Guadalupe Regional Medical Center

Medical Staff Bylaws

Revised and approved: September 20, 2016

James Lee, M. Chair, Governing Board

BYLAWS OF GUADALUPE REGIONAL MEDICAL CENTER MEDICAL STAFF

PREAMBLE

Recognizing that the Medical Staff is responsible for the quality of medical care in the hospital and must accept and assume this responsibility, subject to the ultimate authority of the hospital Governing Body and that the best interests of the patients are protected by concerted effort, the physicians practicing in Guadalupe Regional Medical Center hereby organize themselves in conformity with the Bylaws and Rules and Regulations hereinafter stated.

For the purpose of these Bylaws the word Medical Staff shall be interpreted to include all physicians, dentists and podiatrists who are privileged to attend patients in Guadalupe Regional Medical Center.

Whenever the term Governing Body appears, it shall be interpreted to refer to the Board of Managers.

ARTICLE I NAME

The name of this organization shall be the "Medical Staff of Guadalupe Regional Medical Center".

ARTICLE II PURPOSES

The purposes of this organization shall be:

1. To ensure that all patients admitted to the hospital or treated in the hospital are provided with quality of care that is commensurate with acceptable standards and available community resources.

2. To provide a means whereby problems of medico-administrative nature may be discussed by the Medical Staff with the Governing Body and the CEO.

3. To initiate and maintain self-government.

4. To conduct professional review activities and peer review.

5. To assure that the medical administrative procedures and policies be in accordance with the current accreditation manual of The Joint Commissions (T JC) and Centers for Medicare and Medicaid Services (CMS).

6. To provide a structure for Continuing Medical Education that is relevant to the local medical community.

ARTICLE III MEMBERSHIP

Section 1. QUALIFICATIONS

Medical Staff membership is a privilege extended by the Hospital, and not a right of any phYSician, practitioner, or other person. Membership and/or the permission to exercise clinical privileges shall be extended only to individuals who continuously meet the qualifications, standards and requirements set forth in these Bylaws.

The applicant for membership on the Medical Staff shall be a graduate of an approved or recognized school conferring M. D. or D. O. degrees, legally licensed to practice in the State of Texas and qualified for membership in the local Medical or Dental Society. In addition, licensed dentists and podiatrists are eligible for Medical Staff membership. Sex, race, creed and/or national origin are not used in making decisions regarding the granting or denying of Medical Staff membership or clinical privileges.

As of September 2007, all new physician and podiatric applicants to the GRMC staff must have completed a residency program and obtained Board certification within the timeframe specified by their specialty board. The residency program must be recognized by the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, or the Council on Podiatric Medical Education, as appropriate. Board certification must be recognized by the American Board of Medical Specialties, the American Osteopathic Association, or the American Board of Podiatric Specialties, as appropriate. As of May 1, 2011, all staff members who were not previously grandfathered prior to September 2007 must maintain board certification status to maintain medical staff privileges.

In addition, medical staff membership may be revoked if physician is found to be practicing below established standards of care or fails to complete reappointment processes within required timeframes.

Section 2. ETHICS AND ETHICAL RELATIONSHIPS

The principles of medical ethics as adopted or amended by the American Medical Association shall govern the professional conduct of the members of the Medical Staff. Specifically, all members of the Medical Staff shall pledge themselves that they will not receive from or pay to another physician, either directly or indirectly, any part of a fee received for professional services without the patient's knowledge.

Section 3. TERMS OF APPOINTMENT

Subsection 1. Original appOintment shall be made by the Governing Body of the hospital and shall be for a period of one (1) year. At the end of this period, the Governing Body of the hospital may reappoint members of the Medical Staff for a further period of two (2) years.

Subsection 2. In no case shall the Governing Body take action on an application nor refuse to renew an appointment previously made without conference with the Medical Staff.

Subsection 3. AppOintment to the Medical Staff shall confer on the appointee only such privileges as may hereinafter be provided.

Section 4. PROCEDURE FOR APPOINTMENT

Subsection 1. Application for membership on the Medical Staff shall be presented on a prescribed form. An entire application includes a completed application form which addresses relevant training and experience, clinical privileges request form, a signed standard liability release and Medicare/Medicaid penalty acknowledgment, three (3) reference letters, and current copies of the Texas state license, DEA federal narcotics license, and proof of malpractice insurance as specified by the Board of Managers. The license will be verified by Administration through the appropriate state board. Each applicant will also be responsible for obtaining at least three (3) references from professional peers. References must possess direct knowledge of the applicant's current competence and health status (i.e. Department Chair during residency or Chief

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of Staff at hospital of current practice) and two (2) must not be closely associated with the applicant in a business capacity. Applicant must provide information regarding any voluntary or involuntary termination of Medical Staff membership or voluntary or involuntary limitation, reduction, or loss of clinical privileges at another hospital, any previous loss or pending challenges to medical licensure, or the voluntary relinquishment of such licensure or registration. An applicant must also report any malpractice judgments or settlements against him/her.

Applicants are required to complete their application within 60 days. If the application is not complete after an allowed grace period of 30 days beyond the initial 60 days, the application will be retired. Should an applicant still indicate an interest in staff appointment, the entire process must be reinstituted.

Completed applications will be forwarded to the next scheduled Credentials Committee. If approved by the Credentials Committee, the application will be forwarded to the next scheduled Executive Committee meeting and Governing Board meeting, in that order, for further recommendation and final action. The total time from the receipt of the completed application from administration to action by the Governing Board will not exceed 150 days.

Subsection 2. The Credentials Committee shall conduct at the time of initial reapplication and biannually thereafter for reappointment, an evaluation of all staff members in all categories for the purpose of verifying current competence in privileges requested. This Committee, through the appropriate Department Chair, will ascertain that the individual staff member maintains a current state license, DEA license, and adequate malpractice coverage. At reappointment, Medical Staff members must report any malpractice judgments or settlements against him/her which have occurred since previous reappointment, as well as any voluntary or involuntary termination of Medical Staff membership or voluntary or involuntary limitation, reduction or loss of clinical privileges at another hospital, any loss or pending challenges to medical licensure, or the voluntary relinquishment of such licensure or registration.

Furthermore, at reappointment and biannually thereafter, the appropriate Department Chair will also verify the staff member'S physical and mental status as they apply to the ability to perform requested privileges. Department chairs will be formally evaluated by the Chair of the Credentials Committee for physical and mental status as they apply to the ability to perform requested privileges. This evaluation will be forwarded to the Credentials Committee for further recommendation for reappointment.

Subsection 3. Pro-active measures are taken by the Medical Staff to provide education about physician health; prevention of physical, psychiatric or emotional illness; and to facilitate confidential diagnosis, treatment and rehabilitation of physicians who suffer from a potentially impairing condition. If at any time during the diagnosis, treatment or rehabilitation phase of the process it is determined that a phYSician is unable to safely perform the privileges he or she had been granted, the matter is forwarded to the Physician Health Committee for appropriate corrective action that includes strict adherence to any state or federally mandated reporting requirements.

Completed reappointment forms will be forwarded to the Credentials Committee according to an established schedule. The reappOintment period expires two (2) years from the date of last reappointment. If a Medical Staff member does not complete his/her reappointment application in time to meet the reappointment time frame, he/she will have staff privileges terminated and must begin the application process anew.

Subsection 4. After approval by the Credentials Committee, request for reappointment 3

will be forwarded to the next scheduled Executive Committee, and Governing Board meeting, in that order, for further recommendation and final action.

Subsection 5. The Board of Managers shall either accept the recommendation of the Executive Committee or shall refer it back for further consideration, providing explanation for the referral.

Subsection 6. When final action has been taken by the Board of Managers, the candidate is informed of such decision.

Subsection 7. Appeals: In any case where the Credentials Committee does not recommend for reappointment or when reduction of privileges is recommended, the committee shall notify in writing the physician concerned, and he/she shall be given an opportunity of appearing before the Credentials Committee. Decision and recommendation of the Credentials Committee after this hearing will be made to the Executive Committee. Hearing and appellate review beyond the Executive Committee, when applicable, will be in accordance with Article XI and XII.

Subsection 8. The Chair of the Credentials Committee, in counsel with the hospital CEO, may grant temporary staff privileges for up to 120 days to a physician applying for staff membership to fulfill important patient care needs or-when a new applicant with a complete application that raises no concerns is awaiting review and approval of the Executive Committee and Governing Board. At a minimum, the following will be verified prior to granting temporary privileges:

• Current licensure • Relevant training • Current competence • Ability to perform requested privileges • National Practitioner Data Bank report

There will be a fee associated with any request for temporary privileges. In the absence of the Chair of the Credentials Committee, any member of the Credentials Committee may act for the Chair in this capacity. In the absence of the hospital CEO, his/her designee, may act for the CEO in this capacity.

Subsection 9. Disaster privileges may be granted when the emergency management plan has been activated and the organization is unable to handle immediate patient needs.

The decision to grant emergency privileges is made on a case-by-case basis at the discretion of the CEO or his/her designee, or the Chief of Staff or his/her designee upon presentation of any of the following:

a. Current license to practice and a valid ID issued by a state, federal, or regulatory agency (Le., driver's license);

b. Identification indicating that the volunteer physician is a member of a Disaster Medical Assistance Team (DMA T);

c. Identification indicating that the volunteer physiCian has already been granted by a federal, state or municipal entity, authority to render patient care in emergency circumstances; or,

d. Verifiable identity by any current Guadalupe Regional Medical Center Medical Staff member.

The volunteer physician is, preferably, to be paired with a currently credentialed Guadalupe Regional Medical Center Medical Staff member and should be under the

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supervision of such. A name tag will be created to identify the volunteer physician. Verification of credentials is conducted through the normal temporary privileging process as soon as the immediate situation is under control.

ARTICLE IV CATEGORIES OF THE MEDICAL STAFF

Section 1. THE MEDICAL STAFF

The Medical Staff shall be divided into eight (8) categories: (1) Honorary Staff; (2) Active Staff; (3) Consulting Staff; (4) Cross Coverage; (5) Courtesy Staff; (6) Emergency Medical Staff; (7) Community Based Physicians; (8) Telemedicine

Section 2. THE HONORARY MEDICAL STAFF

The Honorary Medical Staff shall consist of physicians who do not have clinical privileges and who are honored by emeritus positions. These may be physicians of outstanding reputation or who have retired from Active hospital service. The Honorary Medical Staff shall be appointed by the Board of Managers on recommendation of the Credentials Committee and shall have no assigned duties or responsibilities.

Section 3. THE ACTIVE MEDICAL STAFF

The Active Medical Staff shall consist of physicians, podiatrists and oral surgeons who are located within a reasonable distance and/or travel time to provide continuous care to his/her patients. "Reasonable" shall be determined as part of the credentialing process based on the physician's specialty and scope of care at the hospital. Active staff members may admit patients and/or utilize the various diagnostic and therapeutic services. Podiatrists must have a co­admitting medical physician for any patient requiring hospitalization. Their responsibilities shall include serving on committees to which they may be appointed and rotating call among like specialists for ER and inpatient coverage, as well as for ER follow-up care. During initial appointment, an Active Staff member will be evaluated under Focused Practice Performance Evaluation (FPPE) parameters established by the appropriate Department Chair and Credentials Committee. Members of the Active Medical Staff shall be eligible to vote, hold office, and transact all business of the Active Staff.

Section 4. THE CONSULTING MEDICAL STAFF

The Consulting Medical Staff shall consist of those physicians of recognized ability who meet the qualifications for Medical Staff membership. Consulting Staff members shall not be eligible to admit patients, but may consult on and treat patients in the hospital only at the request of an Active Staff member. Consultants may evaluate or treat inpatients under the primary care of that Active Staff member and may order outpatient diagnostic or therapeutic services. Consulting Medical Staff members may not vote or hold office.

Section 5. THE CROSS COVERAGE MEDICAL STAFF

A cross cover staff member is typically one who is in a specialty group (i.e. nephrology, cardiology, oncology) and who covers for one main provider in the group with a practice in Seguin; or who provides occasional emergency coverage for an established solo practice specialist in Seguin (I.e. ENT). These providers may admit patients in order to cross cover, but are not eligible to vote or hold office.

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Section 6. THE COURTESY MEDICAL STAFF

The Courtesy Staff shall consist of those members of the dental profession and of the medical profession who are eligible as herein provided for Medical Staff membership and who wish to attend patients in the hospital after consultation with a member of the Aetive Staff. They shall be appointed in the same manner as other members of the Medical Staff, but they shall not be eligible to vote or hold office.

Section 7. THE EMERGENCY MEDICAL STAFF

The Emergency Medical Staff members shall consist of those physicians who meet the licensing criteria which apply for admission to the Active Medical Staff and who are contracted to perform physician services in the hospital's emergency department. They shall be eligible to admit patients directly. The designated Medical Director may hold voting privileges equal to those of the Active Staff.

Section 8. COMMUNITY BASED PHYSICIANS These physicians, typically primary care physicians, are based exclusively in a local office practice and have subrogated their admitting privileges through an established arrangement with an Active Staff physician(s). As such, they are exempted from standard OPPE/FPPE monitoring processes related to inpatient hospital care. These phYSicians have a responsibility to partiCipate in unassigned patient call for the purpose of ER and hospitalist discharge follow­up care, and are eligible to vote.

Section 9. TELEMEDICINE

Practitioners providing patient care services solely through approved telemedicine services must apply for and be granted clinical privileges, but are not eligible for Staff membership. In credentialing and privileging practitioners for telemedicine clinical privileges, the Credentials Committee, Executive Committee and Governing Board may use the credentialing information provided by the distant site (the site where the practitioner providing the services is located) if the distant site meets Joint Commission telemedicine requirements.

Section 10. NON-STAFF PHYSICIANS

Licensed physicians who have not been credentialed by the hospital may order diagnostic or therapeutic tests through Imaging, Lab, Respiratory Therapy, Physical Medicine, or Home Care Services. The hospital is re~ponsible for verifying licensure through the State Board of Medical Examiners or by verifying Medical Staff membership at another JCAHO accredited hospital.

ARTICLE V DEPARTMENTALIZATION OF STAFF

Section 1. DEPARTMENTS

There shall be eleven (11) departments of the Medical Staff: Medical, Surgical, Obstetrics, Emergency Services, Family Medicine, Radiology, Anesthesia, Pathology & Laboratory Medicine, Cardiovascular, Nephrology, and Pediatrics. Each will be under the supervision of its department Chair. The department Chair's responsibilities encompass the following:

• Clinically related activities of the department • Administratively related activities of the department, unless otherwise provided by the

hospital • Continuing surveillance of the professional performance of all individuals in the

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department who have delineated clinical privileges (via OPPE & FPPE process) • Recommending to the medical staff the criteria for clinical privileges that are relevant to

the care provided in the department • Recommending clinical privileges for each member of the department • Assessing and recommending to the relevant hospital authority off-site sources for

needed patient care, treatment, and services not provided by the department or the hospital

• The integration of the department or service into the primary functions of the hospital • The coordination and integration of interdepartmental and intradepartmental services • The development and implementation of policies and procedures that guide and support

the provision of care, treatment, and services • The recommendations for a sufficient number of qualified and competent persons to

provide care, treatment and services • The determination of the qualifications and competence of department or service

personnel who are not licensed independent practitioners and who provide patient care, treatment, and services

• The continuous assessment and improvement of the quality of care, treatment, and services

• The maintenance of quality control programs, as appropriate • The orientation and continuing education of all persons in the department or service • Recommending space and other resources needed by the department or service.

The Department Chair is certified by an appropriate specialty board or affirmatively established by the Executive Committee as having comparable competence.

Section 2. CHIEF OF STAFF

The President of the Medical Staff shall be the Chief of Staff. He/she shall be responsible for the functioning of the clinical organization of the hospital and shall keep or cause to be kept a careful supervision over the clinical work in all departments.

ARTICLE VI DETERMINATION OF QUALIFICATIONS

PRIVILEGES

Section 1. DETERMINATION OF PRIVILEGES

Subsection 1. Determination of initial privileges shall be based upon an applicant's training, experience, and demonstrated competence, character and judgement. Each clinical department develops and sets forth criteria to determine an applicant's ability to perform requested privileges.

Subsection 2. Extensions of privileges will be granted by the Credentials Committee, provided the applicant has demonstrated satisfactory competence. Each clinical department develops Ongoing Professional Performance Evaluation (OPPE) criteria for renewing or revising clinical privileges, including procedures performed and their outcomes.

Section 2. PRIVILEGES OF DENTISTS

Subsection 1. Qualified dentists upon application and approval by the Credentials Committee, shall be eligible for appointment to the Courtesy Staff.

Subsection 2. The applicant for membership shall meet qualification standards set forth in Article III. The scope and extent of surgical privileges for dentistry will be defined and

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overseen by the Surgical Department and Credentials Committee.

The dentist is responsible for the dental care of the patient, and may give orders within the scope of licensure and medical staff rules. Any dental patient requiring inpatient hospitalization must be under the care of an Active Staff physician who is responsible for the H&P. Outpatient surgeries require that a full H&P is conducted and documented by a licensed medical physician.

Section 3. PRIVILEGES OF PODIATRISTS

Subsection 1. Qualified podiatrists, upon application and approval by the Credentials Committee, shall be eligible for appointment to Active Medical Staff.

Subsection 2. The applicant for membership shall meet qualification standards set forth in Article III. The scope and extent of surgical privileges for podiatry will be defined and overseen by the Surgical Department and Credentials Committee.

The podiatrist is responsible for the podiatric care of the patient, and may give orders within the scope of licensure and medical staff rules. Any podiatric patient requiring hospitalization must have a co-admitting medical physician. The podiatrist is responsible for the detailed podiatric history and physical for the admitted and surgical podiatric patient. The co-admitting medical physician is responsible for the medical history and remaining physical exam.

Section 4. ALLIED HEALTH PROFESSIONALS

Allied Health Professionals consist of those duly licensed health care professionals qualified to render direct medical care under the supervision of the attending Medical Staff physician. Examples of such professionals include Nurse Practitioners, and Physician Assistants.

A Nurse Practitioner must be a graduate of an accredited Nurse Practitioner Program and have licensure and Nurse Practitioner designation by the Texas Board of Nurse Examiners. A PhYSician Assistant must be a graduate of a Physician Assistant program accredited by the Committee on Allied Health Education and Accreditation of the American Medical Association and/or have passed the credentialing examination administered by the National Commission on Certification of Physician Assistants. Additional criteria for granting initial and continued privileges include evidence of current state licensure or certification, relevant training and/or experience, current competence, physical and mental health status, and evidence of adequate professional liability insurance.

A scope of practice/privilege delineation will be prepared for each Allied Health Professional by the supervising physician. The scope of practice must ensure that the Allied Health Professional functions as an agent of the supervising physiCian with defined levels of autonomy and not as an independent practitioner.

Because the supervising physician assumes all medico-legal responsibility for the performance of the Allied Health Professional, it is expected that the supervising phYSician conduct ongoing and formal evaluations of competence in developing initial request for privileges, as additional privileges are requested, and at each reappointment period. The supervising physician must have daily contact via telephone or in person with the Allied Health Professional. Every order written by an Allied Health Professional, including those to be carried out by other hospital staff, shall be considered as coming from the supervising physician.

The application for membership as an Allied Health Professional shall be channeled through the Credentials Committee, Executive Committee, and Governing Board for action.

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If approved, initial privileges are granted for one (1) year, and reappointment may be granted every two (2) years thereafter.

Section 5. NON-EMPLOYEE PARAMEDICAL PERSONNEL

Non-Employee Paramedical Personnel (NEPPs) consist of those health care providers who are not employed by the hospital but are sponsored by a Medical Staff physician to perform clinical duties at the hospital. Examples of such personnel include nurses, therapists, and surgical scrubs. Criteria for granting initial and continued status as an NEPP include evidence of relevant licensure or certification, relevant training and/or experience, current competence, physical and mental health status, and evidence of adequate professional liability insurance.

A list of job duties will be prepared for each NEPP by the sponsoring physician. It is expected that the sponsoring physician will conduct ongoing and formal evaluations of competence at initial appointment and at each reappointment period.

The application for membership as an NEPP shall be channeled to the Credentials Committee, Executive Committee, and Governing Board for action. If approved, initial NEPP status is granted for one (1) year, and reappointment may be granted every two (2) years thereafter.

Section 6. CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNAs)

CRNAs (Certified Registered Nurse Anesthetists) consist of duly licensed and registered advanced practice nurses who are qualified to render nurse anesthesia care to patients under a direct order from an attending Medical Staff anesthesiologist. A CRNA must be a graduate of an accredited nurse anesthesia program, be licensed and registered by the Texas State Board of Nurse Examiners, and be certified by the National Board of Certification and Recertification of Nurse Anesthetics (NBC RNA). Additional criteria for granting initial and continued privileges include relevant training and experience, competence, required CNE hours, appropriate physical and mental health status, and proof of adequate professional liability insurance. The current Chairman of the anesthesia department shall act as sponsoring physician for CRNA privilege applications and must approve said privileges. A CRNA within the confines of GRMC shall have the technical capability of providing safely all types of anesthesia (as delegated by an attending or on-call anesthesiologist) and any indicated pre- or post-anesthesia care. Whenever a CRNA is administering an anesthetic, an attending anesthesiologist will be readily available for consultation and/or intervention, as necessary. All CRNA generated medical orders, narcotic orders, anesthetic-related notes and records must be countersigned by an attending anesthesiologist. All CRNAs are subject to OPPE/FPPE performance data to assess competency and all CRNAs shall maintain current ACLS certification. If approved, initial privileges are granted for one (1) year and reappointment may be granted every two (2) years thereafter.

ARTICLE VII OFFICERS AND COMMITTEES

Section 1. OFFICERS

The officers of the Medical Staff shall be the Chief of Staff, Vice Chief of Staff, and Secretary. These shall hold office from January 1 to December 31 following the regular election in November or until a successor is elected. An officer can be removed from his/her position through two-thirds (2/3) vote of the Active Medical Staff. Reasons to be removed include non­fulfillment of officer duties or loss of good standing on the Medical Staff.

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THE CHIEF OF STAFF must be an Active member of the Medical Staff in good standing; duly nominated and elected according to Article IX, Section 3. He/she shall call and preside at all meetings and shall be a member ex-officio of all Committees.

THE VICE CHIEF OF STAFF must be an Active member of the Medical Staff in good standing; duly nominated and elected according to Article IX, Section 3. In the absence of the Chief of Staff, the Vice Chief of Staff shall assume all his/her duties and have all his/her authority. He/she shall also be expected to perform such duties of supervision as may be assigned to him/her by the Chief of Staff.

THE SECRETARY must be an Active member of the Medical Staff in good standing; duly nominated and elected according to Article IX, Section 3; and he/she shall ensure that accurate and complete minutes of all meetings are maintained, call meetings on order of the Chief of Staff, and perform such other duties as ordinarily pertain to his/her office.

Section 2. COMMITTEES

Committees of the Medical Staff shall be standing and special. All committees, other than the Executive Committee, shall be appointed by the Chief of Staff.

Subsection 1. The Executive Committee shall consist of the Chief of Staff, Vice Chief of Staff, Secretary, and the immediate Past Chief of Staff and shall act as a liaison group between the Medical Staff, Board of Managers, and Administration of the hospital. This liaison function will be performed at each regular meeting of the Governing Board. The Executive Committee will meet monthly to perform the following functions:

a. Receiving and acting upon the reports and recommendations from Medical Staff committees, departments, services, and assigned activity groups.

b. Implementing the approved policies of the Medical Staff.

c. Recommending to the Governing Body all matters relating to appointments and reappointments, staff categorization, department/service assignments, clinical privileges, and, except when such is a function of the Medical Staff, corrective action.

d. Fulfilling the Medical Staffs accountability to the Governing Body for the quality of the overall medical care rendered to the patients in the hospital.

e. Initiating and pursuing corrective action when warranted, in accordance with Medical Staff Bylaws provisions.

f. Informing the Medical Staff of the Joint Commission & CMS accreditation program(s) and the accreditation status of the hospital. Medical Staff members shall be actively involved in ensuring accreditation compliance.

g. The Executive Committee is empowered to act for the organized Medical Staff between meetings of the organized Medical Staff.

Subsection 2. The Credentials Committee shall consist of a Chair, appointed by the Chief of Staff of the Medical Staff. The Chairs of the Surgical, Medical, Obstetrical, Emergency, Pediatrics, Family Medicine, Radiology, Anesthesia, and Pathology & Laboratory Medicine Committees will be the other members of the Credentials Committee.

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Its duties shall be to investigate the credentials of all applicants for membership and to make recommendations in conformity with Article III of these Bylaws; to extend privileges as set forth in Article VI of these Bylaws; to review any records that may be referred by the Chief of Staff; and to arrive at a decision regarding the performance of the Medical Staff member.

The Credentials Committee will review and approve each applicant's request for hospital-specific delineated clinical privileges, allowing the physician to provide patient care services independently within the scope of the granted privileges. The Committee may recommend limitation of privileges if a physician's experience and/or training appears inconsistent with or insufficient for providing a particular service.

Subsection 3. The composition of the Peer Review Committee is the past five Chiefs of Staff. The Chair will be the Senior member. The Chief of Staff may appoint a replacement member on the Peer Review Committee if a conflict of interest is evident for a particular investigation or as otherwise needed. The purposes of this Committee are:

a. To evaluate, monitor, and enforce professionalism by medical staff peers.

standards of quality care, ethics and

b. To make recommendations for disciplinary or modification, cancellation or limitation of privileges Staff.

corrective measures including of any member of the Medical

c. To act as the Nominating Committee for new officers of the Medical Staff.

Subsection 4. The Performance Improvement Review (PIR) Committee consists of the past Chief of Staff, Chief of Staff, Chief Medical Officer, and a member of the Governing Board. The purpose of PIR is to provide overview of quality issues and physician competency, including OPPE and FPPE reviews.

Subsection 5. Joint Conference Committee shall consist of the Executive Committees of the Medical Staff and the hospital Board of Managers with the Chair elected from its membership. It will meet at the call of the Chair or on request of any of its members and a report of proceedings will be made in writing to the Executive Committee of the hospital Board and the Medical Staff. Five (5) members will constitute a quorum. The purposes of the Joint Conference Committee are to:

a. Hear and review appeals in accordance with Article XI, Section 6, Subsection 8.

b. Consider other matters of importance referred to it by the Executive Committee of the Medical Staff or the Board of Managers from time-to-time.

Subsection 6. The Bylaws Committee shall consist of a Chair and two (2) members of the Active Medical Staff appointed by the Chief of Staff. Its duties shall be to consider proposed amendments to the Medical Staff Bylaws. The Bylaws Committee will make recommendations to the Medical Staff in regard to Bylaws changes in accordance with the guidelines established in Article XII, Section 2, of the Medical Staff Bylaws.

Subsection 7. Pharmacy, Nutrition & Therapeutics function shall be addressed by appropriate Medical Staff member committee.

Subsection 8. Each of the eleven (11) departments (Surgical, Medical, Obstetrics, Emergency Services, Radiology, Anesthesia, Family Practice, Cardiovascular,

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Nephrology, Pediatrics and Pathology & Laboratory Medicine} will determine need for individual department meetings to review quality indicators pertinent to their scope of care. Department Chairs are appointed by the Chief of Staff based on the physician's clinical and administrative qualifications. The Executive Committee may decide to remove a Chair from the position should the Chair be placed on probation for clinical quality or professional reasons.

Subsection 9. Infection Control function shall be addressed by appropriate Medical Staff member Committee related to the surveillance, prevention and control of infection.

Subsection 10. The Physician Health Committee will meet as needed to provide education about physician health and to facilitate confidential diagnOSis, treatment and rehabilitation of physicians who suffer from a potentially impairing condition.

ARTICLE VIII MISCELLANEOUS PROVISIONS

A history and physical (H&P) must be completed by the attending physician, or other qualified licensed individual in accordance with State law, no more than 30 days before or 24 hours after admission or registration of each patient, but prior to surgery or a procedure requiring anesthesia services. When the H&P is completed before admission, an update must be performed within 24 hours of admission or registration, but prior to surgery or a procedure requiring anesthesia.

ARTICLE IX MEETINGS AND ELECTIONS

Section 1. GENERAL STAFF MEETINGS

Subsection 1. Meetings of the general staff will meet four (4) times a year (February, May, August & November with election of officers in November. Attendance is by individual voluntary participation.

Section 2. SPECIAL MEETINGS

Special meetings of the Medical Staff may be held on the call of the Chief of Staff or upon the written request of any five (5) members of the Active Staff. Notice of time and place of such meetings shall be given to all members of the Staff at least 24 hours prior to the date of the meeting.

Section 3. ELECTIONS

At the November meeting of the Medical Staff, the election for the ensuing year shall be conducted.

The Peer Review and Ethics Committee shall act as the Nominating Committee for the staff. At least one (1) name for each office from the Active Staff shall be presented to the Medical Staff for nomination. The Active Staff shall be notified, in writing, of the nominees one (1) week prior to the election. Nominations also may be made from the floor at the time of the election. Election shall be by closed ballot in case of a contested office.

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ARTICLE X CONFLICT MANAGEMENT

Should the Medical Staff, Executive Committee, Governing Board and/or Administration have a conflict in relation to hospital policy, formal arbitration may be used.

ARTICLE XI MEDICAL STAFF PEER REVIEW

I. Peer Review The Guadalupe Regional Medical Center Medical Staff provides an ongoing structure for Peer Review. Peer Review is defined as the formal process of evaluating, monitoring, and enforcing standards of quality care and professionalism by medical staff peers. Example criteria for conducting performance reviews include:

• Department-specific triggers for committee chart review • Sentinel events • Core measure data • Timely and accurate medical record completion • Patient perception of care survey results • Adverse drug events • Infections • Complications • Readmissions

The method for Peer Review monitoring includes an integration of various committees and functions, including Medical Staff Departments, the Performance Improvement Review (PIR) Committee, the Credentials Committee, the Pharmacy Nutrition & Therapeutics (PNT) Committee, Physician Health and Infection Control. At this committee level, reviews are conducted and action plans implemented as deemed appropriate. Methods that may be considered at this level include:

• Counseling • Intensified record review • Proctoring • Recommendation for modification in privileges

The duration of performance monitoring will be determined as appropriate to each situation.

The provider undergoing peer review may request to be heard by the peer review committee. If this occurs the committee shall grant the physician up to 10 minutes to address the committee.

II. OPPE/FPPE Ongoing and Focused Professional Practice Evaluation is performed to evaluate privilege-specific competency of practitioners at GRMC. Department-specific criteria and thresholds are collaboratively developed by the Department Chair, Credentials Committee, Performance Improvement Review (PIR) Committee and Executive Committee.

FPPE plans are developed and tailored for new medical staff members, existing staff members requesting new privileges, and those identified as requiring more intensive review based on trends or triggering events. The Department Chair, in conjunction with the Credentials Committee, will assess results of the FPPE process. Once satisfactory performance of requested privileges is confirmed, the medical staff

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member will be moved from FPPE to OPPE status. In case of dispute, the Executive Committee will make ultimate determinations as to whether FPPE status is appropriate.

OPPE monitoring is conducted on an ongoing basis, with comparative staff summary results reviewed at least bi-annually by the PIR Committee.

Medical Staff members who are found to fall outside of established parameters of care will be promptly notified, provided relevant education, and placed in Focused Professional Practice Evaluation (FPPE) status.

If performance remains outside of expected parameters 60 days after notification, the physician will be required to meet with the Executive Committee to discuss the variance in practice.

If performance still remains outside of expected parameters 90 days after meeting with the Executive Committee, the physician will have hospital privileges suspended for seven days subject to review by PI Review and/or Executive Committee. After the seven day suspension, any recurrence or persistence of the performance deviation in comparison to established parameters and medical staff norms will be considered justification by the Executive Committee to revoke privileges.

This process may be expedited if deemed necessary for patient safety.

III. Disruptive Behavior /Incidents Incident reports involving unprofessional behavior will be handled as per the policy on Disruptive Behavior by Physicians.

IV. External Peer Review On occasion, the Executive Committee may request external peer review. In making a determination to obtain external peer review, the Executive Committee may consider the following, among other things: 1. A request of the physician of concern who does not believe he/she received an

unbiased review internally. 2. The department cannot provide an unbiased reviewer based on issues of

competitive or partnership practices. 3. In the case that the department Chair is the subject of the review, this case would

be forwarded directly to the Executive Committee for consideration and assignment of external peer review if there is no unbiased expert internally.

ARTICLE XII PROCEDURE FOR DISCIPLINARY ACTION

Section 1. APPLICABILITY

This Article applies to disciplinary action involving any member of the Medical Staff holding clinical privileges and to any Allied Health Professional holding clinical privileges. All references in this Article to a Medical Staff member subject to the disciplinary process shall be read to include such an Allied Health Professional.

Section 2. ROUTINE DISCIPLINARY ACTION

Subsection 1. Criteria for Initiation: Whenever the activities or professional conduct of any Medical Staff member with clinical privileges appear to be below or contrary to the standards or aims of the Medical Staff, disruptive of the hospital operations, or to violate

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these Bylaws or hospital pOlicies, investigation or corrective action may be requested by any Medical Staff member or committee of the Medical Staff, the CEO, or the Board of Managers.

Subsection 2. Requests and Notices: All requests for investigation or corrective action shall be in writing, shall contain concise reference to the particular activities or conduct which constitute the grounds for the request, and shall be directed to the Executive Committee. The Chair of the Executive Committee shall promptly notify the CEO of any such request.

Subsection 3. Action upon Receipt of Request: The Executive Committee shall first review the request and shall take one of the following actions:

a. No Action. No action will be taken if the request does not allege any facts which would indicate that the subject Medical Staff member engaged in any conduct or activity meeting the Criteria for Initiation stated in Subsection 1.

b. Invitation to a Meeting. If, in the sole judgment of the Executive Committee, the matter might be clarified by discussion with the subject Medical Staff member, the Executive Committee may invite the member to a meeting with the Executive Committee or its designee for such discussion. Such an invitation for discussion shall not constitute an investigation, and the Medical Staff member shall have no procedural rights in regard to any such discussion. Unless a discussion results in a decision to take no action, the Executive Committee shall refer the matter for investigation.

c. Investigation. As noted above, the Executive Committee may decide to take no action on the request or to postpone further action until after discussion with the subject Medical Staff member. If it decides to take no action, whether before or after meeting with the subject Medical Staff Member, the matter is resolved. If the Executive Committee decides further action or investigation is needed, it shall refer the matter to the Peer Review and Ethics Committee for investigation. The Executive Committee and Peer Review and Ethics Committee may meet and discuss the Executive Committee's concerns at the time of the referral or at any time.

d. Notice. The Executive Committee shall notify the CEO of its action on the request. If the CEO believes the Executive Committee has incorrectly determined that no investigation is needed, he or she may direct the Executive Committee to refer the matter to the Peer Review and Ethics Committee for investigation.

Subsection 4. Investigation and Report:

a. Time Limit and Status of Member. The Peer Review and Ethics Committee shall have 30 days to complete its investigation, unless the Executive Committee provides otherwise. Except in the case of precautionary or automatic suspension of privileges, the subject Medical Staff member's privileges and responsibilities shall continue during the investigation and until final disposition of the case.

b. Meeting with Member. As part of the investigation, the subject Medical Staff member shall be given an opportunity to discuss the matter with the Peer Review and Ethics Committee. This meeting is not a hearing and the Medical Staff member has no procedural rights in the meeting. If the Peer Review and Ethics Committee determines that it requires a meeting with the subject Medical Staff member, it shall require the subject Medical Staff member to attend a meeting, of which reasonable notice shall be given in writing unless the time and place are agreed. If the subject Medical Staff member fails or refuses to appear and cooperate in the investigation of the matter, the

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Peer Review and Ethics Committee shall inform the CEO and the Executive Committee, and the failure or refusal to attend the meeting or to cooperate shall be treated as a voluntary relinquishment of privileges. If there is a meeting, the Peer Review and Ethics Committee shall include a summary of information gathered from the Medical Staff member in its report and recommendation to the Executive Committee.

c. Investigatory Powers. The Peer Review and Ethics Committee shall have the authority to interview whomever it deems appropriate, to review any documents it deems appropriate, and to utilize the services of an outside medical specialist consultant if the hiring of such consultant is approved by the CEO. If the Peer Review and Ethics Committee has reason to believe the mental or physical capacity of the Medical Staff member may be at issue, it may require the subject Medical Staff member to undergo a physical and/or mental examination by a practitioner of the Committee's designation with the results being reported to it and to the subject Medical Staff member by written consent of the Medical Staff member. Failure of the subject Medical Staff member to submit to the examination shall be treated as a voluntary relinquishment of privileges.

d. Report of Peer Review and Ethics Committee. The Peer Review and Ethics Committee and Executive Committee may meet together at any time to discuss the matter under investigation. The Peer Review and Ethics Committee shall report its findings and recommendation to the Executive Committee in writing not more than 10 days after the close of the investigation. The Executive Committee can extend that deadline if needed.

Subsection 5. Procedures Before the Executive Committee Following Report and Recommendation:

a. Decision of Executive Committee. After receiving the report and recommendation of the Peer Review and Ethics Committee, the Executive Committee shall decide upon a proposed action. The Executive Committee may propose to:

(1) dismiss the matter, taking no action with respect to the subject Medical Staff member;

(2) issue a warning, admonition, or reprimand; (3) impose conditions on the Medical Staff member's privileges; (4) modify or suspend the Medical Staff members privileges for any period; (5) revoke the Medical Staff member's privileges, or (6) if the Executive Committee determines that it lacks sufficient information

to decide the matter, it may conduct such further investigation as it deems appropriate or remand the matter to the Peer Review and Ethics Committee with directions for further investigation.

b. Right of Member to a Hearing Under Article XIII. A Medical Staff member has the right to one hearing and one appeal under Article XIII on any proposed action reducing, restricting, suspending, revoking, denying, or failing to renew his or her clinical privileges, except that the Medical Staff member shall not be entitled to a hearing or appeal if the reduction, restriction, suspension lasted no longer than 14 days, during which time an investigation was being conducted to determine the need for further action.

Notwithstanding the above, no Medical Staff member has a right to a hearing for voluntary relinquishment or automatic actions under Section 4 of this Article.

c. Notice of Action. The Chair of the Executive Committee shall issue written notice of 16

the proposed action to the subject Medical Staff member and the CEO. The notice shall describe the proposed action and the reasons for the proposed action. A copy of the written report of the Peer Review and Ethics Committee shall be enclosed with the notice. If the proposed action is one which would entitle the Medical Staff member to a hearing, the notice shall further state the following:

(i) that the Medical Staff member has a right to request a hearing under Article XIII of these Bylaws,

(ii) that the Medical Staff member has 30 days from the date of his or her receipt of this notice to request a hearing, and

(iii) a summary of the Medical Staff member's rights in the hearing to be conducted under Article XIII of these Medical Staff Bylaws, including:

(a) that the hearing will be conducted by a committee of individuals appointed by the hospital CEO or his/her deSignee who shall not be in direct economic competition with the member, to the extent practicable;

(b) that the right to a hearing may be forfeited if the Medical Staff member fails, without good cause, to appear;

(c) that in the hearing the Medical Staff member will have the following rights: to be represented by an attorney or other person of his or her choice, to have a record made of the proceedings, to call, examine, and cross-examine witnesses, to present evidence as deemed relevant by the committee, and to submit a written statement at the close of the hearing; and

(d) that upon completion of the hearing, the Medical Staff member will have the right:

to receive the written recommendation of the committee, including a statement of the basis for the recommendations, and to receive the written final decision including a statement of the basis of the decision.

The notice shall be hand-delivered to the Medical Staff member or sent by commercial or U.S. postal service with delivery confirmation.

d. Effective Date of Action. For proposed actions for which there is no right to a hearing, the action shall become effective 10 days after the date of the notice, unless the CEO has recommended otherwise, in which case the CEO shall present the matter to the Board of Managers as soon as possible.

For proposed actions for which there is a right to a hearing, and if no request for hearing is timely requested, the action shall become effective 31 days after the member's receipt of the notice, unless the CEO has recommended otherwise, in which case the CEO shall present the matter to the Board of Managers as soon as possible.

Section 3. PRECAUTIONARY RESTRICTION OR SUSPENSION

Subsection 1. Criteria for Initiation: Whenever it appears that failure to act immediately may result in an imminent danger to the health of any individual, the Chief of Staff, the Chair of a Medical Staff member's department, or the CEO or his or her representative acting in consultation with any member of the Executive Committee may immediately restrict or suspend a Medical Staff member's clinical privileges as a precaution.

Subsection 2. Notice and Effectiveness: The action shall be effective immediately. The person imposing the action shall immediately give oral notice to the Medical Staff

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member, CEO, Chief of Staff, and Chairs of all departments in which the Medical Staff member holds privileges, to be followed as soon as practicable by written notice to the Executive Committee, Medical Staff member, and the Chair of Board of Managers or designee. The written Notice shall state the action taken, by whom, and that it was taken as a precaution pending further inquiry. It shall not state the factual basis for the action. The Chair of the Executive Committee and the responsible department Chair shall have the authority and the responsibility to provide for alternative medical coverage for the hospitalized patients of the suspended Medical Staff member. The wishes of the patients regarding alternate care shall be considered.

Subsection 3. Executive Committee: As soon as practicable and within 14 days of the precautionary action, the Executive Committee shall consider the action. The Medical Staff member shall be given the opportunity to address the Executive Committee concerning the issues, on such terms and conditions as the Executive Committee may impose. Such meeting of the Executive Committee, with or without the Medical Staff member, shall not constitute a hearing, nor shall any procedural rules with respect to hearings and appeals apply. The Executive Committee shall modify, continue, or terminate the precautionary restriction or suspension and shall furnish the Medical Staff member and CEO with written notice of its decision. If any restriction or suspension is continued in effect for 14 days or more, the Executive Committee shall refer the matter to Peer Review and Ethics Committee for investigation as provided by Section 2, Subsection 4, and further proceedings under that section. If the precautionary suspension or restriction is removed, the Executive Committee shall also notify all persons who were notified of the precautionary restriction or suspension.

Subsection 4. Procedural Rights: Unless the Executive Committee terminates the precautionary restriction or suspension within 14 days, the Medical Staff member shall be entitled to the procedural rights afforded by Article XIII, and to notice as provided by Article XII, Section 2, Subsection S.c.

Section 4. AUTOMATIC RELINQUISHMENT, SUSPENSION OR LIMITATION

Subsection 1. Licensure:

a. Revocation and Suspension. Whenever a Medical Staff member's license to practice in Texas is revoked or suspended, medical staff membership and clinical privileges shall be automatically relinquished by the member as of the date such action becomes effective and through its effectiveness.

b. Restriction. Whenever a Medical Staff member's license to practice in Texas is limited or restricted, any clinical privileges that the member has been granted at this hospital that are within the scope of said limitation or restriction shall be automatically limited or restricted in a similar manner, as of the date such action becomes effective and through its term.

c. Probation. Whenever a Medical Staff member is placed on probation by the applicable Texas licensing authority, his or her membership status and clinical privileges shall automatically become subject to the same terms and conditions of the probation as of the date such action becomes effective and through its term.

Subsection 2. Exclusions from Government Programs - Medicare, Medicaid, or Other Federal Programs: Whenever a Medical Staff member is excluded or de-barred from Medicare, Medicaid, or other federally funded programs, medical staff membership and clinical privileges shall be considered automatically relinquished as of the date such

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action becomes effective. Any practitioner listed on the United States Department of Health and Human Services Office of the Inspector General's List of Excluded Individuals/Entities or the "List of Excluded Individuals/Entities by Texas OIG" will be considered to have automatically relinquished his or her privileges.

Subsection 3. Controlled Substances:

a. DEA Certificate and DPS Registration. Whenever a Medical Staff member's United States Drug Enforcement Agency (DEA) certificate or registration with the Texas Department of Public Safety (DPS) is revoked, limited, or suspended, the member shall automatically and correspondingly be divested of the clinical privilege to prescribe medications covered by the certificate or registration, as of the date such action becomes effective and through its term.

b. Probation. Whenever a Medical Staff member's DEA certificate or DPS registration is subject to probation, the member's clinical privilege to prescribe such medications shall automatically become subject to the same terms of the probation, as of the date such action becomes effective and throughout its term.

Subsection 4. Medical Record Completion: Medical Staff members who exceed defined threshold levels for medical record completion will be referred, as needed to the Executive Committee. Disciplinary measures may include privilege suspension and, in extreme cases, privilege revocation.

Subsection 5. Allied Health Professionals: The clinical privileges of an Allied Health Professional are terminated upon the termination of the Allied Health Professional's employment or sponsorship by his or her sponsoring physician.

Subsection 6. Procedural Rights: No procedural rights under this Article or Article XIII are available in connection with action under this section. Any member who believes there is an error in any action under Subsections 1, 2, or 3 of this section should first resolve it with the governmental entity, if any, and then bring the matter to the attention of the Executive Committee.

Section 5. REPORTING OF PEER REVIEW ACTIONS

Whenever action taken under Sections 2 or 3 of this section adversely affects a Medical Staff member's clinical privileges for more than 30 days, the CEO or his or her designee shall provide notice of such action to the National Practitioner Data Bank and, on behalf of the Executive Committee, to the Texas Medical Board. A Medical Staff member's voluntary surrender or voluntary restriction of privileges while under investigation, to avoid an investigation, or during the pendency of a hearing or appeal shall also be reported. Reports shall be submitted to the National Practitioner Data Bank and to the Texas Medical Board (or other applicable licensing authority) within 15 days of the date the action becomes effective.

Nothing in this section shall preclude any Medical Staff member making an independent report to the Texas Medical Board.

ARTICLE XIII PROCEDURE FOR HEARING AND APPELLATE REVIEW

Section 1. APPLICABILITY

Upon receipt of notice under Article XII, Section 2, Subsection S.c., a Medical Staff member is entitled to request a hearing and, if needed, an appeal as provided in this Article. For

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purposes of this Article, the term "Medical Staff member" includes an Allied Health Professional with clinical privileges.

Section 2. REQUEST FOR HEARING

A Medical Staff member who has been notified of an adverse action that entitles him or her to a hearing has 30 days from his or her receipt of notice to request a hearing, in writing, addressed to the CEO. It is the Medical Staff member's responsibility to ensure that the request is received in the CEO's office on or before the 30th day. If no request for hearing is received within 30 days, the right to a hearing will be considered waived and the action proposed by the Executive Committee shall become effective immediately, unless otherwise directed by the Board of Managers.

Section 3. APPOINTMENT OF HEARING OFFICER OR AD HOC COMMITTEE

When a hearing is requested, the CEO shall appoint three Medical Staff members to serve as an ad hoc hearing committee, with one appointed to serve as Chair. In choosing a committee, the CEO or designee shall consult with the Medical Staff member requesting the hearing and shall attempt to ensure that at least one member of the ad hoc hearing committee is acceptable to the member requesting the hearings. No individual shall be appointed to the committee who has participated in the matter at an earlier stage or who is in direct economic competition with the member requesting the hearing, unless that cannot be avoided. No member of the hearing committee who was not present throughout the hearing shall vote. If needed, the CEO may appoint a replacement member at any time before the hearing begins.

To assist the ad hoc committee, the CEO may appoint and replace as needed an attorney or other individual experienced in conducting due process proceedings to conduct the hearing. That individual may not be in direct economic competition with the Medical Staff member requesting the hearing. The members of the ad hoc committee shall maintain confidentiality and shall not discuss the matters at issue before the hearing provided by this Article. Specifically, they shall not, before the hearing, discuss the matter with the affected Medical Staff member or anyone who is expected to take part in the hearing.

Section 4. NOTICE OF HEARING

Within 15 days of receipt of a request for hearing by a Medical Staff member entitled to a hearing, the CEO shall issue a written notice of hearing to the member stating the time and place of the hearing and including the names of the hearing officer and/or ad hoc committee members, the names of the witnesses expected to testify at the hearing on behalf of the Executive Committee, and a list of patient records, if any, to be presented by the Executive Committee. The list of witnesses and patient records may be modified as needed, and failure to name a witness or record will not preclude the witness or record from being considered at the hearing if the ad hoc committee deems such consideration to be appropriate in a reasonable effort to determine the facts. The ad hoc committee may give the member time to prepare to address newly identified witnesses or records if the ad hoc committee believes that to be necessary for fairness or to assure full explication of the facts. The date of the hearing shall be at least 30 days after the date of the notice, unless the time is shortened by agreement of the ad hoc committee, the Executive Committee, and the Medical Staff member. The notice shall be hand-delivered to the Medical Staff member or sent by commercial or U.S. postal service with delivery confirmation. Any objection the Medical Staff member may have to any matter stated in the notice shall be considered waived if not presented in writing to the Chair of the hearing committee within 10 days of the Medical Staff member's receipt of the notice.

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Section 5. CONDUCT OF HEARING

Subsection 1. Record: The CEO or designee shall provide for an accurate record to be made of the hearing.

Subsection 2. Appearance: The personal presence of the Medical Staff member for whom the hearing has been scheduled shall be required. A Medical Staff member who fails without good cause to appear and cooperate at such hearing shall be deemed to have waived his or her rights in the same manner as provided in Section 2 of this Article XIII and to have accepted the action proposed by the Executive Committee. That action shall thereupon become and remain in effect as provided in said Section 2.

Subsection 3. Postponements: Hearings may be postponed only for good cause shown and in the sole discretion of the ad hoc committee.

Subsection 4. Representation: Subject to the laws relating to the confidentiality of medical information, the affected Medical Staff member shall be entitled to be accompanied at the hearing by representatives of the Medical Staff member's choice. If the Medical Staff member will be represented by an attorney, he or she must notify the CEO of the identity of the attorney at least 10 days before the hearing. The hospital shall provide counsel to represent the Executive Committee, if requested.

Subsection 5. Presiding Officer. The Chair of the ad hoc committee or his or her designee shall preside over the hearing to determine the order of procedure during the hearing to assure that all participants have a reasonable opportunity to present relevant oral and documentary evidence and to maintain decorum.

Subsection 6. Evidence: The hearing need not be conducted according to rules of law relating to the examination of witnesses or presentation of evidence. Any relevant matter upon which responsible persons customarily rely in the conduct of serious affairs may be considered whether or not it would be admissible in court. The ad hoc committee has the authority to decide what evidence to allow and to consider. The Medical Staff member for whom the hearing is being held shall be entitled to submit a written statement concerning any issue of procedure or of fact and such statement shall become a part of the hearing record. The affected Medical Staff member relinquishes all responsibility of the hospital. its Medical Staff, and employees from any liability with respect to any evidence or testimony.

Subsection 7. Order of Proceedings and Burden of Proof. The Executive Committee shall appoint one or more of its members or some other Medical Staff member or members to represent it at the hearing, to present the facts in support of its proposed action, and to examine witnesses, if any. The Executive Committee shall first present its evidence in support of the proposed action and the affected Medical Staff member shall thereafter be responsible for supporting his or her challenge to the proposed action by showing that the proposed action is unsupported by the evidence or otherwise erroneous. The Ad Hoc Committee shall recommend in favor of the Executive Committee unless it finds that the Medical Staff member has proved by a preponderance of the evidence that the proposed action of the Executive Committee was unsupported by the evidence or otherwise erroneous. It is the member's burden to demonstrate that he or she satisfied and has continuously satisfied all criteria for clinical privileges and that he or she fully complies with all medical staff and hospital policies.

Subsection 8. Procedural Rights: The affected Medical Staff member shall have the following rights: To call and examine witnesses, to introduce written or other evidence. to cross-examine any witness on any relevant matter, and to rebut any evidence. If the

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Medical Staff member does not testify in his or her own behalf, he or she may be called by the representative of the Executive Committee or by the ad hoc committee and examined as if under cross examination. The Medical Staff member shall have the right to submit a written statement at the close of the hearing.

Subsection 9. Recessing and Closing the Hearing: The ad hoc Committee may, without special notice, recess the hearing and reconvene the same for the convenience of the participants or for the purpose of obtaining new or additional evidence or consultation. Upon conclusion of the presentation of oral and written evidence and statements, the hearing shall be closed. The ad hoc committee may thereupon, at time convenient to itself, conduct its deliberations outside the presence of the Medical Staff member for whom the hearing was convened.

Section 6. REPORT AND RECOMMENDATION OF THE AD HOC COMMITIEE AND ACTION BY THE EXECUTIVE COMMITTEE

Within 30 days of the conclusion of the hearing, the ad hoc committee shall render a written report which shall contain its recommendation for action and detailed, specific reasons. If authorized by the Hospital, the Committee may delegate the task of drafting the report to the individual who conducted the hearing. The Chair of the ad hoc committee shall deliver the report to the Medical Staff member, the Executive Committee, and the CEO. The member's copy shall be delivered by hand or by commercial or U.S. Postal service with delivery confirmation. The Executive Committee will convene within 14 days of receipt of the report and either adopt, mOdify, or reject the recommendation. It shall give written notice of its proposed action to the Medical Staff member and the CEO. The Medical Staff member's copy will be delivered by hand or by commercial service or U.S. Postal Service with delivery confirmation. If the Executive Committee proposes any disciplinary action; the Medical Staff member may appeal as provided in Section 7. If no appeal is timely requested, and if the Board of Managers does not provide otherwise, the proposed action becomes effective upon the expiration of the time for appeal.

Section 7. APPEAL TO THE BOARD OF MANAGERS

Subsection 1. Notice of Request: Within seven days after receipt of notice of disciplinary action proposed after a hearing, the affected Medical Staff member may, by written notice to the Board of Managers delivered to the CEO, request an appellate review by the Board of Managers. Such notice shall include a brief statement of the reasons for the appeal. The notice may include a request for oral argument. It is the Medical Staff member's duty to ensure that the CEO receives the request within seven days of the member's receipt of the Executive Committee's proposed action.

Subsection 2. Waiver: If such appellate review is not requested with seven days, the affected Medical Staff member shall be deemed to have waived his or her right to the same and to have accepted such adverse proposed action, and the same shall become effective immediately.

Subsection 3. Appellate Review Body: The Board of Managers shall determine whether the appellate review will be conducted by the Board of Managers as a whole or by an appellate review committee appOinted by the Board Chair and composed of three members of the Board of Managers who have not participated in the matter at an earlier stage and who are not in direct competition with the Medical Staff member. If a committee is appointed, one member shall be designated as Chair.

Subsection 4. Written Statements: Within 30 days after receipt of the decision of the Executive Committee, the Medical Staff member who requested an appeal shall deliver

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his or her written statement detailing the grounds for his or her disagreement. The written statement shall be delivered to the CEO, who shall see that the Executive Committee and the appellate review committee or Board receive a copy. Within 15 days of the delivery of the Medical Staff member's written statement, the Executive Committee shall submit a written response, which shall be delivered to the Medical Staff member and the CEO, who shall provide copies to the appellate review committee or Board.

Subsection 5. Nature of Appellate Review Proceedings: The review will be conducted based on the record of the proceedings and the written statements of the parties. In addition, the appellate review committee or the Board may decide to permit oral argument, in which case it will give the Executive Committee and the Medical Staff member at least 10 days prior written notice of the time and place for hearing the argument. The time for oral argument will be limited as the appellate review committee or Board directs. Oral argument for the Medical Staff member shall be presented only by the member, unless the appellate review committee or Board otherwise directs. Argument in support of the Executive Committee's proposed action may be presented by a member of the Executive Committee or other designees of the Executive Committee. Failure of the Medical Staff member to appear at a scheduled argument and to answer questions as directed will constitute a waiver of his or her right to appeal. The appellate review committee or Board may direct the parties to appear and answer questions, even if no oral argument was requested. The appellate review committee or Board may deliberate outside the presence of the parties.

Subsection 6. Recommendation by Appellate Review Committee: After the conclusion or waiver of all steps described in Subsections 1-5, the appellate review committee, if any, shall recommend in writing to the Board that the decision of the Executive Committee's proposed action be upheld, reversed or modified. The Board shall consider and decide the matter as soon as practicable.

Subsection 7. Final Decision by the Board of Managers: Within ten (10) days after the conclusion of the appellate review, the Board of Managers shall make its final decision in the matter and shall direct the CEO to send notice thereof to the affected Medical Staff member by certified mail, return receipt requested, with a copy to the Executive Committee.

No Medical Staff member shall be entitled as a matter of right to invoke a hearing and appellate procedure established by these bylaws on the same matter on more than one occasion.

ARTICLE XIV RULES AND REGULATIONS

The Medical Staff shall adopt such Rules and Regulations as may be necessary for the proper conduct of its work. Such Rules and Regulations shall be a part of these Bylaws. They may be amended at any regular meeting without previous notice by a two-thirds (2/3) vote of the membership of the Active Medical Staff present. Such amendments shall become effective when approved by the Governing Body.

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ARTICLE XV ADOPTION AND AMENDMENT TO BYLAWS

Section 1. ADOPTION OF BYLAWS

These Bylaws are adopted by the Medical Staff for the proper conduct of its work. They shall become effective when approved by the Board of Managers. The Bylaws will be reviewed on a regular basis by the Bylaws Committee.

Section 2. AMENDMENT TO BYLAWS

Amendments to these Bylaws may be submitted by the Bylaws Committee at any regular Medical Staff meeting. After staff members are notified of proposed changes in writing, a two­thirds (2/3) vote of the membership of the Active Medical Staff present is required for adoption. Amendments shall become effective when approved by the Board of Managers.

Section 3.

The organized medical staff has the ability to adopt medical staff bylaws, rules and regulations, and policies, and amendments thereto, and to propose them directly to the governing body.

If the voting members of the organized medical staff propose to adopt a rule, regulation, or policy, or an amendment thereto, they first communicate the proposal to the Medical Executive Committee. If the Medical Executive Committee proposes to adopt a rule or regulation, or an amendment thereto, it first communicates the proposal to the medical staff; when it adopts a policy or an amendment thereto, it communicates this to the medical staff.

In cases of a documented need for an urgent amendment to rules and regulations necessary to comply with law or regulation, there is a process by which the Medical Executive Committee may provisionally adopt and the governing body may provisionally approve an urgent amendment without prior notification of the medical staff. In such cases, the medical staff will be immediately notified by the Medical Executive Committee. The medical staff has the opportunity for retrospective review of and comment on the provisional amendment. If there is no conflict between the organized medical staff and the Medical Executive Committee, the provisional amendment stands. If there is a conflict over the provisional amendment, formal arbitration may be used until a revised amendment is agreed upon by all parties.

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