diagnosis (xxi) Discharge summary (xxii) Autopsy findings (xxiii) Psychiatric evaluations (when applicable), shall also include the additional

requirements set forth in Article 16.C.1(a)(4), below.

(4) In addition to the requirements set forth above, the inpatient hospital Medical Records of patients admitted to BPC shall include the following requirements. (i) Psychiatric Evaluations: Psychiatric Evaluation will be completed within 24

hours of admission by the admitting or attending psychiatrist, and the medical records of such evaluation will contain the following additional requirements:

(a) Identification including legal status (b) History of present illness (c) Psychiatric history (d) Non-Psychiatric medical history and treatment (e) Mental status examination (f) ) Strengths (g) Diagnostic Impression (Current DSM) (h) Treatment Plan

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(ii) Discharge Summary: The discharge summary of a patient discharged from BPC must contain:

(a) Identification (b) Date of admission (c) Date of discharge (d) Final Diagnosis (e) Psychiatric History (brief description of present illness & history –

status on admission (f) Summary of psychological testing (g) Pertinent physical and laboratory findings (h) Course of treatment and complications (i) Condition on Discharge (j) Follow-up appointments (k) Prognosis

(5) All entries must be legible and must be dated, timed, and signed promptly by the

person who is responsible for ordering, providing, or evaluating the service furnished.

(6) Parts of the medical record that are the responsibility of the physician must be

authenticated by the appointee, dated, and timed. Authentication may be a written signature, or initials, or authentication may be in the form of a computer code if the appointee has signed an approved statement to the effect he/she is the only one who has the code and the only one who uses it; the signed statement must be on file in the administrative offices of the health system.

(7) A short form medical record is acceptable for mothers and newborns with

uncomplicated deliveries and in cases of minor medical or surgical care which require less than 48 hours hospitalization. The short form should include a history and physical, including: identification data, a description of the patient's condition, pertinent physical findings, an account of the treatment given and any other data necessary to justify the diagnosis and treatment. A discharge progress note including the patient’s condition at discharge, discharge instructions, and required follow-up care may be substituted for the discharge summary.

(8) All newborns shall have a recorded physical examination. (9) Discharge summaries may be completed by a physician on the Medical Staff or a

Nationally Certified Physician Assistant, Certified Nurse Practitioner, Certified Clinical Nurse Specialist, or Certified Nurse Midwife with an appropriate Scope of Practice. All discharge summaries will include the following and must be completed within 30 days of discharge:

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(i) reason for hospitalization; (ii) procedures performed and care, treatment, and services provided; (iii) condition and disposition at discharge; (iv) information provided to the patient and family, as appropriate; (v) provisions for follow-up care.

(b) All medical record releases shall comply with state and federal laws governing confidentiality of medical records.

(c) Access to health care data including clinical, patient, and physician-specific data shall

be afforded to Staff appointees in good standing for bona fide study and research, consistent with laws governing the confidentiality of personal information and only after approval by the Corporate Institutional Review Board.

(d) Clinic Medical Records. There shall be a medical record maintained for every patient

receiving care at a BHS clinic. Such records shall be maintained in accordance with any applicable patient documentation policies.

16.C.2. Failure to Complete Medical Records: The medical record shall be completed at the time of the patient’s discharge, but in no event may the period of time exceed thirty (30) days from the date of discharge. A medical record is considered delinquent when it has not been completed within fifteen (15) days from the date of discharge. The Medical Records Department shall regularly compile and relay information to the Chief Medical Officer concerning all appointees with delinquent records. The Chief Medical Officer shall notify the appointees of the existence of delinquent medical records, as outlined in approved policy and procedure. If the records are not completed within thirty (30) days, the clinical privileges of the appointee shall be automatically relinquished and the appointee shall not be allowed to admit patients to BH or to care for new patients admitted under another appointee’s name, to provide consultation, or to admit patients to the Clinical Decision Unit, Observation Unit, and Short Stay Unit of a BHS Facility. All incomplete records shall be finished before clinical privileges are reinstated. The Medical Records Department shall have eight (8) hours to review the records completed by the appointee to verify that all dictation and written documentation are present for each record. Exceptions may be granted by the Chief Medical Officer. In the case of an emergency, any physician or dentist appointed to the Medical Staff may care for any patient.

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The clinical privileges of an appointee shall not be automatically relinquished if they are absent from the city when their letter of notification arrives and they do not return until after the due date. A grace period will be granted during absence from the city. That grace period will be seven (7) days from the date of the return of the appointee. This grace period does not apply to appointees whose clinical privileges are automatically relinquished at the time of departure from the city or who leave the city after they have received the letter notifying them of their delinquent records and the due date. Exceptions will be granted only when the appointee does not have seven (7) days to complete the records. An appointee whose clinical privileges are automatically relinquished for two weeks or more, or three times in a rolling twelve (12) month period, shall be required to appear before the BHS Medical Executive Committee and agree to a plan of action to complete medical records in a timely fashion. An appointee whose clinical privileges are automatically relinquished four times in a rolling twelve (12) month period shall have their clinical privileges remain automatically relinquished for one (1) month regardless of the status of his/her medical records; failure to complete medical records within that one (1) month period shall be considered automatic relinquishment of all clinical privileges and resignation from the Medical Staff upon concurrence of the BHS Medical Executive Committee. 16.D. HISTORIES AND PHYSICALS 16.D.1. Qualified Practitioners: Only physicians of the Medical Staff, licensed physicians who are in a residency program at a BHS Facility, Nationally Certified Physician Assistants (NCPA), Certified Nurse Practitioners or Certified Clinical Nurse Specialists (CNS) and Certified Nurse Midwives with a Scope of Practice at Bellin are permitted to record medical histories and perform physical examinations that are acceptable by the hospital for the record. Qualified oral surgeons are also permitted to perform and dictate histories and physical exams for their patients. Podiatrists on the Medical Staff are permitted to perform and dictate histories and physical exams for their patients, except for high risk patients (patients who fall in the ASA Physical Status Classifications III through V, and any patient who will receive other than local anesthesia), which will require a history and physical by a qualified physician. 16.D.2. Requirements: A physical examination and medical history must be completed on each patient admitted to the hospital. The history and physical must have been performed within 24 hours after the hospital admission. If the patient had a complete history and physical exam within thirty (30) days prior to the hospital admission, the physician or qualified Allied Health Professional may use that history and physical for the hospital record provided that he/she performs an assessment and documents an update note within 24 hours after admission. The assessment must include a physical examination of the patient to update any components of the patient’s current medical status that may have changed since the prior history and physical or to address any areas where more current data is needed and which confirms the necessity for the

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procedure or treatment is still present and that the history and physical is still current. The update note must be on or attached to the history and physical. (a) For surgical patients, a physical examination and medical history shall be included in

the chart prior to surgery, except in emergencies. If using a history and physical completed within the past thirty (30) days, an assessment must be completed and an updated note included on the chart within 24 hours after admission but prior to the surgery unless the patient was admitted to the hospital more than 24 hours prior to surgery, in which case the assessment and updated note must be included on the chart within 24 hours after admission.

(b) For non-surgical patients, the history and physical and update note (if applicable) must

be included in the patient’s medical record within 24 hours after admission. Residential hospice respite care patients housed within the hospital will not be required to meet this requirement, unless the patient status becomes acute care, at which time, the history and physical requirement would apply.

16.D.3. Content: (a) Inpatient: For inpatients, a complete history and physical examination must include the

following minimum required elements:

(1) Chief complaint, defined as the presenting symptom(s) for which the patient required hospitalization and treatment;

(2) Chronology of the present illness which should include information to justify an

inpatient hospitalization and substantiate the choice of acute care versus outpatient/observation care, as well as any failure of outpatient therapy or treatment and recent hospitalizations. If admitted for elective surgery, the indications and results of pertinent diagnostic tests should be included;

(3) Past medical history, including surgeries or procedures performed under

anesthesia, prior hospitalizations and chronic medical conditions; (4) Family history; (5) Social history; (6) Current prescribed medications and dosages; (7) Allergies; (8) Inventory of body systems; (9) Physical examination – it is recommended this assessment include, as medically

indicated, notations of the head and neck, chest, cardiovascular, abdominal,

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genitourinary and rectal, extremities, neurologic, and mental status examinations. At a minimum, the following findings must be documented: the examination of the body part / system leading to admission and/or surgery, an assessment of the patient’s mental status, and examination of the heart and lungs by auscultation;

(10) Summary of diagnostic tests to date; (11) Provisional diagnosis on admission; (12) Treatment plan.

(b) Outpatients: A limited history and physical examination is accepted for outpatients undergoing procedures. The patient history should include documentation of the following minimum requirements regardless of type of anesthesia: (1) Indications / symptoms for the surgical procedure; (2) List of current medications and dosages; (3) Allergies; (4) Existing comorbid conditions.

(c) For patients having no anesthesia or topical or local anesthesia, the physical

examination should include documentation of the following minimum requirements:

(1) Assessment of mental status; (2) An examination specific to the procedure to be performed and any comorbid

conditions.

(d) For patients having IV conscious sedation or a regional block, the physical examination should include documentation of the following minimum requirements:

(1) Assessment of mental status; (2) An examination specific to the procedure to be performed and any comorbid

conditions; (3) Examination of the heart and lungs by auscultation.

(e) For patients having general, spinal or epidural anesthesia, the physical examination

should include documentation of the following minimum requirements:

(1) Assessment of mental status;

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(2) An examination specific to the procedure to be performed and any comorbid conditions;

(3) Examination of the heart and lungs by auscultation; (4) Assessment and documented statement about the patient’s general condition.

16.E. CONSULTATIONS 16.E.1. Consultations Encouraged: Consultation with another qualified physician shall be encouraged in all cases in which: (a) The patient is not a good medical or surgical risk. (b) The diagnosis is uncertain. (c) There is question as to the best therapeutic measures to be utilized. (d) There is a question of criminal action (e.g. child abuse, rape). 16.E.2. Attending Physician Requesting Consultation: (a) The attending physician is responsible to request consultation for evaluation and/or

treatment of a patient, ideally through direct communication (telephone or face-to-face) with the consultant.

(b) The attending physician shall document an order in the chart for consultation, including

the purpose of consultation. (c) At the time of first documentation in the medical record by the consulting physician,

the clerical staff shall enter the consultant into the computer system for this patient. 16.E.3. Consultant’s Responsibilities: (a) The consulting physician or an eligible Advanced Practice Clinician, as defined on his

or her privilege card, shall be a member of the Medical Staff who evaluates and treats a patient at the request of the attending physician, and in coordination with the attending physician.

(b) The consultant will evaluate the patient in a timely fashion, in agreement with the

attending physician. (c) The consultant’s findings and recommendations will be documented immediately in the

patient’s chart. At minimum, this will include a brief, electronically documented note and, when clinically appropriate, a complete dictated or electronically documented report.

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(d) The consultant will communicate findings as clinically appropriate with the attending

physician. The consultant and attending will coordinate communication with the patient and family.

(e) In the event of a dispute between the attending physician and consultant, the attending

physician is responsible to direct care and to communicate plans to the patient and family. (f) In all emergency situations, physicians on the Medical Staff will use professional

judgment to intervene appropriately. 16.F. SURGERY 16.F.1 Anesthesia (Amended Effective March 11, 2020) (a) In Accordance with State of Wisconsin exemption from MD/DO supervision of

CRNAs, CRNAs certified as Advance Practice Nurse Prescribers practicing at any BHS Facility may provide anesthesia services in the following categories without MD/DO supervision if the collaborating physician, with whom the CRNA is working, approves such practice and the anesthetic plan, as appropriate:

(1) Monitored Anesthesia Care (MAC): anesthesia care that includes the monitoring of the patient. Deep sedation/analgesic is included in MAC.

(2) Deep sedation/analgesia: a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

(3) General Anesthesia: a drug-induced loss of consciousness characterized by a lack of arousability, insensitivity to painful stimulation, and amnesia that requires monitoring and control of most bodily functions including hemodynamic and respiratory functions.

(4) Spinal Anesthesia: The induction of lower extremity anesthesia by injection of local anesthetic into the sub-arachnoid space.

Notwithstanding the foregoing, at all times that a CRNA provides services without MD/DO supervision, an Anesthesiologist shall be available for consultation as needed and the collaborating physician shall remain responsible for the quality of the anesthetic care delivered by the CRNA.

(b) A pre-anesthesia evaluation must be performed within 48 hours prior to any inpatient or outpatient surgery or procedure requiring anesthesia service for each patient who receives general, regional or monitored anesthesia care.

(c) A post anesthesia evaluation must be completed and documented no later than 48 hours

after surgery or a procedure requiring general, regional, or monitored anesthesia.

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16.F.2. Informed Consent: Except in emergencies, appropriate informed consent forms are duly signed by the patient or his or her legal representative prior to performing any non-routine invasive medical, surgical, or diagnostic procedure, and shall be included in the medical record. 16.F.3. Surgical Attire: Any Staff appointee entering the surgical suite is required to wear acceptable surgical attire. 16.F.4. Pregnancy Verification: Reasonable efforts shall be used to determine the pregnancy status of all patients with childbearing potential prior to those individuals undergoing procedures or receiving treatments that pose a significant risk of harm to a fetus. 16.F.5. On-Time Surgery: Surgeons must be in the operating room and ready to begin surgery at the scheduled time. 16.F.6. Pre-Op Testing: Preop testing will be at the discretion of the surgeon and anesthesiologist involved in the care of the patient, provided that the testing is medically necessary according to accepted professional standards.

16.F.7. Visitors in the Operating Room: Visitors are not permitted in the operating rooms. Exceptions can be made for physicians including residents, paramedical personnel, students, one person designated by the patient to attend a C-section, provided that the surgeon is in accord. 16.F.8. Surgical Assistant: A qualified surgeon assistant shall be present at a surgical operation when his/her presence is necessary in the opinion of the attending surgeon, or of the appropriate surgical department. The operating room supervisor has the authority granted by the Medical Staff and Administration to make an exception to the above rules in the event of an emergency or in unusual circumstances. 16.F.9. Post Operative/Post Procedure Documentation: An operative/procedure report describing techniques, findings and tissues removed or altered shall be completed in its entirety immediately following the procedure (upon completion of the surgery/procedure before the patient is transferred to the next level of care), signed by the surgeon/procedural physician and made a part of the patient’s medical record within 24 hours.

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In the event that the operative/procedure report cannot be created and placed on the patient’s chart before transfer to the next level of care, an immediate postoperative/postprocedure note is required to be documented. This note shall include identification or description of the name of the primary surgeon/procedural physician and assistants, the preprocedure and postprocedure diagnosis, the procedure(s) performed, the specimens removed (if applicable), estimated blood loss (and blood administered if applicable), any complications (if encountered), the type of anesthesia administered, and any grafts or implants. 16.F.10. Tissue: All tissue removed in surgery shall be sent to the hospital pathologist for examination, unless the tissue is exempted from review with BHS Medical Executive Committee approval. 16.F.11. Amputation: All amputated limbs must be sent to the hospital pathologist for disposal or release to the family of the patient for burial. 16.F.12. Safety Hazards: The BHS Safety Officer, Chief Medical Officer, or Chief Executive Officer shall have the authority to close any surgical suite due to safety hazard.

16.G. OBSTETRICS AND GYNECOLOGY 16.G.1. Elective Sterilization: Elective sterilization of patients by tubal ligation or section of the vas deferens may be performed in the hospital provided that proper authorization forms have been signed. 16.G.2. Abortion: It is the position of BHS that abortions should be rarely performed and only under very limited circumstances. Therefore, an abortion may be performed at Bellin Hospital by a qualified physician only after consultation with one other physician who is of the same specialty who confirms that the following conditions are present: (a) Continuation of the pregnancy would present a serious and imminent threat to the

health or life of the mother and no other options are available to allow for the continuation of the pregnancy; or

(b) Continuation of the pregnancy would result in delivery of an infant with grave and

irreparable physical or mental deformity with a life expectancy of no more than one year.

It is the responsibility of the physician performing this procedure to obtain the patient’s written consent in compliance with the requirements outlined in Wisconsin Statutes.

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16.G.3. Personal Values: No physician or other professional personnel shall be compelled to perform an act which violates his/her good medical judgment. Neither physician, hospital, nor hospital personnel shall be required to perform any action violative of personally held moral principles. In such a circumstance, good medical practice requires only the physician or other professional personnel withdraw from the case so long as the withdrawal is consistent with good medical practice and does not place the patient in jeopardy. 16.H. DOCUMENTATION OF ORDERS 16.H.1. Verbal Orders – Authentication: (a) All orders for diagnostic tests and treatments must be in writing or electronically

entered and authenticated. Use of verbal and telephone orders shall be limited to circumstances in which patient care needs require them. An order may be dictated by phone or given verbally by a Medical Staff appointee, or by a licensed physician who is at Bellin as part of his/her training. Verbal/telephone orders will be repeated from the electronic entry back to the prescriber to ensure that the listener has properly heard, understood, and documented the communication. The verbal/telephone order must be recorded and authenticated by a registered nurse, physical therapist, exercise physiologist, pharmacist, dietitian, respiratory therapist, and other health professionals qualified to perform the ordered procedure on behalf of the Medical Staff appointee. In addition, a direct verbal order from an appointee of the Medical Staff may be relayed from a registered nurse, physician assistant, or L.P.N. to a hospital registered nurse, physical therapist, exercise physiologist, pharmacist, dietitian, respiratory therapist, and other health professionals qualified to perform the ordered procedure.

(b) All verbal and telephone orders shall be authenticated by the prescribing practitioner

upon the earlier of the following: • The next time the prescribing practitioner provides care to the patient, assesses the

patient or documents information in the patient’s medical record; • Within 48 hours of when the order was given.

(c) When the ordering physician is not able to authenticate his/her verbal order, another

physician who is “covering for” the prescribing appointee may sign verbal or telephone orders given by the prescribing appointee with the understanding that the doctor who signs these orders is assuming responsibility for the prescribing appointee’s order.

16.H.2. Orders from Providers Not on Staff: A licensed MD, DO, podiatrist, dentist, or oral surgeon from any state who does not have admitting privileges at Bellin shall be allowed to give diagnostic and therapeutic orders on outpatients only, if the provider has examined the patient in the state in which the physician holds a license, provided that the physician, podiatrist, dentist, or oral surgeon’s license has

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been verified. Additionally, a Certified Nurse Practitioner, Certified Physician Assistant, or Certified Clinical Nurse Specialist, with a qualified Scope of Practice at Bellin, may also order diagnostic laboratory tests, radiographic services, and EKGs on outpatients. 16.H.3. Orders from Chiropractors: Doctors of chiropractic medicine shall be allowed to order physical therapy, outpatient x-rays, or MRIs within the limitations of their license, to evaluate musculoskeletal pain. Abnormal results that are out of the realm of a chiropractor’s scope of practice require referral by the chiropractor to the appropriate venue or provider, including the Emergency Department, a primary care physician or the appropriate on-call specialty. 16.I. STANDING ORDERS Medical Staff Appointees may adopt standing orders for treatment which shall be followed as proper treatment of the patient until alternate orders are documented by the attending Staff appointee. All appointees shall be required to review and revise their standing orders annually. Nothing in this regulation shall be construed to prevent a Staff appointee from documenting his/her own specific orders. 16.J. PHYSICIAN ROUNDS It is the responsibility of the attending physician to ensure that patients are evaluated on a daily basis by a physician or an Advanced Practice Clinician. 16.K. AUTOPSIES 16.K.1. Requirements: (a) Criteria developed by the Medical Staff Departments identify deaths in which autopsies

shall be performed. (b) Each appointee of the Medical Staff should be actively interested in securing autopsies.

An autopsy requires written consent of the legally-responsible individual or individuals. (c) All autopsies shall be performed by the hospital pathologist or a qualified physician. (d) It is recommended that physicians requesting autopsies either attend the autopsy or

examine, with the pathologist, the organs of the deceased. (e) Autopsy findings become a clinical information source in quality assessment and

improvement activities.

16.L. MASS CASUALTY ASSIGNMENTS Staff appointees may be assigned by the Brown County Office of Emergency Government to posts of duty either at the hospital or within the area. In the event of a disaster situation, it is the duty of Staff appointees to report immediately to the assigned station.

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The Chair of Disaster Emergency in the hospital disaster program will work with the hospital Chief Executive Officer and Emergency Government authorities in the coordination of activities and directions. All policies involving patient care will be the combined responsibility of the three officers mentioned in this paragraph. All Staff appointees agree to relinquish direction of the professional care of their patients to the Chair of Disaster Emergency in the event of a military or civil disaster of severe proportions. During a local disaster, physicians who offer their services to BHS will be allowed to assist with emergent patient care provided they are able to provide picture identification and that his/her medical license has been verified with the State of Wisconsin. A detailed Manual of Disaster Preparation shall be kept in the Medical Library, available to Staff appointees for study. It is the responsibility of each appointee of the Staff to become familiar with the terms and conditions outlined. 16.M. QUALITY OF DRUG Drugs used in the hospital must meet quality standards. To insure high quality no drugs may be ordered unless they are included in one or more of the following listings: United States Pharmacopoeia, National Formulary, and New Nonofficial Drugs. In the event an admitted patient is enrolled in a research protocol involving an investigational drug, the admitting physician is responsible for providing the hospital pharmacy with information regarding the protocol for use of that particular drug and information concerning any special accommodations that are necessary for that patient. 16.N. SPECIAL CARE UNITS 16.N.1. Intensive Care Unit: (a) When a physician admits a patient to the Intensive Care Unit and it is determined that

care is required for which he/she does not have privileges, appropriate consultation with a physician having those privileges is required. BH has an intensivist service available for consultation and management of patients in the Intensive Care Unit.

(b) Nursing policies and procedures for the Intensive Care Unit are written and have been

approved by the Medical Staff and are reviewed every one to three years. Any problems arising within the unit are handled according to established hospital policy. Reference the Rules and Regulations under Section “Consultation,” Letter B, referencing indication for required consultation.

(c) All patients admitted to the Intensive Care Unit are to be seen by the primary/admitting

physician (or designee) within 4 hours of admission (unless evaluated in ER or Urgent Care by admitting MD). They must be seen at least daily thereafter. The Hospital intensivist service can provide consultation and management as an option.

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16.N.2. Inpatient Rehabilitation Department: (a) The inpatient rehabilitation department maintains an open admission policy such that any

physician who has Bellin admitting privileges may serve as an attending for the general medical management of his/her patient. The Rehabilitation Medical Director, or other physician specifically qualified by training and/or rehabilitation medicine experience, will provide the rehabilitation medical management. The Medical Director retains the overall medico-administrative responsibility for the quality of the medical care provided in the department, and must specifically review and authorize all admissions to the unit. (Refer to department pre-admission screening policy and procedure.) The Medical Director shall have final decision-making authority regarding a patient’s rehabilitation program.

(b) If the referring physician is not on Bellin’s Medical Staff or elects not to attend to the

general medical management for a specific patient, the Medical Director shall identify a physician to assume the attending role. The Medical Director shall manage the physical rehabilitation needs of the patient, but may also assume the role of attending physician.

(c) The Medical Director shall make patient visits at least three times per week to manage the

rehabilitation needs and document the rehabilitation problems, goals, progress, and medical status. The attending physician, if other than the Medical Director, shall evaluate the patient at a frequency based on medical needs, but at a minimum three times per week.

16.N.3. Emergency Care: Patients presenting to the hospital requesting emergency services will receive an emergency medical screening exam by a Qualified Medical Person and will receive additional medical treatment within the capabilities of the staff and facilities of Bellin that is necessary to stabilize the medical condition, including the use of “on-call” physicians if necessary. Bellin shall maintain a list of physicians who are on call for duty after the initial screening examination to provide treatment necessary to stabilize an individual with an emergency medical condition. An “on-call” Medical Staff Appointee will be called in for a patient with an emergency medical condition when: (a) Following a medical screening examination, the patient’s condition cannot be stabilized

by the physician treating the patient; and (b) Ongoing care is indicated and the patient has no attending Medical Staff Appointee. 16.N.4. Responsibilities of the “On-Call” Physician: (a) Hospital-Based Call:

(1) The “on-call” Medical Staff Appointee shall respond to a call/page from the

applicable BHS hospital within twenty (20) minutes and complete an

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appropriate assessment of the patient, including coming into the Emergency Department if requested by the Emergency Department Physician (within 30 minutes of the request or longer if agreed by the Emergency Department Physician) to provide stabilizing care (except for medical staff appointees in the Department of Primary Care).

(2) If the patient’s needs are beyond the capabilities of the BHS hospital or the on-

call physician, the on-call physician shall either facilitate the appropriate care for the patient through another member of the Medical Staff, or by arranging for the appropriate transfer of the patient to another facility in accordance with the Emergency Medical Treatment and Active Labor Act (“EMTALA”).

(b) Clinic-based call. The “on-call” Medical Staff Appointee for a BHS clinic shall

respond to a call/page from the applicable BHS hospital and be available for a telephone consultation with the Emergency Department Physician.

16.N.5. Appropriate Transfers: Transfers of patients with an emergency medical condition to another medical facility will occur only when all of the following instances are met: (a) The hospital staff or facilities do not have the capabilities to provide the necessary

medical care to the patient or the patient or his/her legally authorized agent requests the transfer; and

(b) The patient has received care within the capabilities of the hospital and its staff to

stabilize the patient; and (c) The Consent to Transfer form has been completed; and (d) The receiving facility has accepted the transfer; and (e) Appropriate transportation has been arranged for the patient. If the on-call physician does not respond to a call/page or is unavailable to respond to the hospital in a timely manner, the Hospital will page another Medical Staff Appointee within the same specialty (if one is available) to respond as the on-call Medical Staff Appointee. If another Medical Staff Appointee within the same specialty is not available, the Hospital will contact the Department Chairperson for resolution and alternative physician assignment or directions to transfer. If the Department Chairperson is unavailable, the hospital will contact the President of the Medical Staff for resolution. When an on-call physician does not respond or refuses to come to the Emergency Department when requested by the Emergency Department Physician, this information shall be forwarded to the Chair of the applicable Department, and the Chief Medical Officer for peer review and follow-up. Such refusal can result in the revocation of Medical Staff appointment and clinical privileges pursuant to the Medical Staff Bylaws, as well as an investigation and fine of up to $50,000 and/or exclusion from participation in Medicare and Medicaid programs for the hospital and/or physician.

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16.O. POLICIES 16.O.1. Postanesthesia Recovery: Written policies governing the provision of care in the immediate postanesthesia period are available and approved by the Medical Staff. These policies are reviewed and updated as needed by the surgical department. The periodic review of patient care is a function of the Medical Staff. 16.O.2. Patient Care Policies: Policies that impact patient care will be approved by the Medical Staff. The policy will be presented to the Department for recommendation to the BHS Medical Executive Committee and approval by the BHS Medical Executive Committee. 16.P: CONFIDENTIALITY All Medical Staff appointees will respect the confidentiality of protected health information obtained in the course of diagnosing, treating or consulting patients, including the electronic medical record, paper records, and oral communications. Access to medical records shall be afforded to appointees for treatment, peer review, performance improvement, and research approved by the CIRB. 16.Q: DENTAL PATIENTS: A patient admitted for dental surgery shall receive the same basic medical appraisal as patients admitted for other services, and shall be the dual responsibility of the attending dentist and a physician appointee. 16.Q.1: Dentist’s responsibilities shall include: (a) Detailed dental history justifying hospital admission; (b) Detailed description of the examination of the oral cavity and pre-operative diagnosis; (c) Complete operative report, describing findings and techniques used. In cases of

extraction of teeth, the dentist shall clearly state the number of teeth and fragments removed. All tissue, including teeth and fragments, shall be sent to the pathologist for examination, if possible;

(d) Progress notes pertinent to the oral condition; (e) Clinical summary or statement; and (f) Discharge summary.

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16.Q.2: An oral surgeon who has been granted appropriate clinical privileges may be permitted to perform preoperative dental history and physical examinations on his or her patients. 16.Q.3: Physician’s responsibilities shall include: (a) Medical history pertinent to the patient’s general health; (b) Physical examination to determine the patient’s condition prior to and suitability for

anesthesia and surgery; and (c) Supervision of the patient’s general health status while hospitalized.

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PART 6 – ALLIED HEALTH PROFESSIONAL POLICY Medical and Psychological

Bellin Health System

ARTICLE 17

GENERAL

17.A. DEFINITIONS: Except as specifically defined below, the definitions that apply to terms used in all the Medical Staff documents are set forth in the Bylaws of the Medical Staff. (a) “Advanced Practice Clinician” means an individual who is either licensed or certified

by a state board and functions under the supervision of, or in collaboration with, a physician appointed to the medical staff at a BHS Facility. This category of Allied Health Professionals includes advanced practice registered nurses (certified registered nurse anesthetists, certified nurse midwives, clinical nurse specialists, and nurse practitioners) and physician assistants.

(b) “Allied Health Professional” shall include all Licensed Independent Practitioners,

Advanced Practice Clinicians and Dependent Practitioners. (c) “Dependent Practitioner,” as specified in Appendix C, means a non-physician

practitioner who must function in a BHS Facility only as an employee of a Medical Staff appointee under the direct supervision of the same physician.

(d) “Licensed Independent Practitioner” means a licensed or certified nonphysician

practitioner who is granted clinical privileges and may function independently in a BHS Facility.

(e) “Psychologist” shall be interpreted to mean an individual licensed to practice

psychology in the State of Wisconsin. (f) “Scope of practice” means the clinical activities, tasks and functions permitted to be

carried out by a Dependent Practitioner under physician supervision. (g) “Supervising Physician” means a member of the Medical Staff with clinical privileges,

who has agreed in writing to supervise, or collaborate with, a Dependent Practitioner or Advanced Practice Clinician and to accept responsibility for the actions of the Dependent Practitioner or Advanced Practice Clinician, as defined in their Supervisory/Collaborative Agreement, while he or she is practicing in a BHS Facility.

(h) “Supervision” means the supervision of (or collaboration with) a Dependent

Practitioner or Advanced Practice Clinician by a Supervising Physician, that may or

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may not require the actual presence of the Supervising Physician, but that does require, at a minimum, that the Supervising Physician be readily available for consultation. The requisite level of supervision (general, direct, or personal) shall be determined at the time each Dependent Practitioner or Advanced Practice Clinician is credentialed and shall be consistent with any applicable written supervision or collaboration agreement that may exist and applicable state law.

(i) “Voluntary or automatic relinquishment” of clinical privileges or scope of practice

means a lapse in clinical privileges or scope of practice deemed to occur automatically as a result of stated conditions.

Words used in this policy shall be read as the masculine or feminine gender, and as the singular or plural, as the content requires. The captions or headings are for convenience only and are not intended to limit or define the scope or effect of any provision of this policy. 17.B. DELEGATION OF FUNCTIONS: (a) When a function is to be specifically carried out by a member of BHS, a Medical Staff

member, or by a Medical Staff committee, the individual, or the committee through its chair, may delegate performance of the function to someone else.

(b) When a Medical Staff member is unavailable or unable to perform a necessary

function, one or more Medical Staff Leaders may perform the function personally or delegate it to another appropriate individual.

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ARTICLE 18

SCOPE AND OVERVIEW OF POLICY

18.A. SCOPE OF POLICY: (a) This policy addresses those Allied Health Professionals who are permitted to practice

or provide services at a BHS Facility, including those that are BHS or BHS Facility employees. However, those Allied Health Professionals who are employed by BHS or a BHS Facility shall not be entitled to any of the due process rights provided in the Bylaws or in this policy, including Article 23.

(b) This policy sets forth the credentialing process and the general practice parameters for

Allied Health Professionals, as well as the guidelines for determining the need for additional categories of Allied Health Professionals.

18.B. CATEGORIES OF ALLIED HEALTH PROFESSIONALS: (a) Only those categories of Allied Health Professionals that have been approved by the

Board shall be permitted to practice at a BHS Facility. All Allied Health Professionals who are permitted to practice in a BHS Facility shall be classified in one of three broad categories, Licensed Independent Practitioners and Advanced Practice Clinicians or Dependent Practitioners, each having a slightly different relationship to BHS and/or the BHS Facility.

(b) The “Licensed Independent Practitioners” shall include all those Allied Health

Professionals who are licensed under state law and authorized by BHS to function independently in a BHS Facility and who are granted clinical privileges. These individuals generally can bill independently for the services they provide and they require no formal or direct supervision by a physician. A current listing of the types of Allied Health Professionals functioning within each BHS Facility as Licensed Independent Practitioners is attached to this policy as Appendix A. This Appendix may be modified or supplemented hereafter by action of the Board, after receiving the recommendations of the System Credentials Committee, without the necessity of further amendment of this policy.

(c) “Advanced Practice Clinician” shall embody all Allied Health Professionals who

provide a medical level of care or perform surgical tasks (i.e., Certified Physician Assistants (“CPA”), Certified Nurse Practitioners (“CNP”), Certified Registered Nurse Anesthetists (“CRNA”), Certified Nurse Midwives (“CNM”) and Clinical Nurse Specialists (CNS)) and who are authorized to function in a BHS Facility only as employees of, in a collaborative relationship with, or under the supervision of, a physician(s) appointed to the Medical Staff pursuant to defined clinical privileges. The employing, collaborating and/or Supervising Physician(s) shall remain responsible for the actions of the Advanced Practice Clinician in the BHS Facility. A current listing of

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the types of Allied Health Professionals functioning in the hospital as Advanced Practice Clinicians is attached to this policy as Appendix B. This Appendix may be modified or supplemented hereafter by action of the Board, after receiving the recommendations of the System Credentials Committee, without the necessity of further amendment of this policy.

(d) The “Dependent Practitioners” category shall embody all Allied Health Professionals

who are authorized to function in a BHS Facility only as employees of BHS, or as employees of a physician on the Medical Staff under the direct supervision of such physician pursuant to a defined scope of practice. The employing and/or Supervising Physician(s) shall remain fully responsible for the actions of the Dependent Practitioner in the BHS Facility. A current listing of the types of Allied Health Professionals functioning within each BHS Facility as Dependent Practitioners is attached to this policy as Appendix C. This Appendix may be modified or supplemented hereafter by action of the Board, after receiving the recommendations of the System Credentials Committee, without the necessity of further amendment of this policy.

18.C. PROCESS FOR DETERMINING NEED FOR A NEW CATEGORY OF ALLIED HEALTH PROFESSIONAL: (a) Review of Need:

(1) Whenever an Allied Health Professional requests to practice at a BHS Facility

and the Board has not already approved that specific category of practitioner for practice at the facility, the Chief Executive Officer shall refer the matter to the System Credentials Committee to evaluate the need for that specific category of Allied Health Professional. The System Credentials Committee shall report to the BHS Medical Executive Committee, which shall make a recommendation to the Board for final action.

(2) As part of the process of determining need, the Allied Health Professional shall

be invited to submit information about the nature of the proposed practice, the reason access to the BHS Facility is sought, and the potential benefits to the community of having such services available at the facility.

(3) The System Credentials Committee may consider the following factors when

making a recommendation as to the need for the services of a specific category of Allied Health Professional:

(i) the nature of the services that would be offered; (ii) any state license or regulation which outlines the scope of practice or

clinical privileges that the Allied Health Professional is authorized by law to perform;

(iii) any state “nondiscrimination” or “any willing provider” laws that would

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apply to the Allied Health Professional; (iv) the business and patient care objectives of the BHS Facility, including

patient convenience; (v) the community’s needs and whether those needs are currently being met

or could be better met if the services offered by the Allied Health Professional were provided at the BHS Facility;

(vi) the type of training that is necessary to perform the services that would

be offered and whether there are individuals with more training currently providing those services;

(vii) the availability of supplies, equipment, and other necessary resources at

the BHS Facility; (viii) the need for, and availability of, trained staff to support the services that

would be offered; and (ix) the ability to appropriately supervise performance and monitor quality of

care.

(b) Additional Recommendations:

(1) If the System Credentials Committee makes a recommendation that there is a need for the particular category of Allied Health Professional at the BHS Facility, it shall also recommend:

(i.) any specific qualifications and/or training that must be possessed beyond

those set forth in this policy; (ii.) a detailed description of a scope of practice or clinical privileges; (iii.) any specific conditions that apply to practice within the BHS Facility;

and

(iv.) any supervision requirements, if applicable.

(2) In developing such recommendations, the System Credentials Committee shall consult the appropriate Department Chair(s) and consider relevant state law and may contact professional societies or associations. The System Credentials Committee may also recommend the number of Allied Health Professionals that are needed.

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ARTICLE 19

APPLICATION

19.A. GENERAL QUALIFICATIONS OF APPLICANTS:

Any Allied Health Professional who applies to practice within BHS as a Licensed Independent Practitioner, an Advanced Practice Clinician or a Dependent Practitioner shall (where applicable to his or her practice): (a) have a current, unrestricted license, certification or registration to practice in Wisconsin

and/or Michigan, as applicable, have never had a license, certification or registration to practice revoked or suspended;

(b) if employed at a BHS clinic, be located close enough to provide a physical response

time of less than thirty (30) minutes when on call for the clinic and to fulfill their Medical Staff responsibilities;

(c) be covered by current, valid professional liability insurance coverage in such form and

in amounts satisfactory to BHS; (d) have never been convicted of Medicare, Medicaid, or other federal or state

governmental or private third-party payer fraud or program abuse or have been required to pay civil penalties for the same;

(e) have never been and is not currently excluded or precluded from participation in

Medicare, Medicaid or other federal or state governmental health care program; (f) have never had a scope of practice or clinical privileges denied, revoked, resigned,

relinquished, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct;

(g) have never been convicted of, or entered a plea of guilty or no contest to, any felony or

to any misdemeanor relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, or violence;

(h) satisfy all additional eligibility qualifications relating to his or her specific area of

practice that may be established by BHS; (i) if seeking to practice as a Dependent Practitioner or as an Advanced Practice Clinician,

have a written agreement with a Supervising/Collaborating Physician, which agreement must meet all applicable requirements of state law and BHS policy; and

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(j) be able to document his or her:

(1) background, education, relevant training, experience, and current demonstrated clinical competence;

(2) adherence to the ethics of his or her profession; (3) good reputation and character; (4) ability to perform the clinical privileges or scope of practice requested; and (5) ability to work harmoniously with others sufficiently to convince BHS that all

patients treated by the individual will receive quality care and that BHS will be able to operate in an orderly manner.

19.B. WAIVER OF QUALIFICATIONS:

(a) Any individual who does not satisfy one or more of the above threshold eligibility criteria may request that it be waived. The individual requesting the waiver bears the burden of demonstrating that his or her qualifications are equivalent to, or exceed, the criterion in question.

(b) The Board may grant waivers in exceptional cases after considering the findings of the

System Credentials Committee, the BHS Medical Executive Committee, or other committee designated by the Board, the specific qualifications of the individual in question, and the best interests of BHS and the community it serves. The granting of a waiver in a particular case is not intended to set a precedent for any other individual or group of individuals.

(c) No individual is entitled to a waiver or to a hearing if the Board determines not to grant

a waiver. (d) A determination that an individual is not entitled to a waiver is not a “denial” of scope

of practice or clinical privileges. (e) An application form that does not satisfy an eligibility criterion will not be processed

unless the Board has determined that a waiver should be granted. 19.C. NO ENTITLEMENT TO MEDICAL STAFF APPOINTMENT:

(a) Allied health professionals who are applying to practice at BHS shall not be eligible for

appointment to the Medical Staff or entitled to the rights, privileges, and/or prerogatives of Medical Staff appointment.

(b) Allied health professionals shall practice at BHS at the discretion of the Board.

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19.D. HEALTH SYSTEM EMPLOYEES:

(a) The employment of an Allied Health Professional by BHS shall be governed by such policies, manuals, and descriptions as may be established from time to time by BHS as well as by the terms of the individual’s employment relationship. Where applicable, the Chief Executive Officer shall consult appropriate Medical Staff appointees and/or committees regarding the qualifications of those BHS employees whose responsibilities require the delineation of clinical privileges or scope of practice. To the extent that the relevant employment policies or manuals (or the terms of any applicable employment contract) conflict with this policy, the employment policies, manuals, descriptions, and terms of the individual’s employment relationship (and/or any applicable employment contract) shall apply.

(b) Except as provided in Article 18.A.(a) and Article 19.D.(a) above, employed Allied

Health Professionals are bound by all of the same conditions and requirements in this Policy that apply to non-employed Allied Health Professionals.

19.E. NON-DISCRIMINATION POLICY:

No individual shall be denied permission to practice at BHS on the basis of gender, race, creed, religion, color, or national origin.

19.F. ASSUMPTION OF DUTIES AND RESPONSIBILITIES:

As a condition of consideration of an application and as a condition of continued permission to practice in BHS, all Allied Health Professionals shall assume such reasonable duties and responsibilities as the System Credentials Committee, the BHS Medical Executive Committee and/or the Board shall require, including:

(a) providing appropriate continuous and timely care and supervision to all patients in BHS

for whom the individual has responsibility; (b) abiding by all bylaws and policies of BHS, including all bylaws, rules and regulations of

the Medical Staff as shall be in force during the time the individual is granted permission to practice in BHS;

(c) accepting committee assignments and such other reasonable duties and responsibilities

as shall be assigned; (d) providing to BHS, with or without request, and, as it occurs, new or updated information

that is pertinent to any question on the application form, including (but not limited to):

• changes in licensure or certification status, DEA controlled substance authorization, or professional liability insurance coverage;

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• the filing of a professional liability lawsuit against the Allied Health Professional;

• changes in status at any other hospital or health care entity as a result of peer

review activities; • knowledge of a criminal investigation involving the Allied Health

Professional, arrest, charge, indictment, conviction, or a plea of guilty or no contest in any criminal matter;

• exclusion or preclusion from participation in Medicare/Medicaid or any

sanctions imposed; or • any changes in the Allied Health Professional’s ability to safely and

competently exercise clinical privileges, or scope of practice, or to perform the duties and responsibilities of permission to practice because of health status issues, including, but not limited to, impairment due to addiction, alcohol use, or other similar issue (all of which shall be referred for review under the Medical Staff/Allied Health Professional Health Issues and Fitness for Duty Policy;

(e) appearing for personal interviews as requested in regard to the application; (f) refraining from illegal fee splitting or other illegal inducements relating to patient

referral; (g) refraining from assuming responsibility for diagnoses or care of hospitalized patients for

which he or she is not qualified or without adequate supervision; (h) refraining from deceiving patients as to his or her status as an Allied Health

Professional, and always wearing proper BHS identification of name and status; (i) seeking consultation whenever necessary or appropriate; (j) promptly notifying the Chief Executive Officer of any change in eligibility for payments

by third-party payors or for participation in Medicare, Medicaid, or other federal health program, including any sanctions imposed or recommended by the federal Department of Health and Human Services and/or the receipt of a Professional Review Organization citation and/or quality denial letter concerning alleged quality problems in patient care;

(k) abiding by generally recognized ethical principles applicable to the individual’s

profession; (l) participating in quality evaluation and performance improvement activities of BHS; (m) completing, in a timely and legible manner, the medical and other required records for

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all patients as required by the Medical Staff Bylaws, rules and regulations, this policy and other applicable policies of BHS;

(n) working cooperatively with Medical Staff appointees, other Allied Health Professionals,

nurses and other BHS personnel so as not to adversely affect patient care; (o) participating in applicable continuing education programs; (p) agreeing to a criminal background check; (q) agreeing to submit to an appropriate evaluation, which may include diagnostic testing

(including, but not limited to, blood and/or urine testing) and/or to a complete physical, mental, and/or behavioral evaluation, when the Physician and APC Health Committee is concerned with the individual’s ability to safely and competently care for patients and request such testing and/or evaluation. The health care professional(s) to perform the testing and/or evaluations shall be determined by the Medical Staff Leaders and the Allied Health Professional agrees to execute all appropriate releases to permit the sharing of information with the Medical Staff Leaders;

(r) cooperating with all utilization oversight activities; (s) maintaining and monitoring a current e-mail address with the Medical Staff Services

Department, which will be the primary mechanism used to communicate relevant information to the Allied Health Professional;

(t) providing other valid contact information in order to facilitate communication (such as a

mobile phone number or acceptable answering service); (u) paying any applicable application fees, assessments, and/or fines; and (v) constructively participating in the development, review, and revision of clinical practice

and evidence-based medicine protocols and pathways pertinent to his or her specialty (including those related to national patient safety initiatives and core measures), and complying with all such protocols and pathways.

19.G. PROFESSIONAL CONDUCT:

Allied health professionals who are granted permission to practice in BHS are expected to relate in a positive and professional manner to other health care professionals and to cooperate and work collegially with the Medical Staff leadership, management and personnel. Disruptive conduct and behavior, specifically including threatening or abusive language and actions, are unacceptable and below the standard expected of appointees to the Medical Staff.

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19.H. APPLICATION PROCESS:

(a) An application for permission to practice at BHS shall be sent only to those categories of Allied Health Professionals who have been approved by the Board, who meet the general qualifications set forth in this policy, and who meet the specific qualifications relating to each applicant’s area of practice.

(b) Any Allied Health Professional who requests an application for permission to practice

in BHS shall be sent a letter that outlines the general qualifications set forth in this policy and the specific qualifications set forth in the policy relating to each applicant’s area of practice, explains the review process, and outlines the scope of practice or clinical privileges approved by the Board for such Allied Health Professional in BHS along with an application form.

A completed application form with copies of all required documents must be returned to the Chief Executive Officer within sixty (60) days after receipt of the same if the individual desires further consideration.

19.I. INFORMATION TO BE SUBMITTED WITH APPLICATIONS:

(a) The application forms for both initial and renewed permission to practice as an Allied

Health Professional shall require detailed information concerning the applicant’s professional qualifications as requested on the current Allied Health Professional Application

(b) In addition to other information, the applications shall seek the following:

(1) information as to whether the applicant’s clinical privileges, scope of practice, permission to practice, and/or affiliation has ever been voluntarily or involuntarily relinquished, withdrawn, denied, revoked, suspended, reduced, subjected to probationary or other conditions, limited, terminated, or not renewed at any hospital or, health care facility, or other organization, or is currently being investigated or challenged;

(2) information as to whether the applicant’s license or certification to practice any

profession in any state, DEA registration, or any state controlled substance license (if applicable) is or has ever been voluntarily or involuntarily relinquished, suspended, modified, terminated, restricted, or is currently being investigated or challenged;

(3) information concerning the applicant’s professional litigation experience and/or

any professional misconduct proceedings involving the applicant, in this state or any other state, whether such proceedings are closed or still pending, including the substance of the allegations of such proceedings or actions, the substance of the findings of such proceedings or actions, the ultimate disposition of any such proceedings or actions that have been closed, and any additional information

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concerning such proceedings or actions as the System Credentials Committee, BHS Medical Executive Committee or Board may deem appropriate;

(4) current information regarding the applicant’s ability to perform, safely and

competently, the clinical privileges or scope of practice requested and the duties of Allied Health Professionals; and

(5) a copy of government-issued photo identification.

(c) The applicant shall sign the application and certify that he or she is able to perform the

clinical privileges or scope of practice requested and the responsibilities of Allied Health Professionals.

19.J. SUBMISSION OF APPLICATION:

(a) Completed applications shall be submitted to the Chief Executive Officer and must be

accompanied by the designated non-refundable processing fee. As a preliminary step, the completed application form shall be reviewed by the Chief Executive Officer to determine whether the individual satisfies the general and specific qualifications. Individuals who fail to satisfy such qualifications shall be notified that they are not eligible and that their application will not be processed. Such individuals shall also be notified that they do not have a right to due process. After reviewing the application to determine that all questions have been answered, and after reviewing all references and other information or materials deemed pertinent, and after verifying the information provided in the application with the primary sources, the completed application along with all supporting materials shall be transmitted to the System Credentials Committee.

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

form have been answered, all supporting documentation has been supplied and all information verified. An application shall become incomplete if the need arises for new, additional or clarifying information anytime during the evaluation.

(c) Any application that continues to be incomplete ninety (90) days after the applicant has

been notified of the additional information required shall be deemed to be withdrawn. It is the responsibility of the applicant to provide a complete application, including adequate responses from references. An incomplete application will not be processed.

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19.K. BURDEN OF PROVIDING INFORMATION:

(a) The applicant shall have the burden of producing information deemed adequate by BHS for a proper evaluation of competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications.

(b) The applicant shall have the burden of proving that all the statements made and

information given on the application are true and correct.

19.L. MISSTATEMENTS AND OMISSIONS:

Any misstatement, omission and/or representation on the application, whether intentional or not, shall constitute cause for immediate cessation of the processing of the application, and no further processing shall occur. In the event that Licensed Independent Practitioner, Advanced Practice Clinician or Dependent Practitioner status has been granted prior to discovery of such misstatement, misrepresentation or omission, such discovery shall result in automatic relinquishment of all clinical privileges or scope of practice, functions and activities and resignation as a Licensed Independent Practitioner, an Advanced Practice Clinician or a Dependent Practitioner. In either situation, there will be no entitlement to the procedural rights provided in this policy.

19.M. GRANT OF IMMUNITY AND AUTHORIZATION TO OBTAIN/RELEASE INFORMATION:

By applying for permission to practice in BHS, the Allied Health Professional expressly accepts these conditions before, during and after the processing and consideration of the application, whether or not permission to practice (including a scope of practice or clinical privileges) is granted:

(a) Immunity: To the fullest extent permitted by law, the Allied Health Professional releases from any and all liability, extends absolute immunity to, and agrees not to sue BHS or the Board, any member of the Medical Staff or Board, their authorized representatives, and third parties who provide information for any matter relating to the individual’s qualifications to practice as an Allied Health Professional. This immunity covers any actions, recommendations, reports, statements, communications, or disclosures that are made, taken, or received by BHS, their representatives, or third parties in the course of credentialing and peer review activities. Nothing herein shall be deemed to waive any other immunity or privilege provided by federal or state law. (b) Authorization to Obtain Information from Third Parties: The Allied Health Professional specifically authorizes BHS, Medical Staff leaders, and their representatives (1) to consult with any third party who may have information bearing on the individual’s qualifications, and (2) to obtain any and all information from third parties that

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may be relevant. The applicant authorizes third parties to release this information to BHS, and their representatives upon request. (c) Authorization to Release Information to Third Parties: The Allied Health Professional also authorizes BHS, the Medical Staff and their representatives to release information to other hospitals, health care facilities, managed care organizations, government regulatory and licensure boards or agencies, and their representatives when information is requested in order to evaluate his or her qualifications. (d) System Information Sharing: The Allied Health Professional specifically authorizes BHS to share credentialing and peer review information pertaining to his or her clinical competence and/or professional competence among its affiliated entities. This information may be shared at the initial grant of permission to practice, renewal of permission to practice, and/or any other time during the individual’s affiliation with BHS. (e) Hearing and Appeal Procedures: The Allied Health Professional agrees that the hearing and appeal procedures set forth in this part of the Bylaws will be the sole and exclusive remedy with respect to any professional review action taken by BHS. (f) Legal Actions: If an Allied Health Professional institutes legal action challenging any professional review action and does not prevail, he or she will reimburse BHS and any appointee of the Medical Staff or Board involved in the action for all costs incurred in defending such legal action, including reasonable attorney’s fees, expert witness fees, and lost revenues. (g) Scope of Section:

All of the provisions in this Section are applicable in the following situations:

(1) whether or not permission to practice, clinical privileges, or scope of practice is

granted; (2) throughout the term of any affiliation with BHS and thereafter; (3) should permission to practice, clinical privileges, or scope of practice be denied,

revoked, reduced, restricted, suspended, and/or otherwise affected as part of the professional review activities at BHS; and

(4) as applicable, to any third-party inquiries received after the individual leaves BHS

about his or her tenure as an Allied Health Professional.

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19.N. TEMPORARY PRIVILEGES OR SCOPE OF PRACTICE:

(a) Temporary privileges or a temporary scope of practice may be granted by the Chief

Executive Officer with the written concurrence of the System Credentials Committee Chair, the appropriate Department Chair and President of the Medical Staff following their review of the application and related documentation, including: (i) completed application; (ii) primary source verification of current State professional licensure (if applicable); (iii) demonstration of current competence and receipt of professional references attesting to current competence; (iv) relevant training/experience, including primary source verification of education; (v) ability to perform the privilege(s)/scope of practice requested; (vi) National Practitioner Data Bank (NPDB) query (if applicable); and (vii) where applicable, a current unrestricted Drug Enforcement Administration controlled substance certificate, only:

(1) for up to one hundred twenty (120) days when there is an important patient care

need that requires immediate authorization to practice. Specifically, temporary privileges or a temporary scope of practice may be granted in extraordinary and limited circumstances, to meet an important patient care need; or

(2) for up to one hundred twenty (120) days when an applicant is awaiting review by

the Executive Committee and Board following a favorable recommendation of the System Credentials Committee (or its Chair), has no current or previously successful challenges to his or her licensure or registration, and has not been subject to involuntary termination of membership, or involuntary limitation, reduction, denial, or loss of clinical privileges or scope of practice, at another health care facility.

(b) In exercising such temporary privileges or scope of practice, the applicant shall act under the direct supervision of the employing physician.

19.O. LOCUM TENENS:

(a) The Chief Executive Officer may grant an individual serving as a locum tenens of the

Allied Health staff temporary privileges or a temporary scope of practice for a specific time period, not to exceed six months. The Chief Executive Officer may grant such privileges or scope of practice:

(1) after receiving a completed locum tenens application and a request for privileges

or scope of practice form; (2) after making inquiry to the National Practitioner Databank and determining

through primary source verification the applicant’s current State professional licensure, DEA certification, and Medicare and Medicaid participation status (as applicable), and verifying competence, character, ethical standing, ability to perform the privileges/scope of practice requested, and professional liability

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insurance coverage; and (3) after obtaining the written concurrence of the President of the Medical Staff,

appropriate Department Chair and the Chair of the System Credentials Committee.

The Chief Executive Officer shall also obtain such individual’s signed acknowledgment that the individual has had an opportunity to read a copy of this Allied Health Professionals Policy which is then in force, and agrees to be bound by the terms thereof.

(b) The individual serving as a locum tenens must have in force and effect a current license

to practice (if applicable) and professional liability insurance in an amount and terms acceptable to BHS. In exercising such privileges/scope of practice, the applicant shall act under the direct supervision of the employing physician.

19.P. TERMINATION OF TEMPORARY OR LOCUM TENENS SCOPE OF PRACTICE OR PRIVILEGES:

(a) The Chief Executive Officer may, at any time after consulting with the President of the

Medical Staff or Department Chair responsible for the individual’s supervision, terminate temporary or locum tenens scope of practice/privileges.

(b) The granting of any temporary or locum tenens scope of practice/privileges is a

courtesy on the part of BHS and any or all may be terminated if a clinical and/or behavioral question or concern has been raised. Neither the granting, denial, or termination of such scope of practice/privileges shall entitle the individual concerned to any of the procedural rights provided in the Bylaws or in this policy.

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ARTICLE 20

SYSTEM CREDENTIALS COMMITTEE

20.A. COMPOSITION:

(a) The System Credentials Committee shall consist of at least seven (7) appointees to the Active Staff of Bellin Hospital, Bellin Medical Group, BHOH and Bellin Psychiatric Center. There shall be at least one member from Bellin Hospital, Bellin Medical Group, BHOH and Bellin Psychiatric Center. Particular consideration is to be given to Past Presidents of the Medical Staff, past Credentials Committee members, past BHS Medical Executive Committee members, and past department chairs, and to other physicians knowledgeable in the credentialing and quality improvement processes.

(b) The Board or designee shall appoint, and may remove, the members of the System

Credentials Committee. Members shall be appointed for a term of five (5) years, provided that member terms shall be staggered such that no more than two members’ terms expire in the same year. Members may serve additional terms.

(c) Service on the System Credentials Committee shall be considered as the primary

Medical Staff obligation of each member of the System Credentials Committee.

20.B. DUTIES:

The System Credentials Committee shall, in accordance with this policy: (a) review the credentials of applicants for appointment and reappointment to the Medical

Staff and for clinical privileges at a BHS Facility, conduct a thorough review of the applications, interview such applicants as may be necessary, and make a written report of its findings and recommendations;

(b) review, as may be requested, all information available regarding the current clinical

competence and behavior of persons currently appointed to the Medical Staff and, as a result of such review, make a written report of its findings and recommendations; and

(c) review, consider, and make recommendations regarding appropriate threshold

eligibility criteria for clinical privileges within BHS or scope of practice for Dependent Practitioners.

(d) review, consider, and make recommendations regarding allied health professionals, as

set forth in the Allied Health Professionals Policy.

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20.C. MEETINGS, REPORTS AND RECOMMENDATIONS:

(a) The System Credentials Committee shall meet as often as necessary, but at least quarterly, to accomplish its duties. The System Credentials Committee shall maintain a permanent record of its proceedings and actions and shall report its recommendations to the BHS Medical Executive Committee, the Chief Executive Officer, and the Board.

(b) For any regular or special meeting of the System Credentials Committee, the presence

of at least three of the persons eligible to vote shall constitute a quorum, provided that a representative of the BHS Facility where the applicant has applied for privileges is present and votes. Where necessary, in order to meet the quorum requirement, members of the Committee may appear by telephone provided there is a speaker phone available that allows the member to participate in the discussion and the member is provided with any documents prior to the meeting.

(c) The Chair of the System Credentials Committee shall be available to meet with the

Chief Executive Officer and the Board (or its designated committee) on all recommendations made by the System Credentials Committee.

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ARTICLE 21

CREDENTIALING PROCEDURES

21.A. LICENSED INDEPENDENT PRACTITIONER AND ADVANCED DEPENDENT PRACTITIONER CREDENTIALING:

(a) The appropriate Department Chair or his/her designee shall examine the application and

all supporting information and documentation and make a written report to the System Credentials Committee regarding the applicant’s qualifications for the clinical privileges requested. In preparing this report, the Department Chair has the right to meet with the applicant, and the Supervising Physician (if applicable), to discuss any aspect of the application, qualifications, and requested scope of practice or clinical privileges. The Department Chair may also confer with experts within the department and outside of the department in preparing the report (e.g., other physicians, appropriate supervisor within the department, nurse managers).

(b) In the event that the application meets the following conditions, the Department Chair

may elect to forward its report to the Chair of the System Credentials Committee for streamlined review:

(1) the applicant has not changed practice locations more than three times in the past

10 years; (2) all references contain only favorable evaluations, including unqualified

recommendations for clinical privileges; (3) all reference evaluations are completed, and received within a reasonable time of

the initial request; (4) the applicant was not subject to any disciplinary action or conditions during



qualifications for clinical privileges; and (7) no questions have been raised about the applicant by the Department Chair.

Upon receipt of the Department Chair is recommendation for streamlined review, the Chair of the System Credentials Committee, acting for the System Credentials Committee, shall review the report and the information contained in references and shall forward his/her recommendation to the BHS Medical Executive Committee. The

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BHS Medical Executive Committee shall review the recommendation made by the Chair of the System Credentials Committee. If the BHS Medical Executive Committee concurs with the favorable recommendation, the recommendation shall be forwarded to the Board through the Chief Executive Officer for final action. If the BHS Medical Executive Committee has any questions about the applicant, the questions shall be noted and the matter shall be referred to the System Credentials Committee for further action.

(c) Where streamlined review is not recommended, the System Credentials Committee

shall evaluate the application and may use the expertise of any individual on the Medical Staff or at BHS, or an outside consultant, if additional information is required regarding the applicant’s qualifications. In evaluating the application, the System Credentials Committee may also meet with the applicant and, when applicable, the employing or supervising physician.

(d) If the System Credentials Committee’s initial recommendation is adverse to the

applicant, the applicant and, when applicable, the employing or supervising physician, shall be given the opportunity to meet with the System Credentials Committee before a final recommendation is made. This meeting shall be informal and shall not be considered a hearing. Following this meeting, the System Credentials Committee shall make a recommendation to the BHS Medical Executive Committee which shall forward the recommendation to the Board.

21.B. DEPENDENT PRACTITIONER CREDENTIALING:

(a) Applications from Dependent Practitioners requesting a scope of practice at BHS shall

be reviewed by medical staff office personnel. The review shall include:

(1) verification of current licensure or certification; (2) assessment of competence through verification of education, training, experience,

demonstrated current competence and judgment, and favorable recommendations; (3) verification of physician supervision; and (4) verification of professional liability insurance coverage.

(b) The medical staff office personnel shall make a report to the Department Chair. After

evaluating the application, references and recommendation from the medical staff office personnel, the Department Chair will then make a report to the System Credentials Committee recommending appointment or raising questions for review.

(c) In the event that the application meets the following conditions, the Department Chair

is may elect to forward its report to the Chair of the System Credentials Committee for streamlined review:

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(1) the applicant has not changed practice locations more than three times in the past 10 years;

(2) all references contain only favorable evaluations, including unqualified

recommendations for clinical privileges; (3) all reference evaluations are completed, and received within a reasonable time of

the initial request; (4) the applicant was not subject to any disciplinary action or conditions during



qualifications for clinical privileges; and (7) no questions have been raised about the applicant by the Department Chair.

Upon receipt of the Department Chair recommendation for streamlined review, the Chair of the System Credentials Committee, acting for the System Credentials Committee, shall review the report and the information contained in references and shall forward his/her recommendation to the BHS Medical Executive Committee. The BHS Medical Executive Committee shall review the recommendation made by the Chair of the System Credentials Committee. If the BHS Medical Executive Committee concurs with the favorable recommendation, the recommendation shall be forwarded to the Board through the Chief Executive Officer for final action. If the BHS Medical Executive Committee has any questions about the applicant, the questions shall be noted and the matter shall be referred to the entire System Credentials Committee for further action.

(d) Where streamlined review is not recommended, the System Credentials Committee

shall evaluate the application and may use the expertise of any individual on the Medical Staff or at BHS, or an outside consultant, if additional information is required regarding the applicant’s qualifications. In evaluating the application, the System Credentials Committee may also meet with the applicant and, when applicable, the employing or supervising physician.

(e) If the System Credentials Committee’s initial recommendation is adverse to the

applicant, the applicant and, when applicable, the employing or supervising physician, shall be given the opportunity to meet with the System Credentials Committee before a final recommendation is made. This meeting shall be informal and shall not be considered a hearing. Following this meeting, the System Credentials Committee shall make a recommendation to the BHS Medical Executive Committee, which shall forward the recommendation to the Board.

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21.C. CLINICAL PRIVILEGES:

(a) The clinical privileges recommended to the Board will be based upon consideration of

the following:

(1) education, relevant training, experience, demonstrated current competence, including medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal and communication skills, and professionalism with patients, families and other members of the health care team and peer evaluations relating to the same;

(2) ability to perform the privileges requested competently and safely; (3) information resulting from ongoing and focused professional practice evaluation,

performance improvement and other peer review activities, if applicable; (4) adequate professional liability insurance coverage for the clinical privileges

requested; (5) BHS’s available resources and personnel; (6) any previously successful or currently pending challenges to any licensure or

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

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

involuntary termination, limitation, reduction, or loss of appointment or clinical privileges at another hospital;

(8) practitioner-specific data as compared to aggregate data, when available; (9) morbidity and mortality data, when available; and (10) professional liability actions, especially any such actions that reflect an unusual

pattern or excessive number of actions.

(b) All new clinical privileges for Licensed Independent Practitioners and Advanced Practice Clinicians, regardless of when they are granted (initial permission to practice, renewal of permission to practice, or at any time in between), will be subject to focused professional practice evaluation (“FPPE”) in order to confirm competence. The FPPE process for these situations is outlined in the Peer Review Policy and Medical Staff Bylaws.

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21.D. RENEWAL OF PERMISSION TO PRACTICE:

(a) Permission to practice in BHS is a courtesy extended by the Board and shall be granted

for a period not to exceed two (2) years. Renewal of clinical privileges or scope of practice shall be granted only upon submission of a completed renewal application and processing fee, and a performance review from the Supervising Physician(s). The renewal processing fee shall be waived if the complete renewal application (with all required documentation) is submitted to the Chief Executive Officer within the time frame set forth in this Section 21.D. If within 6 months of a voluntary relinquishment of Allied Health Professional clinical privileges or a scope of practice, an applicant reapplies for permission to practice at BHS, the application shall be processed under this Section 21.D. Applications that are received by Bellin more than 6 months after the Allied Health Professional has relinquished his/her privileges or scope of practice shall be processed as an Initial Application.

(b) Once an application for renewal of permission to practice has been completed and

submitted to the Chief Executive Officer, it shall be evaluated in the same manner and follow the same procedures outlined in this policy regarding initial applications.

(c) As part of the process for renewal of scope of practice for Dependent Practitioners, the

following factors shall be considered:

(1) an assessment prepared by the Supervising Physician(s); (2) an assessment prepared by the applicable BHS Facility supervisor (i.e., OR

Supervisor, Nursing Supervisor); and (3) resolution of any verified complaints received from patients or staff.

(d) As part of the process for renewal of clinical privileges for Licensed Independent

Practitioners and Advanced Practice Clinicians, the following factors shall be considered:

(1) an assessment prepared by the applicable Department Chair; (2) an assessment prepared by a peer; (3) results of BHS’s performance improvement and peer review activities, taking into

consideration, when applicable, practitioner-specific information concerning other individuals in the same or similar specialty (provided that, other practitioners shall not be identified);

(4) resolution of any verified complaints received from patients or staff; and (5) any focused professional practice evaluations.

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(e) In addition to the above, for Advanced Practice Clinicians, the following information

shall be considered:

(1) an assessment prepared by the Supervising/Collaborating Physician(s); and (2) an assessment prepared by the applicable BHS Facility supervisor (i.e., OR

Supervisor, Nursing Supervisor).

21.E. CLINICAL PRIVILEGES/SCOPE OF PRACTICE AFTER AGE 65:

(a) The System Credentials Committee shall specifically consider the mental and physical capabilities of each Allied Health Professional who has attained the age of 65 years and who has clinical privileges or a scope of practice at BHS on an annual basis. Recommendations by the System Credentials Committee and the BHS Medical Executive Committee for continued clinical privileges/scope of practice for Allied Health Professionals between the ages 65 and 75 shall be based upon an evaluation of the individual’s current knowledge, skills, conduct, and ability to perform the privileges/scope of practice requested safely and competently.

(b) Upon reappointment following age 75 and every year thereafter:

(1) the Allied Health Professional shall undergo a physical examination, the cost of

which is absorbed by the Allied Health Professional, that is performed by one of the professionals identified by BHS, and the examining physician shall complete a physical examination form indicating either a) the Allied Health Professional is mentally and physically competent to continue to perform the privileges/scope of practice requested, b) the Allied Health Professional is able to perform the privileges/scope of practice but with some restrictions, or c) the Allied Health Professional is not currently able to safely perform the privileges/scope of practice; the form must be returned by the examining practitioner directly to the Medical Staff Services Department;

(2) the Allied Health Professional shall undergo a neuropsychological assessment,

performed by one of the professionals identified by BHS, the cost of which is absorbed by the Allied Health Professional; the examination results must be returned by the examining practitioner directly to the Medical Staff Services Department;

(3) a chart review shall be conducted by the applicable Bellin Hospital Medical Staff

department/BHS to verify current practice patterns and clinical competence.

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21.F. PROCEDURE FOR LEAVE OF ABSENCE:

(a) Allied Health Professionals may request a leave of absence by submitting a written request to the Chief Executive Officer. The request must state the beginning and ending dates of the leave, which shall not exceed one year, and the reasons for the leave, such as military duty, additional training, family matters, or personal health condition. Absence from practice and patient care responsibilities for longer than 60 days shall require an individual to request a leave of absence.

(b) The Board delegates to the Chief Executive Officer the authority to make

determinations in connection with requests for leaves of absence, provided that the Board reserves the right to make final determinations, in its discretion. In determining whether to grant a request, the Chief Executive Officer may consult with the appropriate BHS Department Chair, or the System Credentials Chair and use his or her best efforts to render a determination within thirty (30) days of the receipt of the written request and of any clarifying information that the Chief Executive Officer may request.

(c) No later than thirty (30) days prior to the conclusion of the leave of absence, the

individual may request reinstatement by filing a written statement with the Chief Executive Officer summarizing the professional activities undertaken during the leave of absence. The Chief Executive Officer shall refer the matter to the System Credentials Committee for a recommendation. The individual bears the burden of providing information and documentation sufficient to demonstrate current competence and all other applicable qualifications. The individual shall provide such other information as may be requested by the Chief Executive Officer or the System Credentials Committee at that time, including executing any releases that may be necessary to cause third parties, including the individual’s physician, to respond to any requests for information or clarification.

(d) If the leave of absence was for health reasons, the request for reinstatement must be

accompanied by a report from the individual’s physician indicating that the individual is physically and/or mentally capable of resuming patient care responsibilities and safely exercising the clinical privileges requested.

(e) In acting upon the request for reinstatement, the Chief Executive Officer shall consider

the recommendations of the System Credentials Committee and others, as deemed appropriate, and may approve reinstatement or may limit or modify the clinical privileges/scope of practice to be extended to the individual upon reinstatement or impose conditions for the individual’s practice deemed reasonably necessary for patient safety or the effective operation of BHS.

(f) Absence for longer than one (1) year shall constitute automatic lapse of permission to

practice unless an extension is requested in writing and granted by the Board. Extensions will be considered only in extraordinary cases of hardship and where extension of a leave is found to be in the best interest of BHS or BHS.

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(g) Leaves of absence and reinstatement are matters of courtesy, not of right. In the event that it is determined that an individual has not demonstrated good cause for a leave or for reinstatement, or where a request for extension is not granted, the determination shall be final, with no recourse to the hearing and appeal procedures set forth in this policy.

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ARTICLE 22

PEER REVIEW PROCEDURES FOR QUESTIONS INVOLVING ALLIED HEALTH PROFESSIONALS

(a) Whenever a question or concern is raised about the care or conduct of a Licensed Independent Practitioner or Advanced Practice Clinician, the question or concern shall be addressed through mechanisms outlined in Part 3 of the Medical Staff Bylaws.

(b) Whenever a question or concern is raised about the care or conduct of a Dependent

Practitioner, the BHS Medical Executive Committee will have the discretion to determine: (l) how to review such question or concern; and (2) the action, if any, needed to address and resolve such question or concern.

(c) If a concern about an employed individual’s clinical conduct or competence originates

with the Medical Staff, the concern will be reviewed and addressed in accordance with this part of the Bylaws, after which a report will be provided to Human Resources.

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ARTICLE 23

HEARINGS AND APPEALS PROCEDURES FOR LICENSED INDEPENDENT PRACTITIONERS AND ADVANCED PRACTICE CLINICIANS

This Section is not applicable to Licensed Independent Practitioners and Advanced Practice Clinicians who are employed by or under contract with BHS.

(a) In the event that a Licensed Independent Practitioner or Advanced Practice Clinician is

not granted clinical privileges in BHS, or that privileges previously granted are restricted for a period of more than thirty (30) days, terminated, or not renewed, the Licensed Independent Practitioner or Advanced Practice Clinician shall be notified in writing of the recommendation, the general reasons for the recommendation and that he or she may request a hearing before the adverse recommendation is transmitted to the Board.

(b) The rights and procedures in this Article will also apply if the Board, without a prior

adverse recommendation from the BHS Medical Executive Committee, makes a recommendation not to grant clinical privileges or that the privileges previously granted be restricted, terminated, or not renewed. In this instance, all references in this Article to the BHS Medical Executive Committee will be interpreted as a reference to the Board.

(c) If the Licensed Independent Practitioner or Advanced Practice Clinician desires to

request a hearing, he or she must make such request in writing directed to the Chief Executive Officer within thirty (30) days after receipt of written notice.

(d) If such a request is made, the Chief Executive Officer shall appoint a Hearing Panel

composed of up to three individuals (including, but not limited to, individuals appointed to the Medical Staff, Allied Health Professionals, BHS management or individuals not connected to BHS) and a Presiding Officer who may be legal counsel to BHS. The Hearing Panel shall not include anyone who previously participated in the recommendation, any relatives or practice partners of the Licensed Independent Practitioner or Advanced Practice Clinician, or competitors of the Licensed Independent Practitioner or Advanced Practice Clinician. The hearing shall be convened as soon as practicable, but no sooner than thirty (30) days after the notice of the hearing unless an earlier hearing date has been specifically agreed to in writing by the parties.

(e) As an alternative to the Hearing Panel described in paragraph (d) of this Section, the

Chief Executive Officer may instead appoint a Hearing Officer to perform the functions that would otherwise be carried out by the Hearing Panel. The Hearing Officer shall preferably be an attorney at law. The Hearing Officer may not be in direct economic competition with the individual requesting the hearing and shall not act as a prosecuting officer or as an advocate to either side at the hearing. If the Hearing Officer is an

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attorney, he or she shall not represent clients who are in direct economic competition with the affected individual. In the event a Hearing Officer is appointed instead of a Hearing Panel, all references in this Section to the “Hearing Panel” shall be deemed to refer instead to the Hearing Officer, unless the context would clearly otherwise require.

(f) At the hearing, a representative of the System Credentials Committee shall first present

the reasons for the recommendation. The Licensed Independent Practitioner or Advanced Practice Clinician shall be invited to present information both orally and in writing to refute the reasons for the recommendation, subject to a determination by the Presiding Officer that the information is relevant. The Presiding Officer shall have the discretion to determine the amount of time allotted to the presentation by the representative of the System Credentials Committee and the Licensed Independent Practitioner or Advanced Practice Clinician.

(g) Both parties shall have the right to present other witnesses. The Chairperson of the

Hearing Panel or the Hearing Officer shall permit reasonable questioning of such witnesses.

(h) The Licensed Independent Practitioner/Advanced Practice Clinician and the System

Credentials Committee may be represented by counsel at this proceeding. However, while counsel may be present at the hearing, counsel will not call, examine, or cross-examine witnesses or present the case.

(i) The Licensed Independent Practitioner/Advanced Practice Clinician shall have the

burden of demonstrating that the recommendation was arbitrary, capricious or not supported by substantial evidence. The quality of care provided to patients and the smooth operation of BHS shall be the paramount considerations. Minutes of the hearing shall be kept and shall be attached to the report and recommendation of the Hearing Panel.

(j) Either party may submit a post-hearing memorandum for consideration by the Hearing

Panel or Hearing Officer. (k) The Hearing Panel, or the Hearing Officer, shall prepare a written report and

recommendation within thirty (30) days after the conclusion of the proceeding, and shall forward it, along with all supporting information, to the Chief Executive Officer. The Chief Executive Officer shall send a copy of the written report and recommendation, by certified mail, return receipt requested, to the Licensed Independent Practitioner/Advanced Practice Clinician.

(l) Within ten (10) days after notice of such recommendation, either the Licensed

Independent Practitioner/Advanced Practice Clinician or the System Credentials Committee may appeal in writing to the Chief Executive Officer. The request must include a statement of the reasons, including specific facts which justify an appeal. The request shall be delivered to the Chief Executive Officer either in person or by certified mail. If a written request for appeal is not submitted within the ten (10) day time frame

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specified herein, the recommendation and supporting information shall be forwarded by the Chief Executive Officer to the Chair of the Board for final action. If a timely request for appeal is submitted, the Chief Executive Officer shall review the report and recommendation, the supporting information and the request for appeal.

(m) The grounds for appeal shall be limited to the following: (i) there was substantial

failure to comply with this policy and/or other applicable bylaws or policies of BHS or the Medical Staff, and/or (ii) the recommendation was arbitrary, capricious or not supported by substantial evidence.

(n) The Chief Executive Officer will consider the record upon which the adverse

recommendation was made. New or additional written information that is relevant and could not have been made available to the Hearing Panel or the Hearing Officer, during the initial review of the matter, may be considered in the discretion of the Chief Executive Officer. The Chief Executive Officer will conduct this review within 30 days after receiving the request for appeal.

(o) Upon completion of the review, the Chief Executive Officer shall adopt the

recommendation of the Hearing Panel or the Hearing Officer or make a different recommendation. In his or her discretion, the Chief Executive Officer may refer the matter to any committee or individual he or she deems appropriate for further review and recommendation. The Chief Executive Officer shall make the decision on behalf of the Board based upon the Board’s ultimate legal responsibility to grant privileges and to authorize the performance of clinical activities within BHS. Such decision shall be deemed to constitute final action by the Board.

(p) Licensed Independent Practitioners and Advanced Practice Clinicians shall not be

entitled to the hearing and appeals procedures set forth in the Medical Staff Bylaws, the Credentials Policy or the corporate bylaws.

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ARTICLE 24

CONDITIONS OF PRACTICE APPLICABLE TODEPENDENT PRACTITIONERS AND ADVANCED PRACTICE CLINICIANS

24.A. SUPERVISION BY EMPLOYING OR SUPERVISING/COLLABORATING PHYSICIAN:

(a) Dependent Practitioners and Advanced Practice Clinicians may function in BHS only

so long as they have a Supervising/Collaborating Physician. (b) Any activities permitted to be performed at BHS by a Dependent Practitioner or an

Advanced Practice Clinician shall be performed only under the applicable supervision or direction of the Supervising/Collaborating Physician.

(c) It shall be the responsibility of the Supervising/Collaborating Physician to countersign

all medical record entries made by his or her Dependent Practitioner or Advanced Practice Clinician in accordance with applicable policies and rules and regulations.

(d) If the Medical Staff appointment or clinical privileges of a Supervising/Collaborating

Physician are resigned, revoked or terminated, the Dependent Practitioner’s scope of practice or Advanced Practice Clinician’s clinical privileges shall automatically terminate. The System Credentials Committee may, however, recommend that the Dependent Practitioner or Advanced Practice Clinician be permitted to arrange for another Supervising/Collaborating Physician.

(e) As a condition of a scope of practice or clinical privileges, a Dependent Practitioner or

Advanced Practice Clinician and the Supervising/Collaborating Physician must provide BHS with notice of any revisions or modifications that are made to the supervision agreement. This notice must be provided to the Chief Executive Officer within three (3) days of any such change.

24.B. QUESTIONS REGARDING AUTHORITY OF DEPENDENT PRACTITIONER:

(a) Should any Medical Staff appointee or BHS employee have any question regarding the

clinical competence or authority of a Dependent Practitioner or an Advanced Practice Clinician to either act or issue instructions outside the physical presence of the Supervising/Collaborating Physician in a particular instance, such individual shall have the right to request that the Supervising/Collaborating Physician validate, either at the time or later, the instructions of the Dependent Practitioner or Advanced Practice Clinician. Any act or instruction of the Dependent Practitioner or Advanced Practice Clinician shall be delayed until such time as the individual with the questions can be certain that the act is clearly within the scope of practice or clinical privileges granted by the Board.

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(b) Any question regarding the clinical competence or professional conduct of a Dependent Practitioner or Advanced Practice Clinician shall be reported to the Chief Medical Officer or the Chief Executive Officer. At all times the Supervising/Collaborating Physician shall remain responsible for all acts of the Dependent Practitioner or Advanced Practice Clinician while at BHS.

24.C. RESPONSIBILITIES OF THE SUPERVISING/COLLABORATING PHYSICIAN:

(a) The Supervising/Collaborating Physician shall remain responsible for all care provided

by the Dependent Practitioner or Advanced Practice Clinician in BHS. (b) The number of Dependent Practitioners or Advanced Practice Clinicians acting under

the supervision of one (1) physician, as well as the acts they may undertake, shall be consistent with applicable state and federal statutes and regulations, the rules and regulations of the Medical Staff, and the policies of the Board. The Supervising/Collaborating Physician shall make all appropriate filings with the State Board of Medicine regarding the supervision and responsibilities of the Dependent Practitioner or the Advanced Practice Clinician, to the extent that such filings are required.

(c) It shall be the responsibility of the Supervising/Collaborating Physician to provide, or

to arrange for, professional liability insurance coverage for the Dependent Practitioner or Advanced Practice Clinician in amounts required by the Board that covers any activities of the Dependent Practitioner or Advanced Practice Clinician at BHS and to furnish evidence of such coverage to BHS. The Dependent Practitioner or Advanced Practice Clinician shall act at BHS only while such coverage is in effect.

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APPENDIX A

Those Allied Health Professionals currently practicing as Licensed Independent Practitioners at one or more BHS Facility are as follows:

Audiologists Physical Therapists with Direct Access privileges Psychologists (Ph.D. & Psy.D.) Licensed Psychotherapists Optometrists

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APPENDIX B

Those Allied Health Professionals currently practicing as Advanced Practice Clinicians at one or more BHS Facility are as follows:

Certified Anesthesiologist Assistants Certified Registered Nurse Anesthetists Clinical Nurse Specialists Certified Nurse Practitioners Certified Nurse Midwives Certified Physician Assistants

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APPENDIX C

Those Allied Health Professionals currently practicing as Dependent Practitioners (not employed by Bellin Health and/or brought into the organization by Bellin Health as a contracted worker) at one or more BHS Facility are as follows:

Acupuncturists Electroneurodiagnostic (EEG) Technicians Registered Nurses Licensed Practical Nurses Dental Assistants Dental Hygienists Surgical Technician

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PART 7 – AMENDMENTS AND ADOPTION

ARTICLE 25

AMENDMENTS

Subject to the authority and approval of the Board, the Medical Staff will exercise such power as is reasonably necessary to discharge its responsibilities under these Bylaws, and associated rules and regulations and policies, and under the corporate bylaws of BHS in compliance with law and regulation.

The Medical Staff shall have the responsibility to formulate, review, and recommend to the Board any Medical Staff Bylaws, rules, regulations, policies, procedures and amendments as needed. Amendments to the bylaws and rules and regulations shall be effective when approved by the Board. The Medical Staff must exercise this responsibility regarding bylaws through direct vote of its membership. The Medical Staff can exercise this responsibility regarding rules and regulations (Part 5) and Medical Staff policies (including Part 6) through its elected and appointed leaders, the BHS Medical Executive Committee, or through direct vote of its membership. Such responsibility shall be exercised in good faith and in a reasonable, responsible, and timely manner. 25.A. METHODS OF ADOPTION AND AMENDMENT TO BYLAWS Proposed amendments of these Bylaws initiated by the Medical Staff shall, as a matter of procedure, be referred to the Bylaws Committee. The Bylaws Committee shall refer them to the BHS Medical Executive Committee who shall report on them either favorably or unfavorably to the Bylaws Committee Chair. A special meeting of the Bylaws Committee will be scheduled. The proposed amendments will be circulated to the members of the Medical Staff via e-mail, and will be posted in the Medical Staff Lounge at least fifteen (15) days prior to the special Bylaws Committee meeting to consider any comments or proposed revisions received from the members of the Medical Staff. If the Bylaws Committee proposes any revisions, they will be sent to the BHS Medical Executive Committee and the process will be repeated. The active Medical Staff may also originate proposed amendments to these Bylaws by a petition signed by twenty-five percent (25%) of the members of the active Medical Staff. Such proposed amendments shall be communicated to the BHS Medical Executive Committee before a vote is taken by the active Medical Staff.

Each active member of the Medical Staff will be eligible to vote on the proposed amendment(s) via printed or electronic ballot. All active members of the Medical Staff shall receive at least fifteen (15) days advance notice of the proposed changes. To be adopted, the Medical Staff receives an affirmative vote by a simple majority of the votes cast by those members eligible to vote.

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Amendments so adopted shall be effective when approved by the Board. Neither the Medical Staff nor the Board may unilaterally amend the Bylaws. The BHS Medical Executive Committee shall have the power to adopt such amendments to the bylaws, rules, regulations and policies as are, in the committee's judgment, technical or legal modifications or clarifications, reorganization or renumbering, or amendments made necessary because of punctuation, spelling or other errors of grammar or expression. Such amendments shall be effective immediately and shall be permanent if not disapproved by the Medical Staff or the Board within thirty (30) days of adoption by the BHS Medical Executive Committee. The action to amend may be taken by a motion acted upon in the same manner as any other motion before the BHS Medical Executive Committee. After adoption, such amendments shall, as soon as practicable, be circulated to the members of the Medical Staff via e-mail and be posted on the Medical Staff bulletin board for thirty (30) days and sent to the Chief Executive Officer. If there is a conflict over the provisional amendment, the process for resolving conflict between the active Medical Staff and the BHS Medical Executive Committee is implemented. If necessary, a revised amendment is then submitted to the Board for action.

25.B. METHODS OF ADOPTION AND AMENDMENT TO MEDICAL STAFF RULES, REGULATIONS, AND POLICIES

The Medical Staff shall adopt additional rules, regulations, and policies as necessary to carry out its functions and meet its responsibilities under these Bylaws. Proposed amendments to the rules, regulations and policies may be originated by the BHS Medical Executive Committee. The proposed policies and amendments shall be communicated to the active Medical Staff at least fourteen (14) days before a vote is taken by the BHS Medical Executive Committee. The BHS Medical Executive Committee shall vote on the proposed language changes at a regular meeting, or at a special meeting called for such purpose. Following an affirmative vote by the BHS Medical Executive Committee, any of these documents may be adopted, amended or repealed, in whole or in part, and such changes shall be effective when approved by the Board (or its designated committee). When the BHS Medical Executive Committee adopts a policy or amendment thereto, there will be communication of the policy or amendment to the active Medical Staff.

In addition to the process described above, the active Medical Staff may recommend amendments to any rules, regulations, or policies by submitting a petition signed by twenty-five percent (25%) of the voting members of the Medical Staff. The proposed amendment or policy shall be communicated to the BHS Medical Executive Committee. If the BHS Medical Executive Committee does not pass the proposed amendment, the active Medical Staff can ask for a medical staff vote using the mechanisms noted in the conflict resolution process set forth below. The Executive Committee and the Board (or its designated committee) shall have the power to provisionally adopt urgent amendments to the rules and regulations that are needed in order to comply with a law or regulation, without providing prior notice of the proposed

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amendments to the Medical Staff. Notice of all provisionally adopted amendments shall be provided to each member of the Medical Staff as soon as possible. The Medical Staff shall have fourteen (14) days to review and provide comments on the provisional amendments to the Executive Committee. If there is no conflict between the Medical Staff and the Executive Committee, the provisional amendments shall stand. If there is conflict over the provisional amendments, then the process for resolving conflicts set forth below shall be implemented. 25.C. CONFLICT MANAGEMENT PROCESS

(a) When there is a conflict between the Medical Staff and the BHS Medical Executive

Committee with regard to: (1) proposed amendments to the Medical Staff rules and regulations, (2) a new policy proposed by the BHS Medical Executive Committee, or (3) proposed amendments to an existing policy that is under the authority of the BHS

Medical Executive Committee, a special meeting of the Medical Staff will be called. The agenda for that meeting will be limited to the amendment(s) or policy at issue. The purpose of the meeting is to resolve the differences that exist with respect to Medical Staff Rules and Regulations or policies.

(b) If the differences cannot be resolved at the meeting, the BHS Medical Executive

Committee shall forward its recommendations, along with the proposed recommendations pertaining to the Medical Staff rules and regulations or policies offered by the voting members of the Medical Staff, to the Board for final action.

(c) In the event the Board acts in a manner contrary to an Executive Committee

recommendation, the matter may (at the request of the Executive Committee) be submitted for a joint conference composed of the Medical Staff officers and an equal number of Board members for review and recommendation to the full Board. The Board chair is authorized to vote to break a tie at the joint conference. The joint conference will submit its recommendation to the board within thirty (30) days of its meeting. The action of the Board shall be final. The Board chair may call for a joint conference as described above at any time and for any reason to seek direct input from the Medical Staff leaders, to clarify an issue, or to relay information directly to Medical Staff leaders.

(d) This conflict management section is limited to the matters noted above. It is not to be

used to address any other issue, including, but not limited to, professional review actions concerning individual members of the Medical Staff.

25.D. UNIFIED MEDICAL STAFF PROVISIONS 25.D.1. Adoption: The Board has elected to adopt a single unified Medical Staff that includes BH, BPC and

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BHOH, each a Participating Hospital, and the voting members of the Medical Staff of each have approved of the unified Medical Staff structure by conducting a vote in accordance with the process outlined in Section 25.A for amending these Medical Staff Bylaws. 25.D.2. Bylaws, Policies, and Rules and Regulations of the Unified Medical Staff: The unified Medical Staff has adopted these Bylaws and supplemental policies and rules and regulations to: (a) take into account the unique circumstances of each participating hospital, including any

significant differences in the patient populations that are served and the clinical services that are offered; and

(b) address the localized needs and concerns of Medical Staff members at each of the

participating hospitals.

25.D.3. Opt-Out Procedures: A proposal by a Participating Hospital to opt out of the unified Medical Staff may be initiated by a petition signed by twenty-five percent (25%) of the Active Staff members of such Participating Hospital. Such proposal shall be communicated to and validated by the BHS Medical Executive Committee before a vote is taken by such Active Staff members. Each Active Staff member of the Participating Hospital will be eligible to vote on the proposal to opt out via printed or electronic ballot. All such Active Staff members shall receive at least 15 days’ advance notice of such vote. To be adopted, the proposal must receive an affirmative vote by a simple majority of the votes cast by the Active Staff members of the Participating Hospital. If the vote to opt out of the unified Medical Staff is successful, the vote will take effect upon the approval of new/amended bylaws for the Participating Hospital. If the vote to opt out of the unified Medical Staff is unsuccessful, another such vote may not be held again by that Participating Hospital for two years from the date of the unsuccessful vote.

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ARTICLE 26

ADOPTION

Following approval in the manner described above, these Bylaws are adopted and made effective upon approval of the Board, superseding and replacing any and all previous Medical Staff Bylaws, and henceforth all activities and actions of the Medical Staff and of each individual exercising clinical privileges in the hospital shall be taken under and pursuant to the requirements of these Bylaws. ADOPTION: These Bylaws were approved and adopted by each of the Medical Executive Committees of BH, BHOH and BPC on August 8, 2017, August 16, 2017, and August 2, 2017, respectively; approved and adopted by an affirmative vote of a majority of each of the Active Medical Staffs of BH, BHOH and BPC on September 28, 2017, September 13, 2017, and September 28, 2017, respectively; and approved and adopted by the Board on October 24, 2017. _______________________________________ President of the Medical Staff Robert Mead, M.D. _______________________________________ Vice President of the Medical Staff Steven Gerndt, M.D. _______________________________________ Chair, Board of Directors Terry Fulwiler _______________________________________ Secretary, Board of Directors Mark McMullen

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Amendment to Part 5 - Rules and Regulations of the Bylaws of the Bellin Health Medical Staff

Article 16.F.1 of the Rules and Regulations of the Bylaws of the Bellin Health Medical Staff is hereby amended. This Amendment is effective on March 11, 2020. Approved by the Board of Directors Quality and Excellence Committee on March 11, 2020, a committee designated by the Board of Directors of Bellin Health Systems, Inc. to approve this Amendment, as provided in Article 25.B of the Bylaws of the Bellin Health Medical Staff. Approved by the Bellin Health Medical Executive Committee on March 10, 2020, as required under Article 25.B of the Bylaws of the Bellin Health Medical Staff.

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