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TABLE OF CONTENTS

ARTICLE I .................................................................................................................................................. 1 NAME .......................................................................................................................................................... 1 ARTICLE II ................................................................................................................................................ 1 PURPOSES OF THE MEDICAL STAFF ................................................................................................ 1

2.1 PURPOSES ............................................................................................................................... 1 2.2 RESPONSIBILITIES ................................................................................................................ 1 2.3 INTERPRETATION ................................................................................................................. 2

ARTICLE III .............................................................................................................................................. 2 DIRECT ACTION BY THE BOARD OF DIRECTORS ....................................................................... 2

3.1 COMPLIANCE WITH BYLAW REQUIREMENTS .............................................................. 2 3.2 ASSUMPTION OF DUTIES BY THE BOARD ...................................................................... 2 3.3 DIRECT ACTION BY THE BOARD ON SPECIFIC MATTERS .......................................... 2

ARTICLE IV ............................................................................................................................................... 3 MEDICAL STAFF MEMBERSHIP ......................................................................................................... 3

4.1 NATURE OF MEMBERSHIP .................................................................................................. 3 ARTICLE V ................................................................................................................................................ 3 CATEGORIES OF MEDICAL STAFF ................................................................................................... 3

5.1 MEDICAL STAFF .................................................................................................................... 3 ARTICLE VI ............................................................................................................................................... 3 APPOINTMENT PROCEDURE .............................................................................................................. 3

6.1 APPOINTMENT PROCEDURE .............................................................................................. 3 ARTICLE VII ............................................................................................................................................. 3 CLINICAL PRIVILEGES ......................................................................................................................... 3

7.1 EXERCISE OF PRIVILEGES .................................................................................................. 3 ARTICLE VIII ............................................................................................................................................ 4 REAPPOINTMENT PROCEDURES ...................................................................................................... 4

8.1 REAPPOINTMENT PROCEDURES ....................................................................................... 4 ARTICLE IX ............................................................................................................................................... 4 CORRECTIVE ACTION .......................................................................................................................... 4

9.1 ROUTINE CORRECTIVE ACTION ....................................................................................... 4 9.1.1 REQUESTS AND NOTICES ............................................................................................. 4 9.1.2 INTERVIEWS PRIOR TO CORRECTIVE ACTION ....................................................... 4 9.1.3 INVESTIGATION .............................................................................................................. 4 9.1.4 MEDICAL EXECUTIVE COMMITTEE ACTION .......................................................... 5 9.1.5 DEFERRAL ........................................................................................................................ 5 9.1.6 PROCEDURAL RIGHTS .................................................................................................. 5 9.1.7 OTHER ACTION ............................................................................................................... 6

9.2 AUTOMATIC SUSPENSION .................................................................................................. 6 9.2.1 STATE LICENSE ............................................................................................................... 6 9.2.2 DRUG ENFORCEMENT (DEA) ....................................................................................... 6 9.2.3 PROFESSIONAL LIABILITY INSURANCE ................................................................... 6 9.2.4 PROFESSIONAL REVIEW BODIES ............................................................................... 6 9.2.5 MEDICARE/MEDICAID EXCLUSION ........................................................................... 6 9.2.6 MEDICAL EXECUTIVE COMMITTEE RECOMMENDATION ................................... 7

9.3 SUMMARY SUSPENSION ..................................................................................................... 7 9.3.1 MEDICAL EXECUTIVE COMMITTEE ACTION .......................................................... 8 9.3.2 PROCEDURAL RIGHTS .................................................................................................. 8 9.3.3 OTHER ACTION ............................................................................................................... 8

ARTICLE X ................................................................................................................................................ 8

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FAIR HEARING PLAN ............................................................................................................................. 8 10.1 STATEMENT OF POLICY ...................................................................................................... 8 10.2 DEFINITIONS .......................................................................................................................... 9 10.3 INITIATION OF A HEARING ................................................................................................ 9 10.4 NOTICE OF ADVERSE RECOMMENDATION OR ACTION ........................................... 10 10.5 REQUEST FOR A HEARING ............................................................................................... 11 10.6 HEARING COMMITTEE ...................................................................................................... 12 10.7 HEARING PROCESS ............................................................................................................. 13 10.8 HEARING COMMITTEE REPORT ...................................................................................... 16 10.9 EFFECT OF FAVORABLE RESULTS ................................................................................. 17 10.10 EFFECT OF ADVERSE RESULT ......................................................................................... 17 10.11 APPELLATE REVIEW .......................................................................................................... 17 10.12 APPELLATE REVIEW PROCEDURE ................................................................................. 18 10.13 FINAL DECISION OF THE BOARD .................................................................................... 19 10.14 GENERAL PROVISIONS ...................................................................................................... 20 10.15 AMENDMENT ....................................................................................................................... 20

ARTICLE XI ............................................................................................................................................. 20 CONFIDENTIALITY, IMMUNITY AND RELEASES ....................................................................... 20

11.1 AUTHORIZATIONS AND CONDITIONS ........................................................................... 20 11.2 CONFIDENTIALITY ............................................................................................................. 21 11.3 IMMUNITY FROM LIABILITY ........................................................................................... 21 11.4 ACTIVITIES AND INFORMATION COVERED ................................................................. 21

11.4.1 ACTIVITIES AND INFORMATION .............................................................................. 21 11.4.2 RELEASES ....................................................................................................................... 21 11.4.3 CUMULATIVE EFFECT ................................................................................................. 22

ARTICLE XII ........................................................................................................................................... 22 OFFICERS ................................................................................................................................................ 22

12.1 OFFICERS .............................................................................................................................. 22 12.1.1 QUALIFICATIONS ......................................................................................................... 22 12.1.2 NOMINATION AND ELECTION OF OFFICERS ......................................................... 22

12.2 PRESIDENT OF THE MEDICAL STAFF ............................................................................ 22 12.3 PRESIDENT-ELECT .............................................................................................................. 23 12.4 CREDENTIALS CHAIR ........................................................................................................ 23 12.5 VACANCIES AND REMOVAL OF OFFICERS .................................................................. 23

12.5.1 VACANCIES.................................................................................................................... 23 12.5.2 REMOVAL OF OFFICERS ............................................................................................. 24 12.5.3 INDEMNIFICATION OF OFFICERS ............................................................................. 24

ARTICLE XIII .......................................................................................................................................... 25 COMMITTEES ........................................................................................................................................ 25

13.1 STANDING AND SPECIAL COMMITTEES ....................................................................... 25 13.2 THE MEDICAL EXECUTIVE COMMITTEE ...................................................................... 25

13.2.1 OFFICERS ........................................................................................................................ 25 13.2.2 MEMBERSHIP ................................................................................................................ 25 13.2.3 MEDICAL STAFF REPRESENTATION ....................................................................... 25 13.2.4 FUNCTIONS .................................................................................................................... 26 13.2.5 ACTIONS ......................................................................................................................... 26 13.2.6 MEETINGS ...................................................................................................................... 27 13.2.7 MINUTES ......................................................................................................................... 27

13.3 CREDENTIALS COMMITTEE ............................................................................................. 27 13.3.1 MEMBERSHIP ................................................................................................................ 27 13.3.2 FUNCTIONS .................................................................................................................... 27

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13.3.3 MEETINGS ...................................................................................................................... 28 13.3.4 REPORTS ......................................................................................................................... 28

13.4 PERFORMANCE IMPROVEMENT COMMITTEE ............................................................ 28 13.4.1 CHAIR .............................................................................................................................. 28 13.4.2 MEMBERSHIP ................................................................................................................ 28 13.4.3 FUNCTIONS .................................................................................................................... 28 13.4.4 MEETINGS ...................................................................................................................... 28 13.4.5 MINUTES ......................................................................................................................... 28 13.4.6 REPORTS ......................................................................................................................... 29

13.5 TRAUMA SERVICES COMMITTEE ................................................................................... 29 13.5.1 CHAIR .............................................................................................................................. 29 13.5.2 MEMBERSHIP ................................................................................................................ 29 13.5.3 FUNCTIONS .................................................................................................................... 29 13.5.4 MEETINGS ...................................................................................................................... 29 13.5.5 MINUTES ......................................................................................................................... 29 13.5.6 REPORTS ......................................................................................................................... 29

13.6 DYAD/SERVICE LINES COMMITTEE ............................................................................... 29 16.6.1 CHAIR .............................................................................................................................. 29 13.6.2 MEMBERSHIP ................................................................................................................ 29 13.6.3 FUNCTIONS .................................................................................................................... 29 13.6.4 MEETINGS ...................................................................................................................... 29 13.6.5 MINUTES ......................................................................................................................... 30 13.6.6 REPORTS ......................................................................................................................... 30

13.7 PEER REVIEW COMMITTEE .............................................................................................. 30 13.7.1 CHAIR .............................................................................................................................. 30 13.7.2 MEMBERSHIP ................................................................................................................ 30 13.7.3 FUNCTIONS .................................................................................................................... 30 13.7.4 MEETINGS ...................................................................................................................... 30 13.7.5 MINUTES ......................................................................................................................... 30 13.7.6 REPORTS ......................................................................................................................... 30

ARTICLE XIV .......................................................................................................................................... 30 MEDICAL STAFF MEETINGS ............................................................................................................. 30

14.1 MEETINGS ............................................................................................................................. 30 14.2 SPECIAL MEETING WITH BOARD ................................................................................... 31 14.3 CLOSED MEETINGS ............................................................................................................ 31 14.4 QUORUM ............................................................................................................................... 31

ARTICLE XV ........................................................................................................................................... 31 MEDICAL STAFF AND DEPARTMENTAL POLICIES ................................................................... 31 ARTICLE XVI .......................................................................................................................................... 32 AMENDMENTS TO BYLAWS .............................................................................................................. 32 ARTICLE XVII ........................................................................................................................................ 32 ADOPTION ............................................................................................................................................... 32

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ALLEN HOSPITAL

MEDICAL STAFF BYLAWS

ARTICLE I

NAME

The Name of the Organization shall be the Medical Staff of Allen Hospital (“Hospital”).

ARTICLE II

PURPOSES OF THE MEDICAL STAFF

2.1 PURPOSES

A. Provide an organization of Hospital Medical Staff members for prescribed

interrelationships with the Allen Hospital Board of Directors (“Board”) and the

various departments within the Hospital.

B. Promote excellent patient care.

C. Recognize and define qualifications for granting practice privileges in the Hospital.

D. Oversee and regulate the practice of healing arts within the Hospital.

E. Inform the Board of the Hospital concerning the appropriateness of patient care and

practitioner conduct.

F. Provide a means by which members of the Medical Staff can formulate

recommendations for the Hospital’s policy-making and planning processes.

G. Better quality, better patient experience, at an affordable cost.

2.2 RESPONSIBILITIES

To accomplish the above purposes, it is the obligation and responsibility of the organized

Medical Staff to:

A. Provide a leadership role in Hospital performance improvement activities to improve

quality of care, treatment, services and patient safety.

B. Make recommendations to the Board regarding Medical Staff appointment, service

line assignments, clinical privileges and criteria for reappointment.

C. Enforce compliance with Medical and Hospital staff policies and regulations.

D. Cooperate with the Board in long-range planning to meet future health care needs of

the community.

E. Provide a continuing program of professional education, or give evidence of

participation in such a program. There may be a program of continuing medical

education designed to keep the Medical Staff informed of significant new

developments and new skills in medicine. Medical Staff education should include

Hospital based programs as well as educational opportunities outside of the Hospital.

Documentation of these activities should be kept in order to evaluate the scope,

effectiveness, attendance and amount of time spent at such efforts.

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2.3 INTERPRETATION

These Bylaws do not constitute a contract. They represent a formal policy of the Medical Staff

as recommended by the Medical Staff and adopted by the Board for the purpose of discharging

the responsibilities delegated by the Board and stated above. These Bylaws and industry custom

afford substantial, substantive and procedural protection to individuals in connection with

membership and privilege issues, and the Medical Staff and the Hospital are committed to

respecting the rights of those individuals.

ARTICLE III

DIRECT ACTION BY THE BOARD OF DIRECTORS

3.1 COMPLIANCE WITH BYLAW REQUIREMENTS

The procedures set forth in these Bylaws, Policies, and Credentialing Manual will be followed to

the extent reasonably possible.

3.2 ASSUMPTION OF DUTIES BY THE BOARD

If the Board of the Hospital determines, after consultation with the Medical Staff officers, that

the Medical Staff Executive Committee is unwilling or unable to effectively discharge its

responsibilities under the Medical Staff Bylaws in a particular case, the Board of the Hospital

itself may assume and carry out the responsibilities of the Medical Staff Executive Committee

under these Bylaws.

In such case the Board, in consultation with the Chief Medical Officer, may appoint any

individuals it deems appropriate to assume and carry out the specific powers and responsibilities

which would otherwise be assigned to the President of the Medical Staff and/or Medical Staff

Executive Committee, under the provisions of these Bylaws. The persons so appointed, while

acting in such capacity, shall have all privileges, immunities and other protections available

pursuant to these Bylaws.

3.3 DIRECT ACTION BY THE BOARD ON SPECIFIC MATTERS

The Board reserves the right to enforce the Medical Staff Bylaws, Policies, Credentialing

Manual and general health and safety standards of Hospital wide significance, with or without

prior notice to the Medical Staff. This may be particularly appropriate where the Bylaws, Policy

or Credentialing Manual is outside the responsibility delegated by the Board to the Medical

Staff, or is within an area of shared responsibility, and concerns behavior which can be evaluated

as well by Board members or by health professionals.

The Chair of the Board or the President/CEO, in consultation with the Chief Medical Officer,

shall first attempt to notify the Medical Staff President or designee before undertaking direct

action.

In the case of direct action under this section, the Board or the President/CEO shall establish a

procedure for considering and implementing direct action. For purposes of these Bylaws

“practitioner” means the physician, dentist, podiatrist, clinical psychologist, chiropractor, or

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other non-physician practitioner. When the proposed action is one which would have entitled the

practitioner to a fair hearing, the direct action shall include the provision for a hearing before a

committee appointed by the Board.

The hearing shall be prosecuted by a representative of the Medical Staff designated by the

Medical Staff Executive Committee. The hearing panel shall solicit the position and opinion of

the Medical Staff through its appointed representative. The provisions of the Fair Hearing Plan

shall apply whenever a practitioner has the right to request a hearing under this Plan.

ARTICLE IV

MEDICAL STAFF MEMBERSHIP

4.1 NATURE OF MEMBERSHIP

Membership to the Medical Staff of Hospital is a privilege extended only to professional,

competent practitioners who continuously meet the qualifications, standards and requirements as

set forth in these Bylaws and the Policies of the Medical Staff.

The general qualifications are set forth in the Medical Staff Credentialing Manual and relevant

Medical Staff policies.

ARTICLE V

CATEGORIES OF MEDICAL STAFF

5.1 MEDICAL STAFF

The Medical Staff membership shall be divided into categories based on the Medical Staff policy

entitled Categories of Medical Staff.

ARTICLE VI

APPOINTMENT PROCEDURE

6.1 APPOINTMENT PROCEDURE

The applicant’s application will be processed according to the Medical Staff Credentialing

Manual with full review and approval of the Hospital Credentials Committee.

ARTICLE VII

CLINICAL PRIVILEGES

7.1 EXERCISE OF PRIVILEGES

Members of the Medical Staff shall limit their professional activities in the Hospital to the

exercise of those privileges granted by the Board after review and recommendation by the

Medical Staff Executive Committee. Consultation must be obtained when required for the

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welfare of a patient and when required by Medical Staff or Hospital policy. Privileges are

addressed in the Medical Staff Credentialing Manual.

ARTICLE VIII

REAPPOINTMENT PROCEDURES

8.1 REAPPOINTMENT PROCEDURES

The applicant’s application for reappointment will be processed according to the Medical Staff

Credentialing Manual with full review and approval of the Hospital Credentials Committee.

ARTICLE IX

CORRECTIVE ACTION

9.1 ROUTINE CORRECTIVE ACTION

A request for a routine corrective action may be initiated by any member of the Medical Staff or

the Hospital President/CEO whenever a practitioner engages in, makes or exhibits acts,

statements, demeanor or professional conduct within the Hospital, that is, or is reasonably likely

to be (1) detrimental to the quality of patient care or safety, (2) disruptive to the Hospital’s

operations, (3) an unwarranted impairment to the community’s confidence in the Hospital or (4)

contrary to requirements or intent of the Bylaws, manuals or policies or Hospital policies or

procedures. Violation of Red Rules established under Medical Staff Policies shall constitute

Actionable Conduct and may follow the process set forth in the Medical Staff Policies with

respect to such conduct.

9.1.1 REQUESTS AND NOTICES

All requests for corrective action must be in writing, submitted to the Medical Staff President

and supported by reference to specific activities or conduct which constitutes grounds for the

request. The Medical Staff President promptly notifies the President/CEO, along with the Chief

Medical Officer, of the Hospital in writing of all requests.

9.1.2 INTERVIEWS PRIOR TO CORRECTIVE ACTION

When considering initiating corrective action, the initiating individual may arrange for an

interview with the involved practitioner. At the interview, circumstances prompting the

consideration of corrective action are discussed and the practitioner is asked to present relevant

information on his or her own behalf. A written record is maintained reflecting the substance of

the interview in the physician’s credentials file. If the practitioner fails or declines to participate

in the interview, the appropriate corrective action is initiated. This interview is not a procedural

right of the practitioner and need not be conducted according to the procedural rules provided in

the Bylaws, or in the Fair Hearing Plan.

9.1.3 INVESTIGATION

The Medical Staff President shall report the request to the Medical Executive Committee and the

Medical Executive Committee may either act on the request, or direct that an investigation

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concerning the grounds for the corrective action request be undertaken. The Medical Executive

Committee may conduct such investigation itself or may assign this task to a Medical Staff

officer, section, ad hoc committee or other organizational component. The investigative process

is not a “hearing” as that term is used in the Fair Hearing Plan. It may involve a consultation

with the practitioner involved and with the individual or group making the request, and with

other individuals who may have knowledge of the events involved. If the investigation is

accomplished by a group or individual other than the Medical Executive Committee, that group

or individual must forward a written report of the investigation to the Medical Executive

Committee as soon as practicable after the assignment to investigate has been made. The

Medical Executive Committee may, at any time within its discretion, terminate the investigation

process and proceed with action as provided below.

9.1.4 MEDICAL EXECUTIVE COMMITTEE ACTION

As soon as practicable after conclusion of the investigative process, if any, the Medical

Executive Committee shall act upon such request. Its action may include, without limitation, the

following:

Actions not deemed adverse:

recommending rejection of the request for corrective action;

recommending a warning or a formal letter of reprimand;

recommending a probationary period with retrospective review of cases but without

special requirements for concurrent consultation or direct supervision.

corrective action for First Offense, Second Offense and Third Offense under the Red

Rules of the Medical Staff Policies.

Adverse actions or recommendations:

recommending suspension or diminishment of appointment prerogatives that do not

affect clinical privileges;

recommending individual requirements of consultation or supervision;

recommending reduction, suspension, or revocation of clinical privileges;

recommending reduction or involuntary change of staff category or suspension or

limitation of prerogatives directly related to the practitioner’s provision of patient care;

recommending suspension or revocation of staff appointment;

denial of staff appointment or reappointment; or

other adverse actions as defined in the Fair Hearing Plan.

9.1.5 DEFERRAL

If additional time is needed to complete the investigative process, the Medical Executive

Committee may defer action on the request. A subsequent recommendation for any one or more

of the actions provided above must be made at the next scheduled meeting of the Medical

Executive Committee.

9.1.6 PROCEDURAL RIGHTS

A Medical Executive Committee Section 9.1.4 recommendation that is deemed adverse entitles

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the practitioner to the procedural rights contained in the Fair Hearing Plan.

9.1.7 OTHER ACTION

A Medical Executive Committee Section 9.1.4 recommendation that is not deemed adverse is

transmitted to the Board together with all supporting documentation. Thereafter, the procedures

in the Medical Staff Credentialing Manual are applicable.

9.2 AUTOMATIC SUSPENSION

9.2.1 STATE LICENSE

Revocation: Whenever a practitioner’s license to practice in the State of Iowa is revoked,

there is immediate and automatic revocation of staff appointment and all clinical

privileges.

Restriction: Whenever a practitioner’s license is partially limited or restricted in any way,

those clinical privileges which he or she has been granted that are within the scope of the

limitation or restriction are similarly limited or restricted, automatically.

Suspension: If a license is suspended, the practitioner’s staff appointment and clinical

privileges are automatically suspended effective upon and for at least the term of the

suspension.

Probation: If a practitioner is placed on probation by his or her licensing authority, his or

her voting and office-holding prerogatives may be suspended effective upon and for at

least the term of the probation at the discretion of the Medical Executive Committee.

9.2.2 DRUG ENFORCEMENT (DEA)

If a practitioner’s right to prescribe controlled substances is revoked, restricted, suspended, or

placed on probation by a proper licensing authority, his or her privileges to prescribe such

substances in the Hospital will also be revoked, restricted, suspended or placed on probation

automatically and to the same degree. This will be effective upon and for at least the term of the

imposed restriction.

9.2.3 PROFESSIONAL LIABILITY INSURANCE

For failure to maintain a minimum amount of professional liability insurance, if any, required

under the Bylaws and accompanying policies or manuals, a practitioner’s Medical Staff

appointment and clinical privileges are automatically suspended.

9.2.4 PROFESSIONAL REVIEW BODIES

If a recognized body or organization, which conducts peer review or professional review of

practitioners’ professional care, issues sanctions, the practitioner’s clinical service line leader

will be notified of the issues and sanctions.

9.2.5 MEDICARE/MEDICAID EXCLUSION

Any practitioner whose participation in the Medicare or Medicaid program is terminated by

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either or both of these programs, or who is otherwise excluded or precluded from participation in

either of these programs, shall automatically have all clinical privileges suspended as of the

effective date of the termination, exclusion or preclusion pending review by the Credentials

Committee. If the practitioner’s participation in those programs is not fully reinstated by the

expiration of the practitioner’s then-current reappointment term, the practitioner will be deemed

to have resigned from the Medical Staff at that time. It shall be the duty of all practitioners to

promptly inform the hospital of any action taken by either such program in this regard.

9.2.6 MEDICAL EXECUTIVE COMMITTEE RECOMMENDATION

As soon as practicable (1) after the practitioners license is suspended, restricted or placed on

probation, or (2) after his or her controlled substance number is revoked, restricted, suspended or

placed on probation, the Medical Executive Committee shall convene to review and consider the

facts under which action was taken. The Medical Executive Committee may then recommend

such further action as is appropriate to the facts disclosed in the investigation including limitation

of prerogatives. Thereafter, the applicable procedure in Section 9.1.6 or 9.1.7 is followed.

9.3 SUMMARY SUSPENSION

A. The President of the Medical Staff, the Credentials Committee Chair, the Chief

Medical Officer, the Hospital President/CEO (or his/her designee) or the Chairperson

of the Board of the Hospital shall have the authority to suspend all or a portion of the

clinical privileges of a practitioner whenever failure to take such action may result in

imminent danger to the health and/or safety of a patient, to prevent the reasonable

likelihood of injury to patients, employees, or other persons present in the Hospital or

to the continued effective operation of the Hospital. Such summary suspension shall

be deemed an interim precautionary 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. The impacted practitioner should be notified in writing along with a face-

to-face discussion.

B. Such suspension shall become effective immediately upon imposition. It shall be

immediately reported in writing to the President/CEO, the Chief Medical Officer, the

President of the Medical Staff and the Chair of the Credentials Committee and shall

remain in effect unless or until modified by the President of the Medical Staff or the

Credentials Committee.

C. The suspended individual shall be required to attend a meeting with the Credentials

Committee within five (5) business days of suspension. The purpose of that meeting

shall be limited to the appropriateness of the summary suspension. At that meeting,

the matters precipitating the suspension and the suspended individual’s response to

those matters shall be considered by the Credentials Committee, which shall determine

whether the suspension should be continued, modified, or terminated.

D. Immediately upon the imposition of a summary suspension, the President of the

Medical Staff or the responsible service line leader/medical director shall have the

authority to provide for alternative medical coverage for the patients of the suspended

practitioner who are still hospitalized. The wishes of the patient or representative shall

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be considered regarding an alternate practitioner.

All members of the Medical Staff shall cooperate with the President of the Medical

Staff, the Credentials Committee, the service line leader/medical director, the Chief

Medical Officer, and the President/CEO of the Hospital in enforcing all suspensions.

9.3.1 MEDICAL EXECUTIVE COMMITTEE ACTION

As soon as convenient after the summary suspension, but in any event, within three (3) working

days after the summary suspension has been imposed, the Medical Executive Committee shall

convene to review and consider the action taken. The Medical Executive Committee may

recommend modification, continuation or termination of the terms of the suspension.

9.3.2 PROCEDURAL RIGHTS

Unless the Medical Executive Committee recommends immediate termination or modification of

the suspension to a sanction not deemed adverse in Section 9.1.4 of these Bylaws or the Fair

Hearing Plan, the practitioner is entitled to the procedural rights contained in the Fair Hearing

Plan.

9.3.3 OTHER ACTION

A Medical Executive Committee recommendation to terminate or modify the suspension to a

lesser sanction not triggering procedural rights is transmitted immediately, together with all

supporting documentation, to the Board of the Hospital and the procedure in Section 9.1.7 should

be followed. In this instance, the Medical Executive Committee recommendation will have the

effect of revoking the summary suspension completely or reinstating the practitioner with

whatever corrective action was assessed by the Medical Executive Committee preceding the

decision of the Board of the Hospital.

ARTICLE X

FAIR HEARING PLAN

10.1 STATEMENT OF POLICY

The purpose of this Plan is to set forth procedures and guidelines to govern the Medical Staff and

Board of the Hospital in their consideration and treatment of disputes regarding applications and

corrective action, which procedures and guidelines meet the following two criteria:

A. The procedures and guidelines provide fundamental fairness to any practitioner

whose Medical Staff membership and/or privileges are in dispute, either in the

application, reappointment, or corrective action proceedings, by providing the

practitioner fair notice and an opportunity to be heard with a fair consideration of

the facts, so that only legitimate criteria relating to the quality of treatment and

patient care, the mission and goals of the Hospital, and the discharge of necessary

Medical Staff functions will be applied.

B. The procedures and guidelines are workable and appropriate when considered in

light of the size and resources of this Medical Staff, the Hospital and the Board of

the Hospital. The overriding responsibility is for the health, safety and welfare of

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patients.

10.2 DEFINITIONS

A. Adverse Recommendation/Action: Means a professional review action as defined in

the Health Care Quality Improvement Act of 1986.

B. Adversely affects or adversely affecting: Includes reducing, restricting, suspending

or revoking, denying or failing to renew clinical privileges or appointment.

C. Appellate Review Body: Means the group designated under this Plan to hear a

request for appellate review properly filed and pursued by a petitioner.

D. Board of the Hospital, Medical Staff Executive Committee, or Credentials

Committee: Are included in the meaning of a professional review body as defined by

the Health Care Quality Improvement Act of 1986.

E. Hearing Committee: Means the committee appointed under the Plan to hear a

request for a hearing properly filed and pursued by a practitioner.

F. Parties: Means the practitioner who requested the hearing or appellate review and

the body or bodies upon whose recommendation or action a hearing or appellate

review request is predicated.

G. Physician: Means physician or dentist licensed under Iowa Code Chapters 148, 153

and 153A as amended against whom an adverse professional review action has been

recommended to taken.

H. Practitioner: Means the physician, dentist, podiatrist, clinical psychologist, or other

non-physician practitioner against whom an adverse professional review action has

been recommended or taken.

I. Official Notice: Means the act by which the Hearing Committee will on its own

motion and without the production of evidence, recognize the existence and truth of

certain facts relevant to the controversy and generally regarding as true.

J. Special Notice: Means written notification sent by certified or registered mail, return

receipt requested.

10.3 INITIATION OF A HEARING

A. Triggering Events:

The following recommendations of actions shall, if deemed adverse under this

section, entitle the practitioner to a hearing upon timely and proper request:

Denial of initial staff appointment

Denial of reappointment

Suspension of staff appointment

Revocation of staff appointment

Denial of requested appointment to or advancement in staff category

Reduction in staff category

Suspension or limitation of admitting privileges

Denial or restriction of requested clinical privileges

Reduction in clinical privileges

Suspension of clinical privileges

Revocation of clinical privileges

Individual application of, or individual changes in, mandatory consultation

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requirements

Other professional review action which adversely affects a practitioner

B. When deemed adverse:

A recommendation or action listed in Section 10.3.1 shall be deemed an adverse

action only when it has been:

1. Recommended by Medical Staff Executive Committee and approved by the Board

of the Hospital.

2. Taken by the Board of the Hospital contrary to a favorable recommendation by

the Medical Staff Executive Committee under circumstances where no prior right

to a hearing existed.

3. Taken by the Board of the Hospital on its own initiative without benefit of a prior

recommendation by the Medical Staff Executive Committee.

Corrective action for First Offense, Second Offense and Third Offense under the Red Rules of

the Medical Staff policies shall not be considered adverse and shall not entitle the practitioner to

a hearing.

10.4 NOTICE OF ADVERSE RECOMMENDATION OR ACTION

A. Notice of Decision: The practitioner against whom action has been taken pursuant to

Section 10.3 shall promptly be given a written notice of such action sent by certified

or registered mail. Such notice shall set forth the fact of the adverse action. Details

as to the reasons for such action need not be set forth unless or until the practitioner

requests review.

B. Contents of Special Notice:

1. The notice shall describe the adverse action.

2. Advise the practitioner of the recommendations or action and of the right to

request a hearing pursuant to the provisions of the Medical Staff Bylaws, Policies,

or Credentials Manual and the Health Care Quality Improvement Act of 1986.

3. That the practitioner shall have thirty (30) days from receipt of the notice to file a

written request for a hearing which must be delivered to the President/CEO or the

Chief Medical Officer, either in person or by certified or registered mail.

4. That a failure to file a request for hearing within the thirty (30) day period will

waive any right to such hearing and to any appellate review, and that such waiver

shall constitute acceptance of the adverse action or recommendation.

5. State that the hearing, if requested, shall be held:

a) Before an arbitrator mutually acceptable to the practitioner and the Hospital.

b) Before a hearing officer, who is appointed by the Hospital and who is not in

direct economic competition with the practitioner involved, or

c) Before a panel of individuals who are appointed by the Hospital and are not in

direct economic competition with the practitioner involved.

6. State that the right to a fair hearing may be forfeited if the practitioner fails,

without good cause, to appear.

7. State that, in the hearing, the practitioner involved has the right to:

a) Have a record of the proceedings, copies of which may be obtained by the

practitioner upon payment of any reasonable charges associated with the

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preparation thereof.

b) Call, examine, and cross-examine witnesses.

c) Present evidence determined to be relevant by the arbitrator, hearing officer or

Hearing Committee; regardless of its admissibility in a court of law.

d) Represented by an attorney or other person of the practitioner’s choice so long

as the practitioner identifies the representative in the request for hearing, and

e) Submit a written statement at the close of the hearing.

8. State that upon completion of the hearing, the practitioner involved has the right

to:

a) Receive a written recommendation of the arbitrator, officer, or panel including

a statement of the basis for the recommendations, and

b) Receive a written decision, including a statement for the basis for the decision.

9. State that any higher authority required or permitted under this plan to act on the

matter following a waiver is not bound by the adverse recommendation or action

that the practitioner has accepted by virtue of the waiver, but may take any action,

whether more or less severe, that it deems warranted by the circumstances.

10. State that upon receipt of the practitioner’s hearing request, the President of the

Medical Staff and the Hospital President/CEO, or Chief Medical Officer, will

notify the practitioner of the date, time and place of the hearing which shall be at

least thirty (30) days and not more than forty-five (45) days after the date of the

notice and the reasons for the adverse recommendation or action.

10.5 REQUEST FOR A HEARING

A. A practitioner shall have thirty (30) days following the receipt of a notice pursuant to

file a written request for a hearing. Such request shall be a written notice delivered to

the President/CEO, or Chief Medical Officer, either in person or by certified or

registered mail.

B. Waiver by failure to request a hearing: A practitioner who fails to request a

hearing within the time and in the manner specified waives the right to such hearing

or appellate review. Such waiver applies only to the matters that were the basis of the

adverse recommendation or action triggering the notice. The President of the

Medical Staff and the Hospital President/CEO, or Chief Medical Officer, shall

promptly send the practitioner special notice of each action taken under any of the

following sections. The effect of the waiver is as follows:

1. A waiver constitutes acceptance of that action and which shall thereupon become

effective pending the final decision of the Board. A waiver of a hearing on a

Medical Staff Executive Committee or Credentials Committee recommendation

also constitutes a waiver of a right to appeal a Board decision. The Board

considers the adverse recommendation as soon as practical following the waiver.

2. If the Board’s action in the matter is in accord with the Medical Staff Executive

Committee’s recommendation, such action shall constitute the final decision of

the Board.

3. If the Board’s action has the effect of changing the Committee’s recommendation,

the matter shall be re-submitted to the Medical Staff Executive Committee or the

Credentials Committee as a new adverse action and will re-instate the Fair

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Hearing Plan.

C. The President/CEO, or Chief Medical Officer, shall promptly send the practitioner a

special notice of each action taken pursuant to this plan and shall notify the President

of the Medical Staff of each action.

Following a waiver, but before the final action of the Board, the practitioner may submit

additional information relevant to the case. If the source of the additional information referred to

in this section is the practitioner or an individual or group functioning, directly or indirectly, on

his or her behalf, the provisions of the Section shall not apply unless the practitioner can

demonstrate to the satisfaction of the Medical Staff Executive Committee or the Credentials

Committee that the information was not reasonably discoverable in time for presentation to or by

the Hearing Committee if the practitioner’s waiver is in connection with an appellate review.

10.6 HEARING COMMITTEE

A. Composition: Within ten (10) days after receipt of a request for hearing, or as soon

thereafter as reasonably possible, the President/CEO, after consultation with the Chief

Medical Officer and President of the Medical Staff, will appoint a Hearing

Committee and provide each member of the Hearing Committee with copies of the

action/recommendation, the notice to the affected practitioner and the practitioner’s

request for hearing. The Committee shall be formed under the following guidelines:

1. The Committee will be composed of not fewer than three (3) practitioners, a

majority of whom must be physicians, and none of whom should be in direct

economic competition with the affected practitioner.

a) The Committee should, to the extent possible be comprised of practitioners

with privileges at the Hospital, but this guideline shall not control when its

application would result in insufficient Committee members, or would

require appointment to the Committee of a practitioner who has initiated the

complaint.

b) The Committee need not be limited to Active Staff or even members of the

Medical Staff.

2. When the practitioner requesting the hearing is a non-physician practitioner,

reasonable efforts shall be made for at least one member of the Hearing

Committee to be a non-physician, preferably but not necessarily of the same

profession as the individual requesting the hearing. A practitioner who is not

affiliated with the Hospital may be appointed to fill this position, if necessary.

3. No person will be disqualified from serving on the Committee because of prior

knowledge regarding the facts.

4. One of the members of the Committee will, at the time of appointment, be

designated Chair of the Committee by the President/CEO, or Chief Medical

Officer, and will be provided with a list of witnesses who are, at that time,

expected to testify at the hearing in support of the action or recommendation.

5. If the hearing is based on action by the Board, rather than action by the Medical

Staff Executive Committee, one member of the Hearing Committee may be a

member of the Board or another non-practitioner.

B. Hearing Officer: The President/CEO, the Chief Medical Officer, or the President of

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the Medical Staff may appoint a hearing officer, as fact finder, in lieu of an arbitrator

or the Hearing Committee described above. When so appointed, a hearing officer

shall have the same authority and responsibilities as an arbitrator or the Hearing

Committee, and shall follow, insofar as practical, the same procedure. Such a hearing

officer is to be distinguished from a “presiding officer” appointed to assist the

Hearing Committee.

C. Authority of Hearing Committee: The Hearing Committee (through its Chair or

presiding officer) shall have authority to:

1. Establish the time, place, manner and procedure for conducting the hearing,

consistent with these Bylaws.

2. Hold a preliminary meeting or pre-hearing conference with the parties for the

purpose of clarifying issues, establishing procedures, or otherwise aiding the

Committee.

3. Rule on the admissibility of the evidence and determine the weight to be accorded

to evidence which is admitted.

4. Request other members of the Medical Staff, other clinical practitioners with

privileges at the Hospital, or outside expert to examine questions within their

respective specialty or knowledge where a dispute exists between the position of

the affected practitioner and the Medical Staff Executive Committee, and report to

the Hearing Committee their opinions and basis for these opinions.

5. Conduct a hearing, consider and receive evidence, and deliberate and reach a

determination in the form of a formal recommendation.

6. Direct the attendance and participation of witnesses and the submission and

introduction of documentary evidence, whether or not offered by the Medical

Staff Executive Committee of the affected practitioner.

7. Take such other action that will facilitate its business.

D. Decision of Committee: The decision of the Hearing Committee shall be the final

action or recommendation submitted to the Board. Upon reaching a decision, the

Committee must reduce it in writing setting forth the recommendation or action and

the grounds upon which it is based. A quorum consists of not less than one-half (1/2)

of the Committee members. There may be no voting by proxy.

10.7 HEARING PROCESS

A. Notice of Time and Place of Hearing: Upon receipt of a request for hearing, the

President/CEO, or Chief Medical Officer, shall deliver such request to the President

of the Medical Staff or to the Board of the Hospital, depending on whose

recommendation or action prompted the request for a hearing.

1. The President/CEO, or Chief Medical Officer, shall promptly schedule and

arrange for a hearing.

2. The hearing date should not be more than forty-five (45) days, but at least thirty

(30) days, unless waived from the date of receipt of the request for a hearing.

3. A hearing for a practitioner who is under suspension then in effect shall be held

within ten (10) days of receipt of the request, unless waived.

B. Statement of Acts/Omissions: The notice of hearing shall contain a concise

statement of the practitioner’s alleged acts or omissions, a list by number of the

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specific patient records in question and other reasons or subject matter forming the

basis for the adverse recommendation or action which is the subject of the hearing.

C. Attendance: Failure without good cause of the affected practitioner who requested

the hearing to appear and proceed at the hearing will be deemed to constitute a

voluntary acceptance of the action or recommendation of the Credentials/Medical

Staff Executive Committee/Board. Failure without good cause of the Board or the

Credentials Committee/Medical Staff Executive Committee or its designee to appear

and proceed at such a hearing will be deemed to constitute a withdrawal of the

recommendation or action involved.

D. Representation: The practitioner may be accompanied and represented at the

hearing by anyone the practitioner chooses, so long as the person is identified in the

practitioner’s request for hearing.

E. Rights of Parties:

1. During a hearing, each party may:

a) Call and examine witnesses

b) Introduce exhibits relevant to the issues

c) Cross-examine any witness or any matter relevant to the issues

d) Impeach any witness

e) Rebut any evidence

2. If the practitioner does not testify on his/her own behalf, the practitioner may be

called and examined as if under cross-examination. Neither party has the power

of subpoena.

F. Chair’s Role: The Chair or presiding officer will conduct the hearing.

1. The Chair shall be appointed by the President of the Medical Staff in consultation

with the Chief Medical Officer.

2. The Chair will act to ensure that all participants in the hearing have a reasonable

opportunity to be heard and to present oral and documentary evidence, and shall

generally maintain decorum.

3. He/she will determine the order of procedure during the hearing and will have the

authority, in his/her discretion and in accordance with the Bylaws, to make all

rulings on questions which relate to matters of procedure and admissibility of

evidence.

4. If a person other than the Chair acts as presiding officer, he/she may upon request

of the Hearing Committee participate in its deliberations as a consultant, but shall

not be entitled to vote on the decision of the Committee.

5. The Chair and all other members of the Committee shall vote.

G. Procedure:

1. The hearing need not be conducted according to rules of law relating to the

examination of witnesses or presentation of evidence.

2. Any relevant matter upon which responsible persons customarily rely in the

conduct of serious affairs shall be admitted, regardless of the admissibility of such

evidence in a court of law.

3. Each party shall, prior to or during the hearing, be entitled to submit memoranda

concerning any issue of law or fact and such memoranda shall become a part of

the hearing record.

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4. The presiding officer may, but shall not be required to, order that oral evidence be

taken, only after an oath or affirmation.

H. The Committee shall be entitled to consider any pertinent material contained on file

in the Hospital and all other information which can be considered in connection with

applications for appointment or reappointment to the Medical Staff and request for

clinical privileges.

I. Evidence: No evidence, testimony, or documentation shall be considered by the

Committee which has not been received as evidence or accepted by the Committee on

the basis of judicial notice of the fact at a meeting at which both sides have been

present. The decision of the Committee shall be based upon the evidence.

J. Burden of Proof: The body (Medical Staff Executive Committee, or Board of the

Hospital) whose adverse recommendations or action occasioned the hearing shall

have the initial obligation to present evidence in support thereof. The practitioner

shall thereafter be responsible for supporting, by preponderance of evidence, a

challenge that the adverse recommendation or action lacks any substantial factual

basis, or that the basis or conclusions drawn there from are either arbitrary,

unreasonable or capricious.

K. Cross-examination and Rebuttal: No testimony shall be offered or submitted to the

Committee by the practitioner or by individuals called upon for information by the

Committee itself without both the affected practitioner and the Medical Staff

Executive Committee having the opportunity to be present, to question the witnesses,

to respond and to rebut the evidence.

L. Committee Members: Members of the Hearing Committee are actively encouraged

to take a participatory role in the proceedings, to question witnesses, to call upon

witnesses for information within their knowledge, to direct the submission of

additional evidence and documentation, to question the Medical Staff Executive

Committee and the affected practitioner and to see that the record contains all the

information which the Committee considers necessary in order to reach a decision.

M. Record:

1. A record of the hearing must be kept that is of sufficient accuracy to permit an

informed and valid judgment to be made by any group that may later be called

upon to review the record and render a recommendation or decision in the matter.

2. The recording of the hearing should be performed by a court reporter.

3. The Committee may order that oral evidence be taken only on oath or affirmation

administered by an individual designated by the Committee who is entitled to

administer such oaths in this state.

4. The list of witnesses, exhibits, and closing written statements shall be included in

the final document.

5. The practitioner shall be entitled to a copy of the record upon payment of any

reasonable charges associated with the preparation thereof.

N. Written Statement: Both parties may submit written statements at the conclusion of

the hearing, within time limits established by the Committee. Such statements shall

not constitute evidence.

O. Postponement: Requests for postponement of a hearing may be granted by the

Hearing Committee only upon a showing of good cause and only if the request is

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made as soon as reasonably practical.

P. Recess: The Hearing Committee may recess the hearing and reconvene the same

without additional notice for the convenience of the participants or for the purpose of

obtaining new or additional evidence or consultation.

Q. Presence of Hearing Committee Member and Vote: A majority of the Hearing

Committee must be present throughout the hearing and deliberations. A quorum

consists of not less than one-half (1/2) of the Committee members. If a Committee

member has not attended all of the proceedings, the Chair will determine his/her

eligibility to deliberate and vote. The transcripts, tape recording or video recording

shall be made available to the member for review before the deliberation and vote.

R. Deliberation: Upon conclusion of the presentation or oral and written evidence,

memoranda, and proposed findings, the hearing shall be closed. The Hearing

Committee may thereupon, at a time convenient to itself, conduct its deliberations in

private session and outside the presence of the individual who requested the hearing.

At any time prior to rendering its decision, the Committee may in its discretion, upon

fair notice to each party, reconvene the hearing and hear additional evidence or

argument.

10.8 HEARING COMMITTEE REPORT

A. Written Report: Within fifteen (15) days after final adjournment of the hearing, the

Hearing Committee shall make a written report of its findings and recommendations

with specific reference with the hearing record and all documentation considered, and

forward the report, along with the record and other documentation to the President of

the Medical Staff, the Chief Medical Officer, the Hospital President/CEO, and the

Medical Staff Executive Committee.

B. Action on Report: Within ten (10) days after receipt of the report, the Medical Staff

Executive Committee, shall consider the same and affirm, modify or reverse the

Hearing Committee’s recommendation or action in the matter. It shall transmit the

result, together with the hearing report, the report of the Hearing Committee and all

other documentation considered to the President/CEO, and Chief Medical Officer,

who shall transmit it to the Board in a timely manner at its next meeting.

C. Notice of Result: The President/CEO, or Chief Medical Officer, shall promptly send

a copy of the written report to the practitioner by special notice, to the President of

the Medical Staff, and to the Board.

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10.9 EFFECT OF FAVORABLE RESULTS

A. Credentials/Medical Staff Executive Committee: If the result is favorable to the

practitioner, the President/CEO, or Chief Medical Officer, shall promptly forward it

with all supporting documentation to the Board for its final action.

B. Adopted by the Board of Directors of the Hospital: If the Board’s result is

favorable to the practitioner, such results shall become the final decision of the Board

and the matter shall be closed.

C. The Board: The Board shall take action thereon by adopting or rejecting the

Credentials/Medical Staff Executive Committee’s results in whole or in part, or by

referring the matter back to the Committee for further reconsideration.

1. Any such referral back shall state the reasons therefore, set a time limit within

which a subsequent recommendation to the Board must be made, and may include

a directive that an additional hearing be held. Upon subsequent recommendation

and any new evidence in the matter, the Board shall take final action.

D. The President/CEO or Chief Medical Officer: Shall promptly send the practitioner

special notice informing him/her of each action taken.

10.10 EFFECT OF ADVERSE RESULT

If the result of the Medical Staff Executive Committee or of the Board of the Hospital continues

to be adverse to the practitioner, the special notice shall inform the practitioner of a right to

request an appellate review by the Board of the Hospital and request information as provided in

this plan.

10.11 APPELLATE REVIEW

A. Request: A practitioner shall have fifteen (15) days following receipt of a notice to

file a written request for an appellate review. Such request shall be delivered to the

President/CEO or Chief Medical Officer either in person or by certified mail and may

include a request for a copy of the report and record of the Hearing Committee and all

other material, favorable or unfavorable, which was considered in making the adverse

action or result.

B. Wavier by Failure to Request: A practitioner who fails to request an appellate

review within the time and in the manner specified waives any right to such review.

Such waiver shall have the same force and effect as that provided in Section 2.

C. Notice of Time and Place for Appellate Review: Upon receipt of a timely request

for appellate review, the President/CEO or Chief Medical Officer shall deliver such

request to the Board.

1. The Board shall schedule and arrange for an appellate review which shall not be

less than ten (10) days from the date of receipt of request. An appellate review

for a practitioner who is under a suspension then in effect shall be held as soon as

the arrangements for it may be reasonably made, but not later than twenty-one

(21) days after the request was received.

2. The President/CEO or Chief Medical Officer shall send the practitioner special

notice of the date, time, and place of the review. The time may be extended by

the appellate review body for good cause.

D. Appellate Review Body: The Board shall determine whether the appellate review

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shall be conducted by the Board as a whole, or by an Appellate Review Committee of

three (3) members of the Board, appointed by the Chair of the Board. If a Committee

is appointed, one of its members shall be designated as Chair.

10.12 APPELLATE REVIEW PROCEDURE

A. Nature of Proceedings: The proceedings by the review body are a review based

solely upon the hearing record, the Hearing Committee’s report, all subsequent results

and action, the written statements, if any, provided below and any other material that

may be presented and accepted.

B. Written Statements:

1. The practitioner seeking review shall submit a written statement detailing the

findings of fact, conclusions, and procedural matters with which he/she disagrees

and the reasons for such disagreement. The statement may cover any matter

raised at any step in the hearing process.

2. The statement shall be submitted to the appellate review body, through the

President/CEO or Chief Medical Officer at least five (5) days prior to the

scheduled date of the appellate review, except if the time limit is waived by the

review body.

3. A similar written statement may be submitted by the group whose adverse action

occasioned the review, and if submitted, the President/CEO or Chief Medical

Officer shall provide a copy thereof to the practitioner at least two (2) days prior

to the scheduled date of the review.

C. Presiding Officer: The Chair of the appellate review body shall be the presiding

officer and shall determine the order of procedure during the review, make all

required rulings and maintain decorum.

D. Oral Statement: The appellate review body, in its sole discretion, may allow the

parties or their representatives to personally appear and make oral statements in favor

of their positions. Any party or representative so appearing shall be required to

answer questions put by a member of the appellate review body.

E. Consideration of New or Additional Matters: New or additional matters or

evidence not raised or presented during the original hearing or in the hearing report

and not otherwise reflected in the record may be introduced at the appellate review

only in the discretion of the appellate review body and as the appellate review body

deems appropriate, only if the party requesting consideration of the matter or

evidence shows that it could not have been discovered in time for the initial hearing.

The requesting party shall provide, through the President/CEO or Chief Medical

Officer, a written substantive description of the matter or evidence to the appellate

review body and the other party at least three days prior to the scheduled date of the

review.

F. Recesses and Adjournment:

1. The appellate review body may recess and reconvene the proceedings without

additional notice for the convenience of the participants or for the purpose of

obtaining new or additional evidence or consultation.

2. Upon the conclusion of oral statements, if allowed, the proceedings shall be

closed.

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3. The review body shall then, at a time convenient to itself, conduct its deliberation

outside the presence of the parties.

4. Upon the conclusion of the deliberations, the appellate review shall be declared

adjourned.

G. Action Taken:

1. The appellate review body may affirm, modify or reverse the adverse result or

action taken by the Medical Staff Executive Committee or by the Board.

2. In its discretion, the body may refer the matter back to the Hearing Committee for

further review and recommendation. The matter shall be returned to the appellate

review body within twenty-one (21) days with a recommendation in accordance

with its instructions.

3. Within ten (10) days after receipt of such recommendations after referral, the

Board shall make its final decision.

10.13 FINAL DECISION OF THE BOARD

A. Within fifteen (15) days after the conclusion of the appellate review, the Board shall

render its final decision in the matter in writing.

B. The notices shall be sent to the practitioner by special notice, to the President of the

Medical Staff and to the Medical Staff Executive Committee.

C. If this decision is in accord with the Medical Staff Executive Committee’s last

recommendation in the matter, it shall be immediately effective and final.

D. If the Board’s action has the effect of changing the Medical Staff Executive

Committee’s last recommendation, the Board may refer the matter to a Joint

Committee.

E. The Joint Committee Review: Within ten (10) days of its receipt of the matter

referred to it under this plan, a Joint Committee shall convene to consider the matter

and shall submit its recommendations to the Board. The Joint Committee shall be

composed of a total of seven members selected in the following manner:

Three (3) Board members, appointed by the Chair of the Board

Four (4) Medical Staff appointees, appointed by the President of the Medical

Staff, in consultation with Chief Medical Officer

F. The Board’s action on the matter following receipt of the Joint Committee’s report

shall be immediately effective and final.

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10.14 GENERAL PROVISIONS

A. Hearing Officer Appointment and Duties: The use of a hearing officer to preside at

the evidentiary hearing is optional and is to be determined by the President of the

Medical Staff, in consultation with the Chief Medical Officer, and the Hospital

President/CEO. A hearing officer may or may not be an attorney at law but must

have experience in conducting hearings.

B. Representatives: The practitioner is responsible for the payment of any fees or

expenses incurred for the practitioner’s representatives.

C. Number of Hearings and Reviews: Notwithstanding any other provision of the

Medical Staff Bylaws or of this plan, no practitioner is entitled to request more than

one (1) hearing and appellate review with respect to the subject matter that is the

basis of the adverse recommendation or action triggering the right.

D. Release: By requesting a hearing or appellate review under this Plan, a practitioner

agrees to be bound by the provisions of the Medical Staff Bylaws and supporting

policies or manuals relating to immunity from liability.

10.15 AMENDMENT

A. Amendment: This Fair Hearing Plan may be amended, repealed, in whole, or in

part, when deemed necessary by the Medical Staff Executive Committee, submitted

to the general Active membership and recommended to and adopted by the Board,

subject always to the Bylaws of the respective bodies.

1. The revisions shall be submitted to the Medical Staff Executive Committee

members at least ten (10) days prior to the meeting for review. Approval requires

an acceptance by a 2/3 vote of the membership. An absent member may submit

his/her vote prior to the meeting.

2. After approval by the Medical Staff Executive Committee, it shall be submitted to

the General membership who has Active privileges. Approval requires a majority

vote. An absent member may submit his/her vote prior to the meeting.

B. Restriction of Amendment: The Fair Hearing Plan should not be amended when an

adverse action is being processed. Amendment should only occur after a final

decision is reached.

ARTICLE XI

CONFIDENTIALITY, IMMUNITY AND RELEASES

11.1 AUTHORIZATIONS AND CONDITIONS

By applying for or exercising Medical Staff privileges, a Practitioner:

A. Authorizes representatives of the Hospital and the Medical Staff to obtain, review and

act upon information relating to the Practitioner’s professional status.

B. Agrees to all the provisions of these Bylaws, Hospital Bylaws, Medical Staff

Credentialing Manual and Medical Staff Policies.

C. Authorizes representatives of the Hospital and the Medical Staff to query the National

Practitioner Data Bank at the time of initial appointment and reappointment and

acknowledges that this query runs continuously and the National Practitioner Data

21

Bank sends alerts for practitioners associated with Hospital.

D. Waives legal claims against any representative acting in accordance with this Article.

E. Accepts the provisions of this Article as conditions to the application for clinical

privileges in this Hospital.

F. Agrees to comply with all federal and state regulations.

11.2 CONFIDENTIALITY

A. Information relating to the professional or personal qualifications of any Medical

Staff member, Allied Health Personnel, or applicants for Medical Staff membership

and applicants for approval as Allied Health Personnel shall be confidential to the

fullest extent permitted by law. Such information may be communicated to other

professional or review boards as required by law but shall not become a part of the

Medical Staff file.

B. Any breach of confidentiality of the discussions or deliberations of Medical Staff

Service areas or Committees, except in conjunction with other hospitals, professional

society or licensing authority is outside the appropriate standards of conduct for this

Medical Staff and will be deemed disruptive to the operations of the Hospital. If

determined that a breach occurred, the Medical Executive Committee shall undertake

corrective action as it deems appropriate.

11.3 IMMUNITY FROM LIABILITY

A. No person shall be liable to an Applicant or Member for damages or other relief for

providing in-good-faith information concerning that Applicant or Member to any

representative of this Hospital or its Medical Staff in the process of determining

qualifications for practice within the Hospital.

B. No person representing the Hospital or Medical Staff shall be liable to any Applicant

or Member for damages or other relief for any action taken or statements made while

exercising these duties in good faith in considering the qualifications of an applicant

or Medical Staff member or for otherwise carrying out the functions designated in

these Bylaws.

11.4 ACTIVITIES AND INFORMATION COVERED

11.4.1 ACTIVITIES AND INFORMATION

The confidentiality and immunity provided by this Article shall apply to all information and acts

associated with:

A. Applications for appointment, privileges and specified services.

B. Reappraisals and reappointment proceedings.

C. Corrective actions, hearings and appellate reviews.

D. Patient care audits, utilization reviews, peer reviews and other Hospital or Medical

Staff activities relating to monitoring and improving professional conduct in the

Hospital.

11.4.2 RELEASES

By submitting an application for appointment or reappointment to the Medical Staff, each

22

applicant thereby grants release from liability under these Articles and Bylaws to all

representatives of the Medical Staff and Hospital who shall in good faith and without malice

carry out their designated duties as they relate to the applicant.

11.4.3 CUMULATIVE EFFECT

Provisions of these Bylaws relating to confidentiality, authorizations and immunity from liability

shall be in addition to other protections provided by law. In the event of conflict, applicable law

shall be controlling.

ARTICLE XII

OFFICERS

12.1 OFFICERS

The officers of the Medical Staff shall be the President, Immediate Past President, and President-

elect. The latter shall be elected by mailed ballot or at a meeting of the Medical Staff and shall

hold office from the beginning of the Medical Staff year, which is the calendar year. All officers

shall serve a two (2) year term or until successors are elected. Officers may not succeed

themselves in office, nor may the President be elected to the office of President- Elect until at

least four (4) years after his/her term as President of the Medical Staff has expired. In the event a

candidate does not get a majority of the votes cast, there shall be a runoff between the two (2)

candidates with the most votes.

12.1.1 QUALIFICATIONS

Each officer must be an Active member of the Medical Staff, as defined in Policy, at the time of

the nomination and election and during the term of office. The officer shall be qualified,

experienced and demonstrate an ability for an administrative position. The officer shall not hold

an office in this organization, in any other medical staff organization, or another organization

which could create, or be interpreted as having a conflict of interest.

12.1.2 NOMINATION AND ELECTION OF OFFICERS

A. The Credentials Committee shall act as the Nominations Committee.

B. Refer to the Medical Staff Policy regarding Nomination and Election of Officers.

C. An announcement shall be made to the general membership after the Medical Staff

Executive Committee accepts the election results.

12.2 PRESIDENT OF THE MEDICAL STAFF

The President of the Medical Staff has the authority and duty to:

A. Act in coordination with the President/CEO and Chief Medical Officer of the

Hospital in all matters of mutual concern, including quality of patient care within the

Hospital.

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B. Call and preside at the Medical Staff Executive Committee meetings.

C. Preside at the all-general meetings of the Medical Staff.

D. Serve as an ex-officio member of all Medical Staff Committees.

E. Serve as a member of the Board and receive and interpret the policies of the Board to

the Medical Staff and report to the Board on the performance and maintenance of the

quality of medical care, as authorized under the laws of the State of Iowa.

F. Be responsible for the enforcement of the Medical Staff Bylaws, Credentials Manual

and Medical Staff policies for implementation of sanctions when these are indicated.

G. Appoint service line leaders/medical directors and members, in consultation with the

Chief Medical Officer, to all standing, special, multi-disciplinary Medical Staff

Committees, other than those members designated by these Bylaws.

H. Represent the views, policy needs and grievances of the Medical Staff to the

President/CEO or Chief Medical Officer of the Hospital and to the Board.

I. Be the spokesperson for the Medical Staff in its external professional and public

relations.

J. Vote in the advent of a tie at the Medical Staff Executive Committee.

12.3 PRESIDENT-ELECT

A. In the absence of the President of the Medical Staff, the President- Elect shall assume

all duties and have authority of the President of the Medical Staff (except for the

President’s ex-officio duties).

B. Shall be a voting member of the Medical Staff Executive Committee.

C. Shall automatically succeed the President of the Medical Staff when the latter fails to

serve for any reason.

D. Is a member of Credentials Committee.

E. Chair the Performance Improvement Committee.

12.4 CREDENTIALS CHAIR

A. Chair the Credentials Committee.

B. Call and preside at the Credentials Committee meetings.

C. Annual review of the Medical Staff Credentials Manual.

D. Annual review of the Delineation of Privileges by Category.

E. In the absence of the President and President-Elect, chair the Medical Staff Executive

Committee meeting.

F. Shall be a voting member of the Medical Staff Executive Committee.

12.5 VACANCIES AND REMOVAL OF OFFICERS

12.5.1 VACANCIES

A. If there is a vacancy in the Office of President, the President- Elect shall serve the

remaining term. If the term which the President- Elect shall serve as President is less

than six months, he/she may succeed himself/herself in office.

B. The recently vacated President –Elect office shall be filled by a new President –Elect

by election, as soon as possible. The election shall follow normal election procedures.

C. The Credentials Committee will present nominations to the Active Medical Staff

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membership at the next regular Medical Staff meeting. Other nominations may be

made from the floor by any member of the Medical Staff.

D. The election will be held according to normal election procedures as listed above.

E. A vacancy of the President-Elect shall be filled by a general election as described

above.

F. If vacancies occur not listed above, the Medical Staff Executive Committee shall

decide the proper procedure for filling the vacancy.

12.5.2 REMOVAL OF OFFICERS

A. An officer may, at any time, resign from his/her office, which shall be accepted by the

President of the Medical Staff and the Medical Staff Executive Committee.

B. A proposal for removal of an officer of the Medical Staff, or a member of the Medical

Staff Executive Committee may be submitted for the following reasons:

1. A pattern of disruptive or unprofessional conduct

2. Physical or mental impairment

3. Loss, suspension, or sanctions levied by the Iowa Board of Medical Examiners

4. Loss of Hospital privileges due to performance

5. Failure to fulfill responsibilities of the office

C. Actions:

1. Any member of the Medical Staff or the Hospital President/CEO may submit a

written proposal to the Credentials Committee for investigation and consideration

of removal from office.

2. The Credentials Committee Chair will direct an investigation of the allegations,

with a report submitted to the Credentials Committee.

3. When the allegations appear to be valid, the Chair of the Committee will

recommend a discussion of the findings and the member will be provided a

chance to respond to the allegations presented.

4. After the Credentials Committee determines that the allegations warrant removal

from office, the recommendation will be submitted to the Medical Staff Executive

Committee for a secret ballot vote. The physician involved will be provided

ample time to make a presentation.

5. When the secret ballot vote confirms the removal action, a secret ballot vote of

the General Medical Staff will be taken at any regular or special called meeting,

provided the member involved has been informed at least forty-eight (48) hours

before the meeting and is given at least fifteen (15) minutes at the meeting to

make a presentation. The vote must be two-thirds (2/3) of the members present in

favor of the removal.

6. Inasmuch as no practice privileges are involved, no appeal will be allowed.

12.5.3 INDEMNIFICATION OF OFFICERS

Officers, elected and appointed (service line leaders/medical directors), including all members of

the Medical Staff Executive Committee are indemnified by Hospital for actions within the scope

of their duties.

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ARTICLE XIII

COMMITTEES

13.1 STANDING AND SPECIAL COMMITTEES

All Committees shall be appointed by the President of the Medical Staff in consultation with the

Chief Medical Officer. The President/CEO or delegate shall be an ad hoc member of all

committees without a vote.

Standing Committees shall be: Medical Executive Committee, Credentials Committee,

Performance Improvement Committee, Dyad/Service Lines, Trauma Committee, and the Peer

Review Committee.

Special Committees shall be appointed as required by the President of the Medical Staff, in

consultation with the Chief Medical Officer, to carry out the duties of the Medical Staff. The

President shall indicate the composition and function of such committees which shall confine

their work to the purpose for which they were appointed and shall have no power of action

unless such is specifically granted by the Medical Executive Committee. Special Committees

shall be disbanded upon completion of its duties.

The presence of resource personnel (Hospital Staff) other than members of the Medical Staff

may be requested by the President, the Chief Medical Officer, or by the committee at various

committee meetings. Such resource personnel shall be nonvoting. A meeting may be face to

face, conference call or e-mail/mail ballot.

13.2 THE MEDICAL EXECUTIVE COMMITTEE

13.2.1 OFFICERS

A. President of the Medical Staff, who shall be the Chair of the Committee

B. President –Elect

C. Credentials Chair

13.2.2 MEMBERSHIP

Acceptance of office in the Medical Staff and the Medical Staff Executive Committee

shall constitute an acknowledgement that the member has read and understood the current

Bylaws.

13.2.3 MEDICAL STAFF REPRESENTATION

A. Representatives to the Medical Staff Executive Committee shall be Active Medical

Staff members in good standing, appointed by the President of the Medical Staff in

consultation with the Chief Medical Officer.

B. By virtue of their positions, the following physicians shall be voting members of the

Medical Staff Executive Committee:

1. Program Director of the Family Practice Residency Program

2. Chair and Medical Director of the Trauma Services

3. Service line/medical director leaders

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4. Other Members at the discretion of the President of the Medical Staff in

consultation with the Chief Medical Officer

C. The Chair of the Board, President/CEO of the Hospital, Chief Operating Officer,

Chief Medical Officer, Patient Safety Officer, Vice President of Patient Care/CNE,

Chief Medical Information Officer (CMIO), and the Performance Improvement

Director are ex-officio members without a vote.

13.2.4 FUNCTIONS

A. Represent and act on behalf of the Medical Staff, subject to such limitations as may

be imposed by the Medical Staff Bylaws.

B. Receive and act upon reports from the Medical Staff Committees, service lines and

assigned activity groups.

C. Coordinate the activities and general policies of the service lines and committees of

the Medical Staff.

D. Make necessary changes or approve recommendations from Clinical Service areas/

committees to the Medical Staff policies, Credentials Manual and other Medical Staff

documents.

E. Implement policies of the Medical Staff.

F. Provide liaison between the Medical Staff, the Hospital President/CEO, the Chief

Medical Officer, and the Board.

G. Fulfill Medical Staff accountability under the laws of the State of Iowa for medical

care rendered to patients within Hospital.

H. Review ethical and competent clinical performance on the part of the Medical Staff

and take appropriate action.

I. Make recommendations on hospital management matters to the Hospital

President/CEO, the Chief Medical Officer, and the Board and make recommendations

to the Board concerning:

1. The structure of the Medical Staff.

2. The mechanism used to review credentials and to delineate individual clinical

privileges.

3. The organization of the performance improvement activities of the Medical Staff,

as well as the mechanism used to conduct, evaluate and revise such activities.

4. The mechanism by which membership on the Medical Staff may be terminated.

5. The mechanism for fair-hearing procedures.

J. Provide for the preparation involved in meeting educational programs, either directly,

or through delegation to a program committee or other suitable committee.

K. Ensure that the Medical Staff is kept abreast of requirements of accreditation

programs, either directly or through delegation to committees.

L. Review and modify any acts of the Medical Staff committees, including

recommendations of the Credentials Committee as it concerns appointment,

reappointment and clinical privilege delineation of Medical Staff members.

13.2.5 ACTIONS

Any action of the Medical Staff Executive Committee may be amended or vetoed by the Medical

Staff at any annual or special called meeting by a majority vote of the Active Medical Staff

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Members in attendance. The President, in consultation with the Chief Medical Officer, shall

determine whether it shall be a voice or paper vote.

13.2.6 MEETINGS

A. The frequency of meetings shall be established by the committee.

B. A quorum of the Medical Staff Executive Committee shall be those members present,

but not less than two (2) voting members. A quorum is required for voting/approving

any issues.

C. In the event a change in date or time or a special meeting is required, the decision

shall be that of the President of the Medical Staff in consultation with the Chief

Medical Officer.

13.2.7 MINUTES

A. A permanent record of the Committee’s proceedings and actions shall be maintained.

Minutes shall be prepared of each meeting and shall include a record of attendance

and absence of members and the results of any vote taken on each matter.

B. Corrections and/or revisions to the finalized minutes shall be made by an additional

dated entry at the end of the minutes.

C. Minutes shall be retained in their original or electronic format as required by the Iowa

Health System dba UnityPoint Health document retention policy.

D. Minutes shall be maintained by the Manager of the Medical Staff Office.

E. Minutes may be requested for review by any member of the Medical Staff.

13.3 CREDENTIALS COMMITTEE

13.3.1 MEMBERSHIP

A. The Chair shall be the Immediate Past President.

B. The President, President-Elect, and the Chief Medical Officer.

C. Six other members, who may be past-presidents who are still Active members,

Clinical Service representatives or members as appointed by the President of the

Medical Staff, in consultation with the Chief Medical Officer, or at the discretion of

the Committee.

D. Service Line Leaders/Medical Directors act as ad hoc members as needed or

applicable based on topic.

E. The Hospital President/CEO, a Board member and Performance Improvement

Director are non-voting members.

F. The Program Manager of the Medical Staff Office shall record the minutes and

provide information as requested.

13.3.2 FUNCTIONS

A. Appointment, re-appointment and approval of requested privileges of medical staff

members, and allied health professionals functioning in the Hospital.

B. Receive referrals from Medical Staff service lines, Committees, or Chairs to evaluate

and investigate quality of care concerns provided by practitioners who are granted

clinical privileges.

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C. Approve and assist in management of the Credentials Manual.

13.3.3 MEETINGS

The frequency of meetings shall be established by the committee.

13.3.4 REPORTS Recommendations for appointment/reappointment are submitted to the Medical Executive

Committee, then to the Board via the Medical Executive Committee minutes and Credentials

report.

13.4 PERFORMANCE IMPROVEMENT COMMITTEE

13.4.1 CHAIR

President-Elect

13.4.2 MEMBERSHIP

Representatives from the clinical service areas, Chief Medical Information Officer, Board

Designee(s), and the Chief Medical Officer.

13.4.3 FUNCTIONS

This committee oversees the quality and performance improvement operations of Hospital. The

Performance Improvement Committee shall have the responsibility of keeping the Board, the

Medical Staff, and the President/CEO aware of the pertinent actions taken or contemplated as a

result of Committee activity. Further, the Performance Improvement Committee shall review

reports from all patient care departments concerning the quality of services provided therein. The

Performance Improvement Committee shall provide a continuous liaison between the Board, the

President/CEO and the Medical Staff and recommend solutions for problems which may arise in

the orderly conduct of the Hospital. The Committee shall consider, advise upon and make

recommendations to the Board and the Chair of the Board with respect to matters of policy

relating to the medical care mission of the Hospital.

The Performance Improvement Committee also shall establish and maintain, with the advice and

assistance of Hospital Administration, quality assessment, quality improvement and risk

management programs that monitor, evaluate and implement opportunities for improvement in

the delivery of optimal patient care. The Performance Improvement Committee shall also

review, as appropriate, the cost of care as it relates to the new care modalities, quality of care

issues, and evaluation of patient care provided.

13.4.4 MEETINGS

The committee shall meet every other month, but no less than four (4) times per year and

coordinated by the Performance Improvement Director.

13.4.5 MINUTES

Are submitted to the Medical Executive Committee and the Board.

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13.4.6 REPORTS

The service line actions and recommendations will be reported back to the Performance

Improvement Committee.

13.5 TRAUMA SERVICES COMMITTEE

13.5.1 CHAIR

Trauma Services Director

13.5.2 MEMBERSHIP

Physician specialties involved in trauma management, hospital representatives and pre-hospital

professionals who participate in trauma care.

13.5.3 FUNCTIONS

Oversees and reviews the care provided to trauma patients. Makes recommendations for

education related to care of the trauma patient.

13.5.4 MEETINGS

Held at least quarterly to review trauma care, protocols and make recommendations for

educational programs. Additional educational case presentation meetings may be held.

Coordinated by the Trauma Services Coordinator. Information regarding the Trauma service is

located in the Medical Staff Policies for the Trauma Service.

13.5.5 MINUTES

Are submitted to the Medical Executive Committee.

13.5.6 REPORTS

Are presented to the applicable Medical Staff service lines.

13.6 DYAD/SERVICE LINES COMMITTEE

16.6.1 CHAIR

Operations Dyad/Chief Medical Officer

13.6.2 MEMBERSHIP

Physicians identified in the Dyad Leadership Structure as Medical Directors.

13.6.3 FUNCTIONS

Operationalize the strategy developed by the organization. Functional arm to implement

structure.

13.6.4 MEETINGS

Leadership typically meets monthly.

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13.6.5 MINUTES

Are submitted to the Medical Executive Committee.

13.6.6 REPORTS

There will be formal reports in addition to minutes.

13.7 PEER REVIEW COMMITTEE

13.7.1 CHAIR

President of the Medical Staff

13.7.2 MEMBERSHIP

The membership of this committee will be defined by policy.

13.7.3 FUNCTIONS

The functions of this committee will be defined by policy.

13.7.4 MEETINGS

Ad Hoc

13.7.5 MINUTES

Are submitted to the Credential Committees or Medical Executive Committee as appropriate

based on the outcome of the meeting.

13.7.6 REPORTS

Reports will be defined by policy.

ARTICLE XIV

MEDICAL STAFF MEETINGS

Members of the Medical Staff are encouraged to attend local and joint educational meetings.

14.1 MEETINGS

A. The President of the Medical Staff, the Chief Medical Officer, the Medical Staff

Executive Committee or the Board may call a meeting with seven (7) days written

notice.

B. Ten percent (10%) of the members of the Active Medical Staff may request a

meeting, by presenting a written request to the President of the Medical Staff. A

meeting shall be called within fourteen (14) days of receipt of the request.

C. Written or printed notice stating the place, day and hour of any meeting shall be

delivered either personally or by mail to each member of the Active Staff, not less

than seven (7), nor more than ten (10) days before the date of such meeting, by or at

the direction of the President of the Medical Staff in consultation with the Chief

Medical Officer. The attendance of a member of the Medical Staff at a meeting shall

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constitute a waiver of such notice.

14.2 SPECIAL MEETING WITH BOARD

The President of the Medical Staff may call for a special meeting of the Board by requesting

such meeting from the Chair of the Board, who will call a special meeting according to the

Hospital Bylaws.

14.3 CLOSED MEETINGS

The President of the Medical Staff may declare a meeting to be closed to all, except Active

Medical Staff members and the President/CEO of the Hospital or the President/CEO’s designee

and require all others to leave forthwith.

If circumstances dictate, the President or Chief Medical Officer may close the meeting to Active

Medical staff members only. The action to close a meeting may also be taken by vote of

majority of the voting members in response to a motion by a member of the Active Staff.

14.4 QUORUM

Those Active Medical Staff members present at any regular or special Medical Staff meeting

shall constitute a quorum.

ARTICLE XV

MEDICAL STAFF AND DEPARTMENTAL POLICIES

Medical Staff Bylaws and Policies must be compatible with each other.

The Medical Staff shall adopt Medical Staff and Department Policies as may be necessary for the

proper conduct of its work. Such Policies shall be a part of these Bylaws, except that they may

be amended by the following procedures.

Such amendments shall become effective when approved by the Board.

A. Policies: There are two methods by which Policies may be adopted or amended:

1. By the Medical Executive Committee:

The Medical Staff delegates authority to the Medical Executive Committee to adopt or

amend policies of the Medical Staff, provided however, that the Medical Staff also

retains independent authority to adopt or amend policies in accordance with paragraph

(2), immediately below. Policies may be adopted, amended, or repealed at any regular or

special meeting of the Medical Executive Committee, provided that notice of the

proposed adoption, amendments, additions or repeals are made available to members of

the Medical Executive Committee and general medical staff as part of the agenda

published no later than seven (7) days prior to the meeting, and that written comments on

the proposed changes are brought to the attention of the Medical Executive Committee

before the vote. Policies will be adopted, amended, or repealed by a majority of a quorum

at a meeting, or by a majority of the votes cast by ballot, and the adopted, amended or

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repealed provision shall be forwarded to the Board for action; or

2. By the Medical Staff:

Alternatively, the voting members of the Medical Staff may adopt and amend policies as

they deem appropriate by a majority of votes cast by the Active Medical Staff Members

eligible to vote who are present at any Medical Staff meeting called for such purposes, or

by a majority of the ballot votes cast by the Active Medical Staff Members eligible to

vote in a mail ballot, and may propose such policies and amendments thereto directly to

the Board. However, prior to presenting the policy or amendment to the Board, the voting

members of the Medical Staff must first communicate the proposal to the Medical

Executive Committee.

ARTICLE XVI

AMENDMENTS TO BYLAWS

These Bylaws and Fair Hearing Plan may be adopted, amended or repealed by the following

combined action:

The affirmative vote of at least two-thirds (2/3) of the active appointees in attendance at a regular

or special meeting at which a quorum of the active appointees, as defined in these Bylaws, is

present OR the return of mailed or electronic ballots. For all Bylaws amendments, a copy of the

proposed documents or amendments must be distributed to each staff appointee entitled to vote

thereon at least fourteen (14) days prior to the meeting OR with the mailed or electronic ballot.

A revision or amendment which has been passed by the Medical Staff membership, but not yet

considered by the Board, may be subject to motion to rescind, which will again bring the

proposal before the membership.

If the motion to rescind prevails, the revision/amendment will have been lost and the Medical

Staff Bylaws will remain as before.

If the motion to rescind loses, the revision/amendments will again be pending for consideration

by the Board.

Neither the organized Medical Staff nor the Board may unilaterally amend the Medical Staff

Bylaws.

The voting members of the Medical Staff have the ability to propose new bylaws and

amendments to bylaws directly to the Board.

ARTICLE XVII

ADOPTION

These Bylaws, together with the Medical Staff Policies and Credentials Manual, when adopted

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by the Active Staff, shall replace any previous Bylaws, and shall become effective when

approved by the Board and shall, when adopted and approved, be binding on the Board and the

Medical Staff.

The Medical Staff and governing body shall affect a review at least every two (2) years of the

Bylaws and Policies.

Approved with revisions by the Medical Staff Executive Committee on September 12, 2017

Approved with revisions by the Medical Staff on November 14, 2017.