��>� UW���HIJKLMV�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������m ��\bjbj�� I�dbdbq�������������&&&8^� �&(�|�#�#4$$$�$�$�$$�Z�j;�0�$�$�0�0;$$��6�6�6�0R$$�6�0�6�6&ç���$����@������'1RK�d0(�Py4*������ �$��(��6w+,�-2�$�$�$;;�5�$�$�$(��0�0�0�0���������������������������������������������������������������������$�$�$�$�$�$�$�$�$�B �: FLAGLER HOSPITAL MEDICAL STAFF BYLAWS PREAMBLE WHEREAS, Flagler Hospital, Inc. is a notforprofit corporation organized under the laws of the State of Florida; and WHEREAS, its purpose is to serve as a community hospital providing patient care; and WHEREAS, it is recognized that one of the aims and goals of the Medical Staff is to strive for quality patient care in the Hospital, and that while the Medical Staff must work with and is subject to the ultimate authority of the Board, that the cooperative efforts and oversight by the Medical Staff, administration and the Board are necessary to fulfill the Hospital's aims and goals in providing quality patient care to its patients; THEREFORE, these Bylaws are adopted in order to provide for the organization of the Medical Staff of Flagler Hospital and to provide a framework for Medical Staff self-government, subject to Board approval (with the understanding that such approval will not be unreasonably withheld) in order to permit the Medical Staff to discharge its responsibilities in matters involving the quality of medical care, and to govern the achievement of those purposes. These Bylaws provide the professional and legal structure for Organized Medical Staff operations, and Organized Medical Staff relations with the Board of Trustees. DEFINITIONS 1. BOARD OF TRUSTEES, BOARD or GOVERNING BODY means the governing body of the Hospital. 2. PRESIDENT means the chief officer of the Medical Staff elected by Members of the Medical Staff. 3. CEO means the CEO of Flagler Hospital. 4. CLINICAL PRIVILEGES or PRIVILEGES means authorization granted by the Board of Trustees to a Practitioner to provide services based on license, education, training, experience, competence, health status and judgment. 5. GOOD STANDING means any Practitioner who has not been the recipient of any: 1) suspension for any reason (excluding delinquent medical records); 2) involuntary reduction/restriction/revocation of membership, Privileges or reappointment; 3) letters of admonition, censure, reprimand, formal or informal warning, written or oral, as defined in Section 6.2-5(c) of these Bylaws; 4) final adverse or corrective action; 5)incident reports/public citations/reports that display a trend of disruptive or unethical or impaired behavior which warranted discussion at, and adverse action by, the Medical Executive Committee and/or Board of Trustees. 6. HOSPITAL means Flagler Hospital Inc. JOINT CONFERENCE COMMITTEE means a committee comprised of members of the Board and Members of the Medical Staff with the CEO of the Hospital, or his designee. 8. MEDICAL EXECUTIVE COMMITTEE (MEC) means the executive committee of the Medical Staff, which shall constitute the governing body of the Medical Staff as described in these Bylaws. 9. MEDICAL STAFF or STAFF means the formal organization of the Practitioners who are privileged to attend patients in the Hospital. 10. MEDICAL STAFF YEAR means the period from May 1 to April 30. 11. MEMBER means a Practitioner who is a Member of the Medical Staff. 12. PHYSICIAN means an individual with an M.D. or D.O. degree who is currently licensed to practice medicine. 13. PRACTITIONER means, unless otherwise expressly limited, any Physician licensed pursuant to Chapter 458 or 459, Florida Statutes, dentist licensed pursuant to Chapter 466, Florida Statutes, podiatrist licensed pursuant to Chapter 461, Florida Statutes or psychologist licensed pursuant to Chapter 490, Florida Statutes applying for or exercising Staff membership and/or Clinical Privileges in the Hospital. ARTICLE I. NAME 1.1 NAME OF ORGANIZATION The name of this organization is Medical Staff of Flagler Hospital�. ARTICLE II. MEMBERSHIP 2.1 NATURE OF MEMBERSHIP No Practitioner, including those in a medico-administrative position by virtue of a contract with the Hospital, shall admit or provide medical or health-related services to patients in the Hospital unless he or she has been granted Privileges (including temporary or emergency) in accordance with the procedures set forth in these Bylaws. 2.2 QUALIFICATIONS FOR MEMBERSHIP To qualify for Medical Staff membership, a Practitioner must hold an Active/unencumbered license to practice their profession in the State of Florida, and: For Physicians, hold an M.D. or D.O. degree issued by a medical or osteopathic school approved at the time of the issuance of such degree by the Florida Board of Medicine or the Board of Osteopathic Examiners of the State of Florida. (b) Document his/her experience, professional character, judgment, reputation, integrity, background, training, adherence to medical ethics, demonstrated professional competency, mental and emotional stability and health, with sufficient adequacy to demonstrate to the Medical Staff and the Board that patients will receive care of the generally professionally recognized level of quality and efficiency. (c) Items under (b) above be determined, on the basis of documented references from individuals who are familiar with the applicant's professional training and performance, to adhere strictly to the ethics of his/her respective profession, and applicants ability to work cooperatively with others, and to be willing to participate in the discharge of Staff responsibilities. (d) For Physicians providing direct patient care, hold an unrestricted valid Bureau of Narcotics and Dangerous Drugs/Drug Enforcement Agency ("BNDD/DEA") registration number. Exceptions may be granted on a case-by-case basis, as recommended by the MEC, for final approval by the Board of Trustees. (e) Be located within a sufficiently close distance to Flagler Hospital to provide continuous and timely care to his/her patients. (f) Meet the requirements of the Hospital's departments and sections to which the Practitioners are applying, as set forth in their respective rules and regulations. (See Exhibit B: Departmental Rules & Regulations.) (g) Be a graduate of an accredited medical, osteopathic, dental or podiatric school or accredited post-graduate psychology program. (h) Document that the applicant meets the current requirements set forth by the State of Florida for professional liability insurance coverage. (i) May request Privileges to provide services at the Hospital: for which the Hospital has adequate facilities, equipment and staffing; and for which there are no currently exclusive/preclusive arrangements with other Physicians or entities (unless the applicant is authorized to exercise such Privileges within such exclusive/preclusive arrangements). (See Exhibit C: List of such current arrangements.) (j) With respect to Physicians and Podiatrists who make an application for Staff membership and Clinical Privileges at the Hospital (other than an application for reappointment or reinstatement after a leave of absence) on or after May 16, 2002, the Physician must have Board Certification in their primary specialty or subspecialty by a Board recognized by the American Board of Medical Specialties, the American Osteopathic Association or the American Podiatric Medical Association ("Medical Specialty Board"); or, be admissible per the time frame defined by their applicable Medical Specialty Board and become Board Certified within five (5) years after obtaining membership to the Medical Staff. For Practitioners appointed on or after May 16, 2002, a Medical Staff Member may either maintain Board Certification in their practicing specialty area or complete 20 hours of AMA/PRA Category I CME or AOA Category 1 CME in their practicing specialty area every two years to be attested to during their reappointment. Failure to meet the basic qualification of the Medical Specialty Board eligibility or certification shall be considered as a deficiency in professional training, experience and demonstrated professional competency. A Physician qualifying for Staff membership under the provisions of this subsection who does not become Board Certified by a Medical Specialty Board within the time limits specified above will be removed from Staff membership and will forfeit all Clinical Privileges. Extension of time to become Board Certified (not to exceed two years) may be considered and granted by the Medical Executive Committee. The Board of Trustees may grant limited exemptions from the Board Certification and Board Admissibility requirements in this Section 2.2(i), which exemptions shall be reserved for extraordinary circumstances only. In granting such exemptions, the following procedures must be observed: (1) the Physician must submit a statement to the Board of Trustees explaining the extraordinary circumstances; (2) the Physician must include at least two letters of support from Flagler Hospital Active Staff Physicians (who are not members of their practice); (3) complete 20 Category 1 CMEs per year in their specialty; (4) the Board of Trustees must confirm with the Hospitals Medical Staff Services Department that the Physician has no previous or pending corrective actions, complaints, or other issues, and that the Physician is otherwise in good standing (5) the Board of Trustees must consult with the Medical Executive Committee, which shall review the sufficiency of the Physicians statement and letters of support. A Physician who no longer meets criteria for membership/privileges loses all Clinical Privileges under this provision and will not be entitled to exercise the rights granted under the hearing and appellate review provisions provided in these Bylaws and may reapply once the applicant has achieved Board Certification. (k) All new applicants for Membership will be either a U.S. Citizen, or possess the appropriate legal authorizations to work in the U.S., e.g., a valid Green Card, or an Unrestricted Work Authorization� permit form the INS. Telemedicine Practitioners, Locum Tenens Practitioners, Proctors and Allied Health Staff are not eligible for Membership unless an exception is granted by the Medical Executive Committee on a case-by-case basis. 2.3 EFFECT OF OTHER AFFILIATIONS No person shall be entitled to membership in the Medical Staff solely because that person holds a certain degree, is licensed to practice in this or in any other state, is a member of any professional organization, is certified by any clinical board, or because such person had, or presently has, staff membership or privileges at another health care facility. 2.4 NONDISCRIMINATION No aspect of Medical Staff membership or particular Clinical Privileges shall be denied on the basis of sex, race, age, creed, color, national origin or type of license. 2.5 ADMINISTRATIVE AND CONTRACT PRACTITIONERS 2.5-1 EXCLUSIVE CONTRACTORS Notwithstanding any other provision of these Bylaws, including the review, hearing, and appeal procedures, the Hospital may enter into an agreement with one or more Practitioners to provide for the services in the specialties of Pathology, Emergency Medicine, Anesthesiology, and Radiology on an exclusive or closed-Staff basis. Only approved and appropriately credentialed Practitioners are eligible to exercise the exclusive or closed-Staff Privileges in the Hospital. 2.6 BASIC RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP Except for the Honorary and Retired Staff, the ongoing responsibilities of each Member of the Medical Staff include: (a) continuing to meet all qualifications for membership as set forth in Section 2.2; (b) abiding by the Bylaws, Rules and Regulations of the Medical Staff, and Hospital policies mandated by law or regulation, and Hospital rules mandated by law or regulation as interpreted by the Hospital Board, and applicable Departmental and Section Rules; maintaining familiarity with the Bylaws, Rules and Regulations of the Medical Staff and with the Member's Departmental Rules (and Section Rules, if applicable); (c) discharging in a responsible and cooperative manner such reasonable responsibilities and assignments imposed on the Member by virtue of Medical Staff membership, including reasonable committee assignments made in consultation with the Practitioner; (d) preparing and completing in a timely fashion medical records for all the patients for whom the Member provides care in the Hospital; (e) abiding by the Florida Medical Practice Act, TJC regulations, and AMA Rules of Ethics (available for review in the Medical Staff Office); (f) working and interacting cooperatively with Members, nurses, Hospital administration and others so as to promote patient care and a harmonious working atmosphere; to include: encouraging clear communication with respect to orders, prescriptions, diagnostic test and other aspects of patient care; accepting and delivering constructive criticism to and from staff, nurses and ancillary medical personnel, as warranted; responding to pages, medical emergencies and other calls to duty in a timely fashion; encouraging examination of negative patient outcomes for root causes without placing unwarranted blame on others; demonstrating respect towards administration, staff, nurses and ancillary medical personnel; addressing concerns about clinical judgment with associates directly and privately; addressing dissatisfaction with hospital policies or procedures through appropriate grievance channels; otherwise supporting policies promoting cooperation and teamwork. (g) providing continuous care and supervision, either personally or by making appropriate arrangements for coverage for his or her patients as reasonably determined by the Medical Staff, found in its published rules; (h) participating in such emergency service coverage or consultation panels as may be determined by the Medical Executive Committee or by the Board; provided, that in establishing such requirements the Board shall give great weight to the recommendations of the Medical Executive Committee, and the Medical Staff. All Staff Members with Admitting Privileges will be required to take ER call, unless exempted by the MEC or by hospital contract. If a Physician, based on qualifications, can serve on more than one ED call, the Physician may elect his/her choice of which call to serve, provided the MEC feels both calls are sufficiently covered. Exemption to ER Call is granted by the MEC on a case-by-case basis. Any physician requesting exemption to the ER Call based on years of service, may be exempted by the MEC if they have twenty-five (25) years of continuous service on the Active Staff at Flagler Hospital. Any Physician requesting exemption to the ER Call based on age may be exempted by the MEC if they are age 65 and have been on the Active Staff for a minimum of ten (10) years. Prior to the MECs consideration, input will be requested from the appropriate Department. (i) discharging such Medical Staff, department, section, committee, and service functions for which he or she is responsible by appointment, election, or otherwise, and such other Staff obligations as may be reasonably established from time to time by the Medical Executive Committee or the Board; (j) participating in and cooperating with the Medical Staff in meeting its obligations in assessing and improving patient care, including, but not limited to, continuous quality improvement, peer review, utilization management, quality evaluation, Medical Staff proctoring, risk management and related activities required of the Medical Staff, and in discharging other such functions as may be required from time to time as a result of accreditation, regulatory or credentialing requirements placed on the Medical Staff or Hospital, upon timely written notice; informing the Medical Staff Services Department within 15 calendar days of any significant changes in the information required on appointment and reappointment, including, but not limited to, any investigations/ obligations/discipline/restriction/revocation of his/her medical license/certificate/DEA/permits/board status/membership or privileges at another institution or professional society, criminal charges, etc. If a Practitioner experiences a change in mental or physical health status that could impact his/her ability to provide patient care services, the Practitioner must immediately notify the Chief of his/her Department and either the President or the CEO; (l) cooperating with the Hospital providing the Hospital, in its reasonable efforts to ensure that a full range of acute care services are provided at the Hospital, as required by accreditation, regulatory or credentialing requirements placed on Hospital; the Hospital shall, in turn, seek the advice and consent of the Medical Staff and provide such necessary equipment, staffing, and other prerequisites to execute these requirements; (m) refraining from any unlawful harassment or discrimination against any person (including any patient, Hospital employee, Hospital independent contractor, Medical Staff Member, or visitor) based upon the persons age, sex, religion, race, creed, color, national origin, health status, ability to pay, or source of payment; (n) meeting the qualifications for membership as set forth in these Bylaws. A Member may be required to demonstrate continuing satisfaction of any of the requirements of these Bylaws upon a reasonable request of the Medical Executive Committee. Aiding/participating in any Medical Staff approved educational programs, as necessary, for the Medical Staff, nurses and other personnel. Responding in a timely fashion to queries posed by an authorized Medical Staff or Hospital representative in a manner set forth in the query. Failure to respond with diligence and candor, may result in disciplinary proceedings. CONFLICT OF INTEREST All Officers of the Medical Staff shall execute the Flagler Hospital Acknowledgement and Certification With Respect to Conflicts of Interest Policy� on an annual basis. This statement will be signed and presented to the Medical Staff Services Department by June 1st of each year. Disclosures will be acknowledged at the first General Staff meeting and Medical Executive Committee meeting following the June 1st deadline. ARTICLE III. CATEGORIES OF MEMBERSHIP 3.1 CATEGORIES The categories of the Organized Medical Staff shall include the following: Active and Provisional Active. Other categories of the Medical Staff are: Consulting, Provisional Consulting, Community, Honorary and Retired, and Dental, Podiatry and Psychology. At each time of reappointment, the Member's Staff category shall be determined. 3.2 MEDICAL ACTIVE STAFF 3.2-1 QUALIFICATIONS The Active Staff shall consist of Members who: (a) meet the general qualifications for membership set forth in Sections 2.2 and 2.6; (b) have satisfactorily completed their designated term in the Provisional Staff category and have been recommended for approval for advancement. Such transition from the Provisional to Active Staff shall be effective as soon as possible but not later than ninety (90) days after the Provisional status has ended. 3.2-2 PREROGATIVES Except as otherwise provided, the prerogatives of an Active Medical Staff Member shall be to: (a) admit patients to the Hospital and exercise such Clinical Privileges as are granted pursuant to ArticleV; and (b) attend and vote on matters presented at general and special meetings of the Medical Staff and of the Department and committees of which he or she is a member; and (c) hold Staff office and serve as a voting Member of committees to which he or she is duly appointed or elected by the Medical Staff or a duly authorized representative thereof. 3.2-3 OBLIGATIONS All Active Staff Members must be reachable by personal phone &/or beeper at all times whenever they have patient care duties within the Hospital (patients in-house, or are on call) unless they have designated in a timely fashion, orally or in writing, to the Hospital switchboard an alternative Medical Staff Member with appropriate Clinical Privileges and experience to attend such duties. To ensure timely response to patient care duties, if an Active Staff Member is on staff at multiple hospitals which span a large demographic area, they will be required to submit and maintain a viable plan of coverage to the Medical Executive Committee for approval, through the appointment and reappointment process. 3.3 THE CONSULTING MEDICAL STAFF 3.3-1 QUALIFICATIONS The Consulting Staff shall consist of Members who: (a) meet the general qualifications for membership set forth in Sections 2.2 and 2.6; and (b) have satisfactorily completed appointment in the Provisional category. 3.3-2 PREROGATIVES Except as otherwise provided, the Consulting Staff Member shall be entitled to: (a) provide a consultation report at the request of an Active Staff Member; (b) attend meetings of the Medical Staff, including open committee meetings and educational programs, but not vote; Consulting Staff Members shall not be eligible to hold office in the Medical Staff organization. Consulting Staff Members may be appointed to committees and will be able to vote on matters only before such committees. (c) assist in surgery (not be the primary physician of record), if: the Physician was an Active Staff Member at Flagler Hospital, in good standing, for five of the last seven years preceding assignment to the Consulting Staff category, and held the privilege(s) to perform the surgery/procedure while on the Active Staff. 3.3-3 LIMITATIONS Consulting Staff Members shall not admit patients to the Hospital either as inpatients or as outpatient surgical patients, nor shall they be the Physician of primary care or responsibility to any patient within the Hospital. Consulting Medical Staff Members shall not write orders for any patient in the Hospital, nor shall they be eligible for Privileges to interpret diagnostic studies. 3.4 PROVISIONAL STAFF The Provisional Staff shall consist of newly-appointed Members of the Medical Staff (Provisional Active, Provisional Consulting, Provisional Dental Podiatry and Psychology Staff). 3.4-1 QUALIFICATIONS The Provisional Staff shall consist of Members who: (a) meet the general Medical Staff membership qualifications set forth in Sections 2.2 and 2.6; and (b) immediately prior to their application and appointment were not Members (or were no longer Members) of this Medical Staff, or are Members of the Consulting Staff at Flagler Hospital and have requested to be moved to the Active Staff category. (Active Staff Members requesting reassignment to the Consulting Staff category will not be required to serve a Provisional period for this transition.) 3.4-2 PREROGATIVES The Provisional Staff Member shall be entitled to: (a) attend meetings of the Medical Staff, including open committee meetings and educational programs, but shall have no right to vote at such meetings, except within committees when the right to vote is specified at the time of appointment to the committee. Provisional Staff Members shall not be eligible to hold office in the Medical Staff organization, but may serve on committees; and (b) admit patients (Provisional Active Staff only) and exercise such Clinical Privileges as are granted pursuant to ArticleV. 3.4-3 TERM OF PROVISIONAL MEDICAL STAFF STATUS A Member shall remain on the Provisional Staff for a period of five (5) months or until privileging criteria is met, whichever comes first, unless that status is extended by the Medical Executive Committee for an additional period of up to seven (7) months or until privileging criteria is met, whichever comes first, on a determination of good cause, which determination shall not be subject to hearing pursuant to Article VII. 3.4-4 ACTION AT CONCLUSION OF PROVISIONAL STAFF STATUS (a) If the Provisional Staff Member has satisfactorily demonstrated (through focused review and/or proctoring) his or her ability to exercise the Clinical Privileges initially granted, and otherwise appears qualified for continued Medical Staff membership, the Member shall, as soon as possible, be assigned to the Active or Consulting or Dental, Podiatry and Psychology Staff as appropriate, upon recommendation of the Medical Executive Committee and approval by the Board of Trustees; and (b) In all other cases, the Medical Executive Committee shall make its recommendation to the Board regarding a modification or termination of Clinical Privileges or termination of Medical Staff membership, subject to the provisions of Article VII. No more than three extensions May be granted to any Member of the Medical Staff. As a general rule, one extension will be granted for good cause. If the Member does not have enough patient contacts for review, without just cause, at the conclusion of the first extension, the MEC shall accept this non-action as a voluntary resignation. If there are extenuating circumstances, and/or if the Member had some patient contacts during the first year, the MEC may consider a second extension of the Provisional Period, up to six months. At the conclusion of the second extension, if the Member does not qualify for elevation, the MEC will recommend a voluntary resignation be accepted, unless there are extenuating documented reasons to extend the Provisional Period for a third time, for up to six months, but not to exceed the Members reappointment date. 3.5 HONORARY AND RETIRED MEDICAL STAFF 3.5-1 QUALIFICATIONS (a) The Honorary Staff The Honorary Staff shall consist of Members who do not actively practice at the Hospital but are deemed deserving of membership by virtue of their outstanding reputation, noteworthy contributions to the health and medical sciences, and who continue to exemplify high standards of professional and ethical conduct. (b) The Retired Staff The Retired Staff shall consist of Members who have retired from active practice and, at the time of their retirement, were Members in good standing of the Active Staff for a period of at least five (5) continuous years. 3.5-2 PREROGATIVES Honorary and Retired Staff Members are not eligible to admit patients to the Hospital or to exercise Clinical Privileges in the Hospital, or to vote or hold office in this Medical Staff organization, but they may serve upon committees without vote. They may attend Staff meetings, including open committee meetings and educational programs. Honorary and Retired Staff Members are not required to pay dues. 3.6 EMPLOYED STAFF 3.6-1 QUALIFICATIONS The Employed Staff shall consist of Members who: (a) meet the general qualifications for membership set forth in Sections 2.2 and 2.6; (b) are employees (excluding contracted Physicians as defined in Section 2.5-1) of the Hospital in a healthcare provider capacity. 3.6-2 PREROGATIVES Except as otherwise provided, the prerogatives of an Employed Medical Staff Member shall be to: (a) exercise such Clinical Privileges as are granted pursuant to ArticleV, which may include admitting patients to the Hospital; and (b) attend general and special meetings of the Medical Staff and of the Department and committees of which he or she is a member. 3.6-3 OBLIGATIONS All Employed Staff Members must be reachable by personal phone &/or beeper at all times whenever they have patient care duties within the Hospital unless they have designated in a timely fashion, orally or in writing, to the Hospital switchboard an alternative Medical Staff Member with appropriate Clinical Privileges and experience to attend such duties. 3.6-4 LIMITATIONS Physicians employed as Staff Members after January 1, 2014 may not hold office, sit on the MEC or vote on matters presented at a General Staff, Department, Division or Committee meetings. 3.7 THE COMMUNITY PHYSICIAN 3.7-1 QUALIFICATIONS The Community Physicians shall consist of Physicians who hold an Active/Unrestricted MD or DO License, and have completed the appropriate limited credentialing process as well as the appropriate orientation to include EMR and HIPAA training. 3.7-2 PREROGATIVES Except as otherwise provided, a credentialed Community Physician shall be entitled to: (a) refer established patients to Members of the Active Staff. (b) visit their established patients while in the hospital. (c) review their established patients� medical records. (d) obtain results of tests and therapy for their established patients. (e) discuss ongoing management with the attending physician. (f) attend meetings of the Medical Staff, including open committee meetings and educational programs, and may serve as a non-voting member. 3.7-3 LIMITATIONS Community Physicians shall not: admit patients to the Hospital either as inpatients or as outpatient surgical patients, nor shall they be the Physician of primary care or responsibility to any patient within the Hospital. enter orders or give verbal/telephone orders for any patient in the Hospital. be eligible for Privileges to include interpret diagnostic studies. be eligible to vote for or hold office in the Medical Staff organization. serve on Emergency Department Call. enter information in the medical record. REQUEST FOR PRIVILEGES Should a Community Physician wish to become an Active or Consulting Staff Member, he/she may make this request through the Medical Staff Services Department, and will need to provide proof of meeting the requirements for Membership, as outlined in Section 2.2, and Privileges, as outlined in Section 5.2. The Community Physician must first complete any additional required Electronic Medical Records (EMR) training. Upon successful completion of EMR training, the Community Physician will be assigned to the Provisional Active or Consulting Staff category, and will participate in Flagler Hospitals Focused Professional Practice Evaluation (FPPE) program. While participating in the FPPE program the Provisional Member may be required to have co-management of all admissions, and may be required to be physically (real-time) proctored for all surgeries until recommended by the Proctor, and approved by the Credentials Committee and Medical Executive Committee, for stand-alone privileges. It is the responsibility of the Community Physician to secure the agreement of an Active Staff Member for any required proctoring. 3.8 AMBULATORY SURGERY STAFF 3.8-1 QUALIFICATIONS The Ambulatory Surgery Staff shall consist of Members who: (a) meet the general qualifications for membership set forth in Sections 2.2 and 2.6; (b) have satisfactorily completed their designated term in the Provisional Staff category and have been recommended for approval for advancement. Such transition from the Provisional to Ambulatory Surgery Staff shall be effective as soon as possible but not later than ninety (90) days after the Provisional status has ended. 3.8-2 PREROGATIVES Except as otherwise provided, the prerogatives of an Ambulatory Surgery Medical Staff Member shall be to: Provide out-patient surgery services only and exercise such Clinical Privileges as are granted pursuant to ArticleV; and Attend meetings of the Medical Staff, including open committee meetings and educational programs, and may serve as a non-voting member. 3.8-3 OBLIGATIONS All Ambulatory Surgery Staff Members must be reachable by personal phone &/or beeper, and must maintain current alternate coverage; the alternate must be on the Active Staff of Flagler Hospital with similar privileges who will attend to his/her patients should any of his/her patients require immediate transfer to the Hospital. Ambulatory Surgery Staff are not required to take ED Call. 3.9 LIMITATION OF PREROGATIVES The prerogatives set forth under each membership category are general in nature and may be subject to limitation by special conditions attached to a particular membership, by other sections of these Bylaws and by the Medical Staff Rules and Regulations. 3.10 MODIFICATION On its own, pursuant to a request by a Member under Section 4.6-1(b), or at the direction of the Board, the Medical Executive Committee, may recommend a change in the Medical Staff category of a Member consistent with the requirements of the Bylaws, document the reasons for such change, and provide a copy of such documentation to the affected Medical Staff Member. 3.11 DENTAL, PODIATRY AND PSYCHOLOGY STAFF The Dental, Podiatry and Psychology Staff category shall consist of dentists, podiatrists and psychologists who occasionally administer to patients and/or perform procedures at this Hospital. Requests for Clinical Privileges from dentists, podiatrists and psychologists shall be processed in the manner specified in Article V. 3.11-1 QUALIFICATIONS The Dental, Podiatry and Psychology Staff shall consist of Members who meet the general qualifications for membership set forth in Sections 2.2 and 2.6 and the specific requirements established by the Hospital in conjunction with the Medical Executive Committee. PREROGATIVES Except as otherwise provided, the Dental, Podiatry and Psychology Staff shall be entitled to: (a) provide a consultation report at the request of an Active Staff Member; (b) treat patients in the Hospital, provided that a Physician Member of the Medical Staff admits the patient and assumes responsibility for the basic medical appraisal of the patient and for the care of any medical problem that may be presented or may arise during hospitalization. (c) attend meetings of the Medical Staff, including open committee meetings and educational programs, but shall not be eligible to vote or hold office in the Medical Staff organization. Dental, Podiatry and Psychology Staff may be appointed to committees and will have a vote on matters before such committees; (d) Dental surgeons and podiatrists will be assigned to the Department of Surgery; psychologists will be assigned to the Department of Medicine. 3.11-3 LIMITATIONS (a) Dental, Podiatry and Psychology Staff may be subject to consultation requirements and/or other restrictions which may be imposed from time to time at the discretion of the Medical Executive Committee and/or in accordance with Rules and Regulations adopted by the Medical Staff. (b) Psychologist Members may not admit patients to the Hospital. (c) A Physician Member of the Medical Staff shall be responsible for the care of any medical problem that may be present at the time of admission or that may arise during hospitalization and shall determine the risk and effect of the proposed surgical procedure on the total health status of the patient. (d) Dentists, podiatrists, and psychologists shall be responsible for the dental, podiatric and psychological care, respectively, of their patients, including the dental, podiatric or psychological history and dental and podiatric physical examination or psychological examination as well as appropriate elements of the patient's record. (e) Dentists, podiatrists and psychologists may write orders within the scope of their respective licenses consistent with the Medical Staff Rules and Regulations and in compliance with the Hospital and Medical Staff Bylaws. 3.12 PEDIATRIC SPECIAL CONSULTING STAFF CATEGORY EXCLUSIVELY FOR THE DEPARTMENT OF PEDIATRICS This Pediatric Special Consulting Staff category shall consist of physicians who practice in Pediatric Cardiology, Pediatric Neurology, and Pediatric Ophthalmology services. Members of this Staff category will not be eligible to vote or hold office, nor will they be required to attend Department meetings. Members of the Pediatric Special Consulting Staff category may not admit patients to the Hospital, and may not write orders, but may consult on patients in the Hospital, may interpret diagnostic tests, and render opinions for additional treatment. 3.13 ASSIGNMENT TO A LESSER CATEGORY If at any point in time a Practitioner no longer meets the qualifications of a particular Staff category, the Medical Executive Committee may make a recommendation to the Board of Trustees to reassign the Practitioner to a category which better suits his/her practice pattern. All efforts will be made to accommodate the Practitioners wishes. Reassignment to a lesser Staff category will not be considered an adverse action, and does not entitle the Practitioner to the Fair Hearing process. ARTICLE IV. APPOINTMENT AND REAPPOINTMENT 4.1 GENERAL Except as otherwise specified herein, no person (including persons engaged by the Hospital in medico-administrative positions) shall exercise Clinical Privileges in the Hospital unless and until that person applies for and receives appointment to the Medical Staff or is granted temporary Privileges as set forth in these Bylaws. By applying to the Medical Staff for appointment or reappointment (or, in the case of Members of the Honorary Staff, by accepting an appointment to that category), the applicant acknowledges responsibility to first review these Bylaws (a copy of which will be included with the application for privileges) and agrees that throughout any period of membership that person will comply with the responsibilities of Medical Staff membership and with the Bylaws and Rules and Regulations of the Medical Staff as they currently exist and as they may be modified from time to time, via mechanisms specified herein. Any and all such modifications will be communicated to the Practitioner in a timely fashion. Appointment to the Medical Staff shall confer on the appointee only such Clinical Privileges as have been granted in accordance with these Bylaws. 4.2 BURDEN OF PRODUCING INFORMATION In connection with all applications for appointment, reappointment, advancement or transfer, the applicant shall have the burden of producing information for an adequate evaluation of the applicant's qualifications and suitability for the Clinical Privileges and Staff category requested, of resolving any reasonable doubts about these matters, and of satisfying requests for information. No action will be taken by the Credentials Committee on the applicants file until the application is deemed complete, as defined in Section 4.5-3. The applicant's failure to sustain this burden shall be grounds for denial of the application. This burden may include submission to a medical or psychological examination, at the applicant's expense, if deemed appropriate by the Medical Executive Committee, which may select the examining Physician. 4.3 APPOINTMENT AUTHORITY Appointments, denials and revocations of appointments to the Medical Staff shall be made as set forth in these Bylaws, but only after there has been a recommendation from the Medical Executive Committee, and final action by the Board of Trustees, or as set forth in Section 6.2-5. 4.4 DURATION OF APPOINTMENT AND REAPPOINTMENT Initial appointments to the Medical Staff shall be for a period of up to three (3) years.� Reappointments shall be for a period of up to three (3) years.� Practitioner applicants for reappointment must have activity of not less than fifteen (15) Patient Contacts� (defined below) per reappointment cycle, either as a primary attending, proceduralist, diagnostician, or consultant to qualify for reappointment.� For any reappointments granted for less than three (3) years, the required patient contacts will be prorated to be proportional to the length of the reappointment (3 yrs = 15 patients; 2yrs = 10 patients; 1 yr = 5 patient contacts; <. 6 months = 3 patient contacts.) Any other credentialing interval will have the number of patients assigned by those in the Credentialing process (Department Chief/Credentials Committee/MEC). Less activity at the Hospital will be considered a failure to meet minimum requirements. This provision will not apply to Locum Tenens physicians, Community Staff, Dentists/Oral-Maxillofacial Surgeons, Dermatologists, Allergists, Rheumatologists and Radiation Oncologists for elevation or reappointment. If a Practitioner provides a specific service for a community need, and does not meet patient contact criteria, upon the recommendation of the MEC, the Practitioner may be advanced and/or reappointed if the Practitioner has a minimum of 15 patient contacts at another institution/hospital, is in good standing at that institution, and provides their OPPE report from that institution indicating an acceptable level of care. A patient contact� pertains to any patient at Flagler Hospital or a Flagler Hospital operated facility. Medicine Department, Family Medicine Department, Pediatric Department, Cardiology Department: an H&P or Consult or Progress Note or Mental Health Evaluation on Flagler Hospital In-Patients or Observation patients; any invasive procedure on Flagler Hospital In-Patients, same day procedure patients, or Observation Patients in the Hospital. Emergency Department: a direct patient contact. Radiology Department: interpreting a diagnostic imaging study or performing an invasive image-guided procedure. Surgery Department (excluding Pathology), Orthopedic Department, OB/GYN Department: surgery performed at Flagler Hospital or a Flagler Hospital Surgery Center, or any other direct physician interaction, which includes a direct face-to-face contact resulting in an opinion of the physician that is documented in the patient record. This would include an H&P, or an Op Note, or progress note, or consultation note, or discharge summary. Deliveries are also counted as a patient contact� for Obstetricians. Pathologists: interpreting a diagnostic study. Advanced Registered Nurse Practitioners and Physician Assistants: Progress Notes with appropriate contents may be counted as a patient contact. Countersignature of a midlevels documentation and out-patient orders will not count as a patient contact for the supervising Physician. 4.5 APPLICATION FOR INITIAL APPOINTMENT AND REAPPOINTMENT 4.5-1 APPLICATION FORM An application form shall be developed by the Medical Executive Committee. The form shall require detailed information which shall include, but not be limited to, information concerning: (a) the applicant's qualifications, including, but not limited to, professional training and experience, competence, current licensure, current DEA registration (if applicable), and continuing medical education information related to the Clinical Privileges to be exercised by the applicant; (b) references from peers familiar with the applicant's professional competence and ethical character; (c) requests for membership category and Clinical Privileges; (d) past or pending professional disciplinary action(s) to include voluntary or involuntary termination of medical staff membership or voluntary or involuntary limitation or reduction or loss of clinical privileges or membership at another hospital, previously successful or currently pending challenges to any licensure or registration, or the voluntary or involuntary relinquishment of such licensure or registration or related matters; (e) fitness physically and mentally to utilize requested Privileges at or above the standard of care, according to the definition of the American Disabilities Act (ADA); (f) adequate professional liability insurance coverage as specified under 2.2(h); a listing of all past or pending professional liability claims, judgments or settlements regardless of age or amount; and (h) such other information as the Medical Executive Committee may reasonably specify. Each application for initial appointment to the Medical Staff shall be in writing, submitted on the prescribed form with all provisions completed (or accompanied by an explanation of why answers are unavailable), and signed by the applicant. When an applicant requests an application form, that person shall be given a copy of these Bylaws, Rules and Regulations. 4.5-2 EFFECT OF APPLICATION In addition to the matters set forth in Section 2.1, by applying for appointment to the Medical Staff each applicant: (a) signifies willingness to appear for interviews in regard to the application, only if reasonable notice is given and the evaluating person or committee documents its reason, and notifies the applicant; (b) authorizes consultation with others who have been associated with the applicant and who may have information bearing on the applicant's competence, qualifications and performance, and authorizes such individuals and organization to candidly provide all such information; (c) consents to inspection of records and documents that may be material to an evaluation of the applicant's qualifications and ability to carry out the Clinical Privileges requested, and authorizes all individuals and organizations in custody of such records and documents to permit such inspection and copying; (d) releases from any liability, to the fullest extent permitted by all applicable laws, all persons for their acts performed in connection with investigating and evaluating the applicant; (e) releases from any liability, to the fullest extent permitted by all applicable law(s), all individuals and organizations who provide information regarding the applicant, including otherwise confidential information; (f) consents to the disclosure to other hospitals, medical associations, licensing boards, and to other similar organizations as required by law, any information regarding the applicant's professional or ethical standing that the Hospital or Medical Staff may have, and releases the Medical Staff and Hospital from liability for so doing to the fullest extent permitted by all applicable law(s); (g) if a requirement then exists for Medical Staff dues, acknowledges responsibility for timely payment; pledges to provide continuous care for patients; (i) agrees to abide by all provisions of the Florida Medical Practice Act (document is available in the Medical Staff Office for review). 4.5-3 VERIFICATION OF INFORMATION The applicant shall deliver a completed application to the Medical Staff Office and an advance payment of Medical Staff dues or fees, if any is required. If the applicant is denied membership, for any reason, the advanced dues will be refunded to the applicant in full. The Medical Staff Office shall document the time such application is received, and as soon as possible but not later than fifteen (15) business days thereafter, seek to collect or verify the references, licensure, and other information submitted. The CEO or his designee shall also, as soon as possible but not later than fifteen (15) business days after the file is complete, query the National Practitioner Data Bank and Office of Inspector General for Medicare, as required by law, regarding the Practitioner. The Credentials Committee (through the Medical Staff Office) shall bear the burden of reading and documenting the date of receipt of all documents pertaining to Medical Staff applications, and making reasonably prompt efforts to secure information it needs. The Medical Staff Office, as soon as possible but not later than ten (10) business days after the file is deemed complete, will notify the Chief of the Department, that the application is ready for his/her review. An application will be considered a Completed Application� when all questions on the application have been answered, all information has been supplied, the supporting documentation and application fee described above have been submitted by the applicant, the applicants qualifications, training and experience have been verified through the primary source when possible, the National Practitioner Data Bank report has been received, and the applicant's state licensure/registration has been verified. If an applicant for Staff membership does not supply the abovedescribed documents within ninety (90) days of the time the applicant is initially notified in writing to supply them, or if the applicant does not reveal all pertinent information on the initial application, which prolongs the Medical Staff Service Departments continuous credentialing process for more than six months, the applicant will be notified in writing that the processing of his/her application may be closed and will include the reason(s) for such action. Notwithstanding any other provision of these Bylaws to the contrary, an applicant whose application's processing has been so terminated, shall not be entitled to the procedural rights as provided in Article VII of these Bylaws, and may not reapply for membership and/or privileges within six months. 4.5-4 DEPARTMENT AND SECTION REPORTS As soon as possible but no later than fifteen (15) business days after notification of the completed verified application, the Chief of the Department in which the applicant seeks Clinical Privileges shall review the application and supporting documentation, and may conduct a personal interview with the applicant, and shall transmit to the Credentials Committee on the form prescribed by that Committee a written report and recommendations concerning the application. 4.5-5 CREDENTIALS COMMITTEE REPORT At its next regularly scheduled meeting, but never more than thirty (30) business days, after receipt by the Committee Chairman of the Department Chiefs report, the Credentials Committee shall review the application, the supporting documentation, the Department Chief's report, and such other information available to it that may be relevant to consideration of the applicant's qualifications. The Credentials Committees final recommendation will be forwarded to the Medical Executive Committee, for consideration at its next regularly-scheduled meeting. This period will never exceed 60 days. In addition, the Credentials Committee may, upon the recommendation of the Department Chief, President, CEO, or, upon their own initiative, interview the applicant. Medical Staff Members will be notified of Applications in Progress on a monthly basis. 4.5-6 MEDICAL EXECUTIVE COMMITTEE ACTION At its next regular meeting after receipt of the Credentials Committee report and recommendations, the Medical Executive Committee shall consider the application and the report and recommendations of the Credentials Committee and such other relevant information as may be available to it. The Medical Executive Committee may request additional information, initiate further investigation, and/or elect to interview the applicant. The Medical Executive Committee shall forward to the CEO, for prompt transmittal to the Board, a written report and recommendation as to Medical Staff appointment and, if appointment is recommended, as to membership category, Clinical Privileges to be granted, and any special conditions to be attached to the appointment. The Medical Executive Committee, only for documented cause, may defer action on the application for a reasonable period of time, not to exceed ninety (90) days. The reasons for each recommendation shall be stated. 4.5-7 EFFECT OF MEDICAL EXECUTIVE COMMITTEE ACTION (a) Favorable Recommendation: When the recommendation of the Medical Executive Committee is favorable to the applicant, it shall be promptly forwarded, together with supporting documentation, to the Board. (b) Adverse Recommendation: When a final recommendation of the Medical Executive Committee is adverse to the applicant, to deny the application for appointment to the Medical Staff or to deny any Clinical Privileges requested in the application, the Medical Executive Committee shall prepare a written report of its recommendations, including the reasons for its recommendations. The Medical Executive Committee shall notify the applicant of its adverse recommendation. Such notice shall inform the applicant of his or her right to request a hearing to review the adverse recommendation pursuant to the provisions of Article VII of these Bylaws. 4.5-8 ACTION BY BOARD At the Boards next regularly-scheduled meeting, but never more than sixty (60) days following its receipt of the Medical Executive Committee's favorable recommendation regarding an application for initial appointment, the Board, or a subcommittee thereof, shall review the Medical Executive Committee's report and recommendations together with the application and related information. As part of its review, the Board may conduct whatever investigation it deems necessary relating to the application. Following its investigation, the Board shall prepare a written report and recommendation. If the Board's recommendation is favorable to the applicant, it shall be considered final action. If, however, the applicant does not complete the post-appointment requirements as applicable (eg orientation, EMR training, obtaining a badge, etc.) within 90 days from the initial request in writing, the application will be rendered incomplete, the appointment will be rescinded and the application closed. Under these conditions, the applicant may not reapply for appointment within six months. This will not be considered an adverse recommendation, and the applicant will not be entitled to procedural rights outlined in Article VII. If the recommendation of the Board is adverse to the applicant, the Board shall prepare a written report setting forth its adverse recommendation together with its reasons for the recommendation. The applicant shall be notified of his or her right to request a hearing pursuant to Article VII of these Bylaws. In making their recommendation under this section, the Board shall give weight to the recommendation of the Medical Executive Committee and shall not act arbitrarily or unreasonably. If a recommendation by the Medical Executive Committee, or action by the Board, to deny Staff membership, a department, section or Staff category assignment, or particular Clinical Privileges is made on the basis of a non-medical disciplinary cause or reason (for instance, the Hospital is unable to provide adequate facilities or supportive services for the applicant and his patients), such reasons will be documented, the recommendation shall not be considered adverse in nature, shall not entitle the applicant to the procedural rights as provided in Article VII, and shall not be reported to any state or federal agency unless required by law. 4.5-9 APPOINTMENT RECOMMENDATIONS Each appointment and reappointment recommendation shall specify whether Medical Staff appointment or reappointment is recommended, and, if so, the membership category and Clinical Privileges to be granted and any special conditions to be attached to the appointment or reappointment. The reasons for any adverse recommendation shall be stated and supported by reference to the documentation which was considered in evaluating the application, all of which shall be transmitted with the report. Recommendations concerning membership and Clinical Privileges shall be based upon whether the applicant for appointment or reappointment meets the qualifications and can carry out all of the responsibilities specified in these Bylaws and in the Medical Staff Rules and Regulations, and upon the Hospital's patient care needs and the Hospital's ability to provide adequate support services and facilities for the applicant. On a case-by-case basis, and for good cause, the MEC may waive an orientation and/or EMR practicum requirement for an individual Practitioner at the time of initial appointment. 4.5-10 CONFLICT RESOLUTION Whenever the Board's proposed decision will be contrary to the Medical Executive Committee's recommendation, the Board shall submit the matter to the Joint Conference Committee for review and recommendation before making its final decision and giving notice of final decision. 4.5-11 REAPPLICATION AFTER ADVERSE APPOINTMENT DECISION An applicant who has withdrawn his/her application at the request of the MEC or Board of Trustees for cause or received a final adverse decision regarding appointment shall not be eligible to reapply to the Medical Staff for a period of two (2) years. Any such reapplication shall be processed as an initial application, and the applicant shall submit such additional information as may be required to demonstrate that the basis for the earlier adverse action no longer exists. 4.5-12 TIMELY PROCESSING OF APPLICATIONS As per the timetable established above, applications for Staff appointments shall be considered in a timely manner by all persons and committees authorized by these Bylaws to act thereon. Each step in the review process shall be completed as promptly as is reasonably possible in view of the duty to exercise due care in the review of applicants. Whenever the Credentials Committee and CEO agree that the review process has been unduly delayed at any particular step, they may jointly direct the review to be advanced to the next applicable step. 4.6 REAPPOINTMENTS AND REQUESTS FOR MODIFICATIONS OF STAFF STATUS OR PRIVILEGES 4.6-1 APPLICATION (a) At least four (4) months prior to the expiration date of the current Staff appointment (except for temporary appointments), a reapplication form developed by the Medical Executive Committee and approved by the Board shall be mailed or delivered to the Member. If an application for reappointment is not received within 30 days of having been made available to the Practitioner, written notice shall be promptly sent to the applicant advising that the application has not been received. If the reappointment application has not been received in the Medical Staff Services Department at least fourteen (14) calendar days prior to the routinely scheduled Credentials Committee meeting, the Practitioner will be informed there is insufficient time to routinely process his/her reappointment application, and will be given the option of letting his/her reappointment expire, or submit a rush fee� equal to the current initial application fee in order for his/her application to be expedited. The payment of a rush fee� does not guarantee successful completion of the processing of the reappointment. If a rush fee� is submitted, but despite efforts of the Credentialing entities the application still cannot be processed in time, the sole remedy will be a refund of rush fee�. Each Medical Staff Member shall submit to the Medical Executive Committee the completed application form for renewal of appointment to the Staff, and for renewal or modification of Clinical privileges. The reapplication form shall include all information necessary to update and evaluate the qualifications of the applicant including, but not limited to, the matters set forth in Section 4.5-1, and adherence to the basic responsibilities of Medical Staff membership as set forth above in Sections 2.2 and 2.6. Upon receipt of the application, the information shall be processed as set forth commencing at Section 4.5-3. (b) A Medical Staff Member who seeks a change in Medical Staff status may submit such a request in writing. This request will be reviewed by the Credentials Committee, and submitted to the Medical Executive Committee and Board of Trustees for final approval. (c) A Medical Staff Member who seeks modification of Clinical Privileges may submit such a request in writing at any time. The request must be accompanied by an acceptable statement as to the basis for the request and data supporting the request, including documentation of appropriate training and experience. (d) The Credentials Committee and/or Medical Executive Committee shall require that the applicant submit evidence of current competence to exercise the Privileges requested. The Medical Executive Committee may request further evaluation in instances where there is doubt about an applicants ability to perform the Privileges requested. (e) The Medical Executive Committee may waive any required dues, at its discretion, for an individual Medical Staff Member. 4.6-2 EFFECT OF APPLICATION The effect of an application for reappointment or modification of Staff status or Privileges is the same as that set forth in Section 4.5-2. If, during any credentialing cycle, special requirements are placed on a Practitioner, such requirements must have a specified time frame for completion. That time frame should not exceed one year. Any further time requirements must be approved by both the MEC and the Hospital Board. 4.6-3 STANDARDS AND PROCEDURE FOR REVIEW When a Staff Member submits the application for reappointment, or when the Member submits an application for modification of Staff status or Clinical Privileges, the Member shall be subject to a review which may include focused or on-going review and/or proctoring, generally following the procedures set forth in Sections 4.5-4 through 4.5-11. 4.6-4 FAILURE TO FILE REAPPOINTMENT APPLICATION Failure to submit a reappointment application prior to the current reappointment expiration date shall be considered a voluntary resignation by the Practitioner and the procedures set forth in Article VII shall not apply. 4.7 LEAVE OF ABSENCE 4.7-1 LEAVE STATUS At the discretion of the Medical Executive Committee, and upon approval by the Board of Trustees, a Medical Staff Member may obtain a voluntary leave of absence from the Staff upon submitting a written request to the Medical Executive Committee stating the approximate period of leave desired, which may not exceed twelve (12) months, provided that an additional twelve (12) months may be recommended by the Medical Executive Committee, and approved by the Board of Trustees, for good cause in writing. If a military duty or medical emergency (an unplanned medical condition, not considered an impairment� as defined below) arises, a Physician may request an immediate leave of absence, which will be granted by the Medical Executive Committee designee (the President), and ratified by the Medical Executive Committee and the Board of Trustees at a subsequent meeting. During the period of the leave, the Member shall not exercise Clinical Privileges at the Hospital, and membership rights and responsibilities shall be inactive, but the obligation to pay dues, if any, shall continue, unless waived by the Medical Executive Committee for good cause in writing. If a Practitioner is placed on a leave of absence due to an impairment (the inability to practice medicine with reasonable skill and safety because of mental illness, substance abuse, or physical disability), this will not be considered an adverse action against the Practitioners privileges or a surrender of privileges that would require reporting to the National Practitioner Data Bank. The Hospitals arrangement with an impaired Practitioner to go on a leave of absence in order to receive treatment or rehabilitation shall be kept confidential, and disclosure will be made on a strict need-to-know� basis. Therefore, an impaired Practitioners immediate leave of absence may be granted by the President or CEO, and will be ratified by the Medical Executive Committee and the Board of Trustees at their next meeting. If during the term of the Leave of Absence, an appointee to the Medical Staff becomes due for reappointment, the reappointment material shall be forwarded via certifiable mail to his last known address, for completion. Failure without good cause to submit the completed application in the normal manner shall be considered as indicating a desire not to be reappointed. A Practitioner is not eligible for a Leave of Absence if: 1) he/she resigns from a group holding an Exclusive Contract, or 2) the group holding an Exclusive Contract, to which the Practitioner belongs, is no longer providing services at Flagler Hospital. 4.7-2 TERMINATION OF LEAVE At least thirty (30) days prior to the termination of the leave of absence, or at any earlier time, the Medical Staff Member may request reinstatement of Privileges by submitting a written notice to that effect to the Medical Executive Committee. The Staff Member shall submit a summary of activities during the leave. The Medical Executive Committee shall make a recommendation concerning the reinstatement of the Member's Privileges and prerogatives, and the procedure provided in Sections 4.1 through 4.5-13, or paragraph 4.6 as applicable shall be followed. Return from a leave of absence will be final, upon Board of Trustees approval. 4.7-3 FAILURE TO REQUEST REINSTATEMENT Failure, without good cause, to request reinstatement shall be deemed a voluntary resignation from the Medical Staff and shall result in automatic termination of membership, Privileges, and prerogatives. A Member whose membership is automatically terminated shall not be entitled to the procedural rights provided in Article VII. A request for Medical Staff membership subsequently received from a Member so terminated shall be submitted and processed in the manner specified for applications for initial appointments. 4.7-4 REINSTATEMENT AFTER LEAVE FOR REASONS OF HEALTH OR DISABILITY OR MILITARY DUTY A Member who requests reinstatement after a leave for health or disability reasons shall submit a health statement from their personal physician affirming that he or she is fit to safely and competently exercise the requested Clinical Privileges. Prior to the Practitioners return from a LOA, the Medical Executive Committee will determine the appropriate monitoring requirements, if any, to ensure the safety of patients who will be under the Practitioners care. The monitoring requirements may vary, on a case-by-case basis, but will include: 1) length of time to be monitored, 2) method of monitoring, 3) responsible person(s) to monitor the Practitioner. A Member who requests reinstatement after military duty shall submit an official document attesting to their activation to, and their deactivation from, military duty. The Medical Executive Committee may request a medical examination by an examiner of its selection for a valid written reason, to be paid for by the Member. The Member who requests reinstatement agrees that the examiner may provide pertinent medical information to the Medical Executive Committee or its designee. Return from a leave of absence may be granted by the Medical Executive Committee designee (President) and the Hospital designee (CEO), on a temporary basis. The permanent return from a leave of absence will occur when ratified by the Medical Executive Committee and the Board of Trustees, at their next meeting. 4.8 REVIEW OF APPOINTMENT/REAPPOINTMENT FILES Practitioners appointed and/or reappointed to the Medical Staff may have access to their appointment file/reappointment file, by making an appointment with the Medical Staff Office. The review will take place in the Medical Staff Office, and at least one Medical Staff Office employee will remain in the room with the Practitioner during the review process. Neither the file(s), nor any contents thereof, may be removed from the Medical Staff Office. All contents of the appointment file may be reviewed by the Practitioner, with the exception of the references received on the Practitioner during the initial appointment process. All contents of the reappointment file may be viewed. Any incident reports in the Practitioners file will be blinded� to show the text of the concern(s) only. 4.9 PHYSICIAN RECOVERY NETWORK If a Practitioner becomes enrolled in the Physician Recovery Network (PRN), the Practitioner will be placed on an immediate medical Leave of Absence (not considered an adverse action) until such time an initial good standing� letter is received from the PRN. If a Practitioner is enrolled, or becomes enrolled, in the Physician Recovery Network (PRN), the Practitioner will be required to have the PRN submit a good standing� letter to the Medical Staff Services Department at least annually, or more frequently than annually if requested by the MEC or the Board, for as long as the Practitioner is enrolled in the PRN. If the Practitioner has a relapse, the Practitioner will be: placed on an immediate medical Leave of Absence until a good standing� letter is received from the PRN; required to have PRN submit a good standing� letter to the Medical Staff Services Department as least semi-annually, or more frequently if requested by the MEC; required to meet at least semi-annually with the Chief Medical Officer and appropriate Department Chief, who will report their findings to the MEC, until such time the MEC recommends disconnection of these meetings; placed on a Focused Professional Practice Evaluation (FPPE) with duration and specificity requirements outlined by the MEC. Failure to have the PRN submit a good standing� letter at the required frequency may result in a loss of Membership and/or Privileges. This will be considered a voluntary resignation for not meeting required qualifications, and will not be considered an adverse action. Therefore, the Practitioner will not be entitled to procedural rights under Article VII. Once the Practitioner has satisfactorily completed their contract with the PRN, the Medical Executive Committee reserves the right to request continuation of the PRN and/or reserves the right to continued random testing, without prior notice to the Practitioner. ARTICLE V. CLINICAL PRIVILEGES 5.1 EXERCISE OF PRIVILEGES Except as otherwise provided in Section 5.4, a Practitioner providing clinical services at this Hospital shall be entitled to exercise only those Clinical Privileges specifically granted to him or her by the Board upon recommendation of the Department Chief. Said Privileges and services must be Hospital specific, within the scope of any license, certificate or other legal credential authorizing practice in this State and consistent with any restrictions thereon, and shall be subject to the Rules and Regulations of the Medical Staff. 5.2 DELINEATION OF PRIVILEGES IN GENERAL 5.2-1 REQUESTS Each application for appointment and reappointment to the Medical Staff must contain a request for the specific Clinical Privileges desired by the applicant. A request by a Member for a modification of Clinical Privileges may be made at any time, but such requests must be supported by documentation of training, experience, qualifications and competence to exercise such Privileges. A Member must inform the Medical Staff Office if a health problem develops which would impact the Members ability to perform the Privileges requested. 5.2-2 BASES FOR PRIVILEGES DETERMINATION Requests for Clinical Privileges shall be evaluated on the basis of: the Member's education training experience demonstrated professional competence and judgment observed clinical performance performance of procedures on a current basis to maintain the Member's skills and knowledge professional liability claims adverse actions by other Hospitals or professional entities the documented results of patient care and other quality review and monitoring which the Medical Staff deems appropriate privilege determinations may also be based on pertinent information concerning clinical performance obtained from other sources, especially other institutions and health care settings where a Member exercises clinical privileges. Members granted initial Privileges shall be Board Certified/Board Admissible in their specialty of practice. Each Member must become Board Certified in their Specialty or Subspecialty within five (5) years of appointment, unless an extension is granted by the Medical Executive Committee. Such: Privileges granted shall be in keeping with applicable community and/or national standards of practice, and Privileges granted shall be on the basis of consultation of White Papers addressing the privilege area, and Privileges shall be granted to Members who provide a reasonable and tangible plan of call coverage and adequate back-up coverage for vacations, emergencies, and any other unanticipated, absences/ unavailabilities/emergencies, and Privileges shall be granted with consideration to liability implications to Flagler Hospital, the Medical Staffs mission to the community, and shared liability and involvement of fellow Medical Staff Members, and Privileges shall be granted with consideration and adequate planning for necessary resources to support and practice the intended privilege. These resources shall include physical space, adequate and trained medical ancillary personnel, and safe and reasonable technical equipment required. Privileges shall be evaluated in terms of the current need of the service as it relates to the Medical Staff and Hospital mission to the Community. Criteria will be equivalent (not necessarily identical) for Privileges shared by multiple specialties and/or departments. Per The Joint Commission, there needs to be a clearly defined method for the applicant to request deletion of specific activities within their Core/Bundled privileges. For patient safety, if a Member opts out of any part of Core/Bundled privileges, in the event that the Member is serving in a call capacity for the Emergency Care Center, they must secure appropriate coverage to address the privilege from which they opted out. Any and all concerns regarding the granting of privileges by any credentialing body will be directed to the applicant in writing. Privileges shall be granted when the applicant satisfactorily completes mandatory core Electronic Medical Record (EMR) training and passes the Practicum Exam�. There will be a 30 day remedial training� for any applicant who has not completed the mandatory core EMR training or passed the Practicum Exam�. If any additional EMR training is mandated after the initial granting of Privileges, the existing Staff Member must satisfactorily complete the additional mandated EMR training in order to maintain existing Privileges, or the Practitioner will be placed on a voluntary Leave of Absence until the training is satisfactorily completed, or until the Practitioners current reappointment expires, whichever comes first. This will not be considered an adverse action, and the Member will not be entitled to Procedural Rights outlined in Article VII. Training will be deemed mandatory� on the advice of the Chief Medical Information Officer (CMIO) and the consent of the Medical Executive Committee. Individuals who cannot, in good faith, pass the Practicum Exam� (prepared under the direction of the Chief Medical Information Officer, with the consent of the MEC), will be offered individual assistance, and/or given the option to utilize a scribe who can pass the Practicum Exam�. REQUEST FOR PRIVILEGES NOT CURENTLY OFFERED AT FLAGLER HOSPITAL If a Practitioner wishes to request a privilege that is not currently offered at Flagler Hospital, they will need to state the request in writing. If the privilege requested is not significantly different than a privilege currently offered at Flagler Hospital, the Department Chief will acknowledge this in writing, and the request by the Practitioner for the privilege will be forwarded to the Credentials Committee for further action. If the privilege is significantly different than any privilege currently offered at Flagler Hospital, the Practitioner requesting the privilege will be asked to complete a form describing the nature of the procedure, the need for the procedure, and what special equipment and/or specially-trained support staff would be necessary to accommodate the new privilege, and what qualifications and training of an applicant are necessary. This request will be reviewed by the Department Chief, and will be forwarded to the Credentials Committee for further action. The Practitioner may not perform the requested privilege until that privilege has undergone a thorough investigation through the Credentialing process, and the specific Practitioner is granted the privilege by the appropriate Credentialing bodies. TELEMEDICINE PRIVILEGES Upon request, the Medical Executive Committee will investigate the benefits and the risks of the Hospital contracting for telemedicine services, and forward this information for approval by the Medical Staff as a whole and to the Hospital Board of Trustees. MEDICAL HISTORY AND PHYSICAL EXAMINATIONS Medical History and Physical Examinations will be the responsibility of the admitting Physician. Any other Licensed Independent Practitioner who has been granted the Privilege to do so, may perform all or part of the Medical History and Physical Examination pertinent to their specialty. The Medical Staff may determine which out-patient services, if any, require a Medical History and Physical Examination. INPATIENT Who May Perform H&Ps: Only a practitioner who has been granted privileges by Flagler Hospital to do so performs a patients medical history and physical examination and required updates. If a History and Physical has been performed by a practitioner who is not on staff at Flagler Hospital, it may not be used as the admitting H&P. It may be used as an outside referral note, but another H&P must be recorded by the Flagler Hospital admitting physician. A History & Physical may also be recorded by a Physicians Assistant, Nurse Midwife, or Nurse Practitioner provided that they have been granted privileges by the Flagler Hospital Medical Staff to do so. The H&P may be performed by a member of the Flagler Hospital Staff, provided that they have been granted by the Flagler Hospital Medical Staff to do so. History & Physical Requirements: A complete History and Physical Examination shall be recorded within 24 hours of admission. This report shall include all pertinent findings resulting from an assessment of the systems of the body. Timing Requirement: The H&P must be completed no more than 30 days before or 24 hours after admission. Surgery is performed only after the H&P has been completed and recorded in the patients medical record, except in emergency cases. H&P Update: An update note documenting an examination of any change in the patients condition must be documented when the history and physical examination is completed within 30 days prior to admission. This H&P and updated examination must be completed and documented in the patients Flagler Hospital medical record within 24 hours after admission or prior to outpatient surgery. Readmitted Within 30 Days: If a patient is readmitted for treatment of the same or related problem within thirty (30) days following discharge from the hospital, an interval history and physical examination report reflecting any subsequent changes may be dictated or written, and the original documentation is to be included in the medical record. OUTPATIENT A simplified H&P of the patient will be completed and documented per medical staff policy, in accordance with the finalized Federal Register/Conditions of Participation. The simplified H&P must be completed and documented prior to surgery or a procedure requiring anesthesia services, if the patient is receiving specific outpatient surgical or procedural services in accordance with the medical staff policy identifying qualifying patients/procedures based on patient age, diagnoses, type and number of surgeries and procedures scheduled to be performed, comorbidities, and the level of anesthesia required, based upon recognized national guidelines and standards, and applicable state and local health and safety laws. ADMITTING PRIVILEGES Admitting Privileges will be granted only to Active Staff Members. 5.2-7 COMMUNICATION OF PRIVILEGING DECISIONS The final decision regarding granting/modifying privileges, if favorable to the applicant, will be communicated to the applicant in writing, and to other Hospital/Medical Staff personnel/Practitioners in an appropriate and timely fashion. If the decision is adverse to the applicant, the provisions outlined in the Corrective Action and/or Hearings and Appellate Review Articles will apply. 5.3 TEMPORARY CLINICAL PRIVILEGES 5.3-1 CIRCUMSTANCES (a) Upon receipt of a completed application for Medical Staff Privileges from an appropriately licensed Practitioner, and upon the recommendation of the Credentials Committee for Medical Staff or Clinical Staff Privileges, the CEO, or his designee authorized to act in his absence, in consultation with the Medical Staff President or the next ranking Medical Staff Officer available, may immediately grant temporary Clinical Privileges to the applicant, but in exercising such Privileges, the applicant shall act under the supervision of the Chief of Department to which he is assigned. Temporary Privileges shall be granted for no more than 30 days. Temporary Privileges may be extended for two additional thirty (30) day intervals [for a total of ninety (90) days]. Such Privileges shall not be unreasonably withheld. If Temporary Privileges are not renewed for any reason, those reasons will be communicated to the applicant in writing. (b) Temporary Privileges may be granted in the same manner as provided under subparagraph (a) of this section to permit a Practitioner serving as a locum tenens� for a Member of the Medical Staff to attend patients for a period not to exceed 120 days during any 12-month period without applying for Medical Staff membership. Locum Tenens Practitioner applications will be valid for 12 months, after which time the Locum Tenens Practitioners will need to reapply for Privileges. The credentials of the locum tenens� Practitioner must be reviewed and approved by the Department Chief concerned, by the Credentials Committee, and by the President of the Medical Staff. Subsequent locum tenens requests by the same Practitioner within 12 months of initial appointment need not be approved by the full Credentials Committee. (c) Temporary privileges may be granted to a practitioner who is not an applicant for membership in the same manner and upon the same conditions as set forth in subparagraph (a) of this section. Such temporary privileges shall be restricted to the care of a specified patient, at the request of an Active Staff member, and shall be restricted to the treatment, by the Practitioner, of not more than four patients in any 12-month period. In order to provide a new service, not otherwise available at Flagler Hospital, special privileges may be granted to a Practitioner who is not an applicant for membership in the same manner as set forth in Subparagraph (a) of this section. Such temporary privileges shall be restricted to providing coverage, including ER coverage, for an Active Staff Member when that Member is the sole Active Staff Member with Privileges to provide a service. This exception shall not be subject to a 30-day limitation set forth in Subparagraph (a) of this Section, but shall not exceed one year. Emergency temporary privileges may be granted when an emergent patient care, treatment, or service need must be filled. These privileges may be granted by the hospital President/CEO or designee on recommendation of the President and Credentials Committee (following an abbreviated credentialing process) for 30 day increments not to exceed 90 days. Prior to consideration of emergency temporary privileges there must be completion of the appropriate application, consent, and release, verification of current licensure, DEA certificate, OIG, GSA and completion of the National Practitioner Data Bank query (and verification that there are no current or prior successful challenges to licensure or registration), at least one peer reference and verification of hospital where Physician holds active privileges. When the emergency situation no longer exists, the patient(s) shall be assigned by the Department Chief or Medical Staff President to a Physician with appropriate clinical privileges, considering the wishes of the patient. 5.3-2 APPLICATION AND REVIEW On receipt of a completed application and supporting documentation from a Practitioner authorized to practice in Florida, the CEO, if requested, shall grant temporary Privileges to a Member who appears to have qualifications, ability and judgment, consistent with Section 2.2, as soon as possible but no later than fifteen (15) days, after: (a) the applicant's Completed Application, including the recommendation of the Credentials Committee, is forwarded to President of the Medical Staff (b) the President of the Medical Staff, using his/her discretion, recommends temporary Privileges, and the CEO, using his/her discretion, grants temporary Privileges. Refusal to grant temporary privileges will be communicated to the applicant in writing by the President and/or the CEO. (c) the applicant satisfactorily completes any mandated Electronic Medical Record (EMR) training and passes the Practicum Exam�. 5.3-3 GENERAL CONDITIONS (a) If granted temporary Privileges, the applicant shall act under the supervision of the President, or, if designated by the President, the applicable Department or Section Chief, and shall ensure that the President is kept closely informed as to his or her activities within the Hospital. (b) Temporary Privileges shall automatically terminate at the end of the designated period, unless earlier terminated by the President, for good cause in writing. (c) Requirements for monitoring shall be imposed on such terms as appropriate under the circumstances on any Member granted temporary Privileges. (d) Temporary Privileges may at any time be terminated by the President, for good cause in writing, subject to prompt review by the Medical Executive Committee. In such cases, the President shall assign a Member of the Medical Staff to assume responsibility for the care of such Member's patient(s). The wishes of the patient shall be considered in the choice of a replacement Medical Staff Member. (e) A person shall not be entitled to the procedural rights afforded by Article VII because a request for temporary Privileges is denied or because all or any portion of temporary Privileges are terminated or suspended, unless that denial or termination is based on a medical disciplinary cause or reason. (f) All persons requesting or receiving temporary Privileges shall be bound by the Bylaws and Rules and Regulations of the Medical Staff. 5.4 DISASTER PRIVILEGES The President and/or the CEO (or their designee) may grant emergency/disaster privileges to Practitioners, if the Disaster Plan has been activated, and the organization is unable to meet immediate patient needs, and upon presentation of a valid government issued photo identification issued by a state or federal agency (e.g., drivers license or passport), and at least one of the following: Current picture hospital ID card that clearly identifies professional designation. Current license to practice. Primary source verification of the professional license. Identification indicating that the individual is a member of the Disaster Medical Assistance Team (DMAT), or MRC, or ESAR-VHP, or recognized state or federal disaster organizations or groups. Identification indicating that the individual has been granted authority to render patient care, treatment, and services in disaster circumstances (such authority having been granted by a federal, state, or municipal entity). Identification by current hospital or Medical Staff member(s) who possess personal knowledge regarding the persons ability to act as a licensed independent practitioner during a disaster. 5.5 PROCTORING Proctoring may be defined as one or any combination of the following: retrospective chart review within one month of discharge; concurrent chart review within 24 hours of admission or the procedure in questionor earlier, if the chief specifies; availability on campus for immediate consultation and concurrent chart review within 24 hours of admission or the procedure in question; and/or the proctors presence during that portion of a procedure for which the hospital requires proctoring. (A proctor is permittedbut not requiredto intervene at any time during observations to assist the proctored physician if intervention is in the patients best interest. The proctor is not deemed the primary physician, but a proctor is also permitted to become the primary operator at any time during a case that he or she proctors.) If the Proctor is a member of the Medical Staff of Flagler Hospital, he/she must be privileged to perform the treatment/procedure being proctored. If the Proctor is not a member of the Medical Staff of Flagler Hospital, but is experienced in the treatment/procedure to be proctored, the physician will be asked to complete a special Proctoring Application, and the following information will be verified by the Medical Staff Services Department prior to the Proctor being allowed to proctor the treatment/procedure: Current license, in good standing. Current liability insurance equal to the amount currently required for Medical Staff Members. Proof of having privileges to independently perform the treatment/procedure at another accredited hospital, and proof of being in good standing at that hospital. Queries to the National Practitioner Data Bank, State Licensing Board, OIG/GSA, background check, at a minimum. Once the information is verified by the Medical Staff Services Department, and approved by the Credentials Committee, temporary privileges may be granted by the CEO, upon the recommendation of the President. The Proctor will be granted privileges to proctor for up to one year, pending completion of the additional credentialing process, and favorable recommendation by the Board of Trustees. If appointed as a Proctor� to the Medical Staff, the Proctor will be processed for reappointment for one additional year, at which time the Proctors association with Flagler Hospital will cease if the Proctor does not choose to apply for Membership and a change in Staff Category prior to his/her expiration date. If the Board does not make a favorable recommendation after full credentialing is completed, or at reappointment, the Proctors privileges will expire on the date the Board made such determination. A non-favorable recommendation by the Board shall not entitle a Practitioner to a Fair Hearing under these Bylaws. 5.6 � LOCATION FOR PATIENT FOLLOW-UP Practitioners with admitting Privileges must be able to identify a provision for follow up care. This provision may be an actual office or an effective formal arrangement with another licensed local physician. If the Practitioner does not have his/her own office based practice (eg Hospitalists, Interventional Radiologists, etc.), he/she must list the practice(s) location for which coverage is provided. This information must be provided at appointment and reappointment of the Practitioner. If any subsequent changes in the effective coverage plan occur, it is the responsibility of the Practitioner to notify the Medical Staff Services Department within ten business days of such change. ARTICLE VI. CORRECTIVE ACTION 6.1 ROUTINE MONITORING AND EDUCATION 6.1-1 RESPONSIBILITY It shall be the responsibility of the Board, the President and the Medical Executive Committee to design and implement an effective program (1)to monitor and assess the quality of professional practice in the Hospital and (2) to promote quality and efficiency of clinical and Hospital services by (a)providing education and counseling, which will be documented in writing, (b)issuing letters of admonition, warning or censure, as necessary, and (c)requiring routine monitoring when deemed appropriate by the Medical Executive Committee, for documented reason in writing. 6.1-2 PROCEDURE (a) Review and Studies: The Medical Executive Committee shall conduct regular patient care reviews and studies of practice within the Hospital in conformity with the Hospital's general Performance Improvement and Assessment Plan and shall investigate complaints and practice-related incidents in a fair and equitable fashion. Such reviews and studies may be conducted via delegation to another peer review or quality management body at the Hospital, or if the need arises, to an outside agent. (b) Informal Counseling: In order to assist Members in conforming their conduct or professional practice to the standards of the Medical Staff and the Hospital, the President or a designee may issue informal comments or suggestions, either orally or in writing. Such comments or suggestions shall be subject to the confidentiality requirements of all Medical Staff information and may be issued by the President, with or without prior discussion with the recipient, and with or without consultation with the Medical Executive Committee. Such comments or suggestions shall not constitute a restriction of Privileges, shall not be considered to be corrective action, as provided in Section 6.2 of this Article, and shall not give rise to procedural rights under Article VII of these Bylaws. If conduct or professional practice issues remain unresolved after Informal Counseling attempts, the President or designee may request the Member appear before the Medical Executive Committee, in accordance with Bylaws Section 6.4-4, to present his/her perspective and for potential resolution. (c) Following discussion of identified concerns with the affected Member, the Medical Executive Committee may authorize the President to issue a letter of admonition, warning or censure, or to require such Member to be subject to routine monitoring for such time as may appear reasonable. The term "routine monitoring," as used in this Section, shall mean review of a Member's practice for which the Member's only obligation is to provide reasonable advanced notice of admissions, procedures or other patient care activity. All Members of the Medical Staff, regardless of status, shall be subject to potential routine monitoring. The discussions of such actions with individual Members shall be informal. Such action shall not constitute a restriction of Privileges, shall not be considered to be corrective action, as provided in Section 6.2-6 of this Article, and shall not give rise to procedural rights under Article VII. (d) Actions taken pursuant to Subsection 6.1-2(b) of this Section shall need not be reported to the Medical Executive Committee. Actions taken pursuant to Subsection 6.1-2(c) of this Section shall be reported to the Medical Executive Committee promptly after such actions are taken. Such actions taken pursuant to Subsection 6.1-2(c) shall be documented in the Member's Medical Staff file. 6.2 CORRECTIVE ACTION 6.2-1 CRITERIA FOR INITIATION Any person may provide information in writing, with supportive documents if available, to the Medical Staff about the conduct, performance, or competence of its Members. When reliable information indicates a Member may have exhibited acts, demeanor, or conduct reasonably likely to be (1)detrimental to patient safety or to the delivery of quality patient care within the Hospital; (2)unethical; (3) contrary to the Medical Staff or Hospital Bylaws, Rules, Regulations, or standards; or (4)below applicable Medical Staff or Hospital professional standards, an investigation or action with respect to such Member may be initiated by the President, the CEO, the Medical Executive Committee or the Board. The CEO may request the assistance of the appropriate Department Chief or Staff Officer to hear any information and/or complaints brought to him in person. There will be a written record kept of such meetings. 6.2-2 INITIATION A request for an investigation must be in writing, submitted to the Medical Executive Committee, and supported by reference to specific activities or conduct alleged. If the Medical Executive Committee initiates the request, it shall record the reasons. 6.2-3 INVESTIGATION If the Medical Executive Committee concludes that an investigation is warranted, it shall document the reasons and it shall direct an investigation to be undertaken. The Medical Executive Committee may conduct the investigation itself, or may assign the task to an appropriate Medical Staff Officer or committee of the Medical Staff. The Medical Executive Committee in its discretion may appoint Practitioners who are not Members of the Medical Staff as temporary Members of the Medical Staff for the sole purpose of serving on a standing or ad hoc committee, should circumstances warrant. If the investigation is delegated to an Officer or body other than the Medical Executive Committee, such Officer or body shall proceed with the investigation in a prompt manner and shall forward a written report of the investigation to the Medical Executive Committee as soon as practicable. The report may include recommendations for appropriate corrective action. The Medical Executive Committee may refer the matter to the Physician's Aid Committee, consisting of at least five Members of the Medical Staff to be selected from a slate of ten (10) Medical Staff Members elected by Medical Staff Members at the Annual Staff meeting, to investigate and evaluate reports relating to a Practitioner's health, well-being, infirmity or impairment. Such committee may provide advice and counseling on a confidential basis as appropriate, unless the information received by the committee clearly demonstrates that the health, well-being, infirmity or impairment in question poses a risk of harm to others, in which event the Practitioner in question should be considered for corrective action. The Member shall be notified in writing that an investigation is being conducted and shall be given a reasonable time and opportunity to provide information in a manner and upon such terms as the investigating individual or body deems appropriate. The individual or body investigating the matter may, but is not obligated to, conduct interviews with persons involved; however, such investigation shall not constitute a "hearing" as that term is used in Article VII, nor shall procedural rules with respect to hearings apply. Despite the status of any investigation, at all times the Medical Executive Committee shall retain the authority and discretion to take whatever action may be warranted by the circumstances, including summary suspension, termination of the investigative process, or other action. A written record of such proceeding will be maintained. 6.2-4 PROCEDURES FOR PHYSICIAN COMPETENCY INVESTIGATION In the event a Practitioner should appear at the Hospital with the intention of directly or indirectly participating in patient care, and, in the opinion of Hospital Staff or a fellow Practitioner, appears at the time to be impaired, infirmed or incompetent in his or her capacity to render care, or in the event a Practitioner declares himself/herself to be impaired: (a) Upon notification, the President of the Medical Staff, Vice President of the Medical Staff, Department Chief or designated Physician must immediately meet with the Practitioner to assess the situation and report to the CEO or designee. The matter shall be referred to the Medical Executive Committee if the report of impairment, infirmity or incompetence to render care is founded. (b) If a question of impairment or intoxication exists, an appropriate sample(s) should be obtained immediately under direct supervision of the President of the Medical Staff, or designee, in accordance with all applicable laws and evaluated for possible mood-altering substances or other intoxicating substances. A blood alcohol measurement may be requested. If a question of infirmity or incompetence exists, the Practitioner shall be referred for an evaluation by the Medical Executive Committee or a Physician Aid Committee designated by the Medical Executive Committee. If a medical problem is believed to be present, appropriate evaluation will be required. (c) A Practitioner who fails to comply with the Medical Executive Committee's requests that he or she submit to evaluation or who refuses to produce body fluid samples under supervision or who does not comply with the Medical Executive Committee for evaluations or treatment will be subject to an appropriate corrective action determined by the Board, provided the practitioners rights under all applicable laws are respected. 6.2-5 MEDICAL EXECUTIVE COMMITTEE ACTION As soon as practicable after the conclusion of the investigation, the Medical Executive Committee shall take action, which may include, without limitation: (a) determination that no corrective action be taken; (b) deferring action for a reasonable time, not to exceed sixty (60) days, only where good cause circumstances warrant, and are documented; (c) issuing letters of admonition, censure, reprimand, or warning, although nothing herein shall be deemed to preclude Medical Staff Officers from issuing informal written or oral warnings, with a written memo to be placed in the Practitioners file, outside of the mechanism for corrective action. In the event such letters are issued, the affected Member may make a written response which shall be placed in the Member's file; (d) recommending the imposition of terms of probation or special limitation upon continued Medical Staff membership or exercise of Clinical Privileges, including, without limitation, requirements for co-admissions, mandatory consultation, or monitoring; (e) recommending reduction, modification, suspension or revocation of Clinical Privileges; (f) recommending reduction of membership status; (g) recommending suspension, revocation or probation of Medical Staff membership; and (h) taking other actions deemed appropriate under the circumstances, including referral to a substance abuse recovery network. 6.2-6 SUBSEQUENT ACTION (a) If corrective action as set forth in 6.2-5(d)-(h) is recommended by the Medical Executive Committee, the Medical Executive Committee shall give the Practitioner written notice of its recommendation as provided in Section 7.3-1. A copy of that notice shall be sent to the Board. Unless the Medical Executive Committee has decided to impose a summary suspension, the Medical Executive Committee's recommended action shall not go into effect until the Practitioner has either completed or waived any applicable hearing rights provided in Article VII. Any corrective action shall remain in effect until it expires according to its own terms or is modified or terminated by the Medical Executive Committee or the Board. (b) If the Medical Executive Committee does not recommend any corrective action which would entitle the Practitioner to a hearing as specified in Section 7.2, the Medical Executive Committee shall transmit a report of its investigation to the Board. The Board may: (1) adopt the Medical Executive Committee's recommendation; (2) remand the matter to the Medical Executive Committee for further review, investigation and recommendation, upon written notice specifying the reasons therefore; or (3) take different corrective action. In any event, the Board shall give great weight to the Medical Executive Committee's recommendation. For purposes hereof, the Board may appoint one or more designees to act as its representative(s) [the Designee(s)] with respect to interaction with the Medical Executive Committee; provided that the Medical Executive Committee is notified in writing of the identity and authority of such Designee(s) and the Medical Executive Committee shall be entitled to rely on same. The Board's action in adopting such recommendation or taking such other corrective action shall be deemed to be final. 6.2-7 INITIATION BY BOARD If the Medical Executive Committee does not investigate or recommend corrective action, the Board may direct the Medical Executive Committee to initiate an investigation or corrective action, but only after consultation with the Medical Executive Committee's designated representative regarding the Medical Executive Committee's reasons therefore. If the Medical Executive Committee fails to take action in response to such Board direction or after a request for remand as provided in Section 6.2-6 above, the Board may conduct its own investigation and/or impose corrective action, provided such corrective action must comply with Articles VI and VII of these Bylaws. 6.3 SUMMARY RESTRICTION OR SUSPENSION 6.3-1 CRITERIA FOR INITIATION Whenever the failure to immediately suspend or restrict a Members Clinical Privileges may result in an imminent danger to the health of any individual, due to breach of published Medical Staff Bylaws, Rules or Regulations, as determined by concurrent or retrospective evaluation, the Past President or Chief of Staff, the President of the Medical Staff, the CEO, or the Medical Executive Committee with clear documentation, may summarily restrict or suspend the Medical Staff membership or Clinical Privileges of such a Member, or may place the Member on a Precautionary Suspension. If placed on a Precautionary suspension, all Privileges of the Member will immediately be held in abeyance for a period not to exceed 72 hours. At the conclusion of the 72 hours (or sooner, if the situation is resolved), all Privileges of the Member will be reinstated, or a Summary Restriction or Suspension will be imposed. A Precautionary suspension is not considered a Professional Peer Review action, and therefore, is not reportable to the National Practitioner Data Bank. A member is not entitled to the Fair Hearing process if a Precautionary suspension is imposed. (a) If such restriction or suspension has been initiated by the Chief Executive Officer, he/she must make a good faith effort to consult with the President of the Medical Staff or the Past President or Chief of Staff, or in their absence, another Medical Staff Officer. For the purposes of this Section, a good faith effort to consult will require, at a minimum, documented attempts to reach the Past President or Chief of Staff, the President of the Medical Staff, or the designated Medical Staff Officer by Hospital page, and as necessary, by telephone calls to the current office, exchange, home, beeper (if available), and car phone (if available) numbers for such Medical Staff Officers. (b) If such restriction or suspension is initiated by an individual (the Chief of Staff, the President of the Medical Staff, or the Chief Executive Officer), the Medical Executive Committee shall meet to review the suspension within seven (7) days after the summary suspension is imposed, unless a later date is requested by the Member. Such summary restrictions or suspension shall become effective immediately upon imposition. The Medical Executive Committee shall immediately give written notice to the Board and the Member. The Medical Executive Committee may then recommend such further corrective action as may be appropriate, based upon information disclosed or otherwise made available to it and/or it may direct that an investigation be undertaken pursuant to Section 6.2-3. The summary restriction or suspension may be limited in duration and shall remain in effect for the period stated or, if none, until resolved as set forth herein. Unless otherwise indicated by the terms of the summary restriction or suspension, the Member's patients shall be promptly assigned to another Member by the President, considering, where feasible, the wishes of the patient in the choice of a substitute Practitioner. The notice of the suspension given to the Medical Executive Committee shall constitute a request for corrective action, and the procedures set forth in this Article VI shall be followed. The corrective action investigation should be completed, as soon as possible but within a period no less than 30 days, but not to exceed 60 days. The Practitioner shall be entitled to the procedural rights afforded by ArticleVII. The affected Practitioner shall be entitled to a hearing following investigation, which must be completed as soon as possible but within a period no less than 30 days but not to exceed 60 days of the request, unless mutually agreed upon, by both the affected Member and the Hospital. MEDICAL EXECUTIVE COMMITTEE ACTION As soon as possible but no later than five (5) business days after such summary restriction or suspension has been imposed, a meeting of the Medical Executive Committee shall be convened to review and consider the action. The affected Member shall be invited to this meeting, and shall be afforded an opportunity to make a statement concerning the issues under investigation, on such terms and conditions as the Medical Executive Committee may impose, although in no event shall any meeting of the Medical Executive Committee, with or without the Member, constitute a "hearing" within the meaning of Article VII, nor shall any procedural rules of Article VII apply. The Medical Executive Committee may modify, continue, or terminate the summary restriction or suspension, but in any event it shall furnish the Member with notice of its decision. 6.3-3 PROCEDURAL RIGHTS Unless the Medical Executive Committee promptly terminates the summary restriction or suspension, the Member shall be entitled to the procedural rights afforded by Article VII. 6.4 AUTOMATIC SUSPENSION OR LIMITATION In the following instances, the Member's Privileges or membership may be suspended or limited as described, which action shall be final without a right to hearing or further review. 6.4-1 LICENSURE (a) Revocation and Suspension: Whenever a Member's license or other legal credential authorizing practice in this State is partially or completely revoked or suspended, Medical Staff membership and Clinical Privileges shall be automatically revoked as of the date such action becomes effective. It is the Practitioners responsibility to notify the President or CEO immediately of such action taken against him. Failure to do so could result in further corrective action if so determined by the Medical Executive Committee. (b) Restriction: Whenever a Member's license or other legal credential authorizing practice in this state is limited or restricted by the applicable licensing or certifying authority, any Clinical Privileges which the Member has been granted at the Hospital that are within the scope of said limitation or restriction shall be automatically limited or restricted in a similar manner, as of the date such action becomes effective and at least throughout the term of the restriction. (c ) Probation: Whenever a Member is placed on probation by the applicable licensing or certifying authority, his or her membership status and Clinical Privileges shall automatically become subject to the same terms and conditions of the probation, as of the date such action becomes effective and at least throughout the term of the probation. (d) Expired: Upon the expiration of the license, the Practitioners Privileges will be considered immediately suspended and Medical Informatics will suspend any ordering privileges. It is the Practitioners duty to know the expiration date of their license. It is the Practitioners duty not to be practicing on an expired license. If the reappointment cycle lapses on an expired license, it is considered a voluntary suspension. If eligible, the Practitioner may request a Leave of Absence instead. If not eligible for a Leave of Absence, and there are no other options available, it will be considered an involuntary resignation. This will not be considered adverse in nature, and the Practitioner can not avail themselves to the Fair Hearing rights. 6.4-2 DRUG ENFORCEMENT ADMINISTRATION (DEA) CONTROLLED SUBSTANCE CERTIFICATE (a) Whenever a Member's DEA certificate is revoked, limited, suspended, or expired, the Member shall automatically and correspondingly be divested of the right to prescribe medications covered by the certificate, as of the date such action becomes effective and throughout at least the term of the revocation, limitation, or suspension. It is the Practitioners responsibility to notify the President or CEO immediately, if the DEA is revoked, limited, suspended, or expires. Failure to do so could result in further corrective action if so determined by the Medical Executive Committee. (b) Probation: Whenever a Member's DEA certificate is subject to probation, the Member's right to prescribe such medications shall automatically become subject to the same terms of the probation, as of the date such action becomes effective and throughout at least the term of the probation. 6.4-3 MEDICAL EXECUTIVE COMMITTEE DELIBERATION As soon as possible but no later than five (5) business days after action is taken or warranted as described in Section 6.4, the Medical Executive Committee shall convene to review and consider the facts. A written report of such deliberations will be generated and maintained. The Medical Executive Committee may then recommend such further corrective action as it may deem appropriate, based upon information disclosed or otherwise made available to it, and/or it may direct that an investigation be undertaken pursuant to Section 6.2-3. The Medical Executive Committee review and any subsequent hearing shall not address the propriety of the licensure or DEA certificate action, but shall address instead what action the Hospital should take. 6.4-4 FAILURE TO SATISFY SPECIAL APPEARANCE REQUIREMENT A Practitioner may be required by the Medical Executive Committee to attend a meeting at which his conduct or his quality of care is to be discussed. The Practitioner shall be so notified in writing, by certified mail, return receipt requested, at least seven (7) days in advance of the meeting. A Practitioner so notified will be expected to attend such meetings. A Practitioner's presence at such a meeting shall be deemed a waiver of the notice requirement. A failure by the Practitioner to attend a meeting when notice of mandatory attendance was required, unless excused by the President for a good cause in writing, shall result in automatic suspension of the Practitioner's Privileges. Such suspension shall remain in effect until the matter is resolved through any appropriate mechanism including corrective action, if necessary. 6.4-5 MEDICAL RECORDS Members of the Medical Staff are required to complete medical records within such reasonable time as may be prescribed by the Medical Staff Rules and Regulations. 6.4-6 PROCEDURAL RIGHTS -- MEDICAL RECORDS, PROFESSIONAL LIABILITY INSURANCE AND FAILURE TO PAY DUES Members whose Clinical Privileges are automatically suspended and/or who have resigned their Medical Staff membership pursuant to the provisions of 6.4-5 (failure to complete medical records under applicable Medical Staff Rules and Regulations) shall not be entitled to the procedural rights set forth in Article VII. Members whose Clinical Privileges are automatically suspended and/or who have resigned their Medical Staff membership pursuant to the provisions of 6.4-6 shall not be entitled to the procedural rights set forth in Article VII. 6.4-7 NOTICE OF AUTOMATIC SUSPENSION; TRANSFER OF PATIENTS Whenever a Member's Privileges are automatically suspended in whole or in part, a written notice of such suspension shall be given to the Member, the Medical Executive Committee, the CEO and the Board. Giving of such notice shall not, however, be required in order for the automatic suspension to become effective. In the event of any such suspension, the patients whose treatment is affected by the automatic suspension shall be assigned to another Practitioner by the President. The wishes of the patient and the Practitioner shall be considered, where feasible, in choosing a substitute. 6.4-8 AUTOMATIC TERMINATION If a Practitioner is suspended for more than six (6) months, his or her membership (or the affected Privileges, if the suspension is a partial suspension) shall be automatically terminated. Thereafter, reinstatement to the Medical Staff shall require application and compliance with the appointment procedures applicable to new applicants. ARTICLE VII. HEARINGS AND APPELLATE REVIEWS 7.1 GENERAL PROVISIONS 7.1-1 EXHAUSTION OF REMEDIES If adverse action described in Section 7.2 is taken or recommended, the applicant or Member agrees to follow and complete the procedures set forth in these Bylaws, including appellate procedures, before attempting to obtain judicial relief related to any issue or decision which may be subject to a hearing or appeal under this Article. 7.1-2 INDIVIDUAL EVALUATIONS VS. REQUESTS TO REVIEW RULES AND REQUIREMENTS Any Practitioner who wishes to challenge an established rule or requirement must notify the Medical Executive Committee and the Hospital's Board of the rule or requirement he or she wishes to challenge and of the basis for the challenge. The Board shall then consult with the Medical Executive Committee regarding the request. No Practitioner shall initiate any judicial challenge to a rule or requirement until one of the following requirements are met: (1) the Board, following consultation with the Medical Executive Committee, has either decided not to reconsider, or has upheld, the particular rule or requirement, or (2) the Practitioner provides written notice of the challenge to the Board, and the Board, during the next meeting which will occur as soon as reasonable but no more than forty-five (45) days after actual receipt of the notice, decides not to reconsider, or upholds, the particular rule or requirement. 7.1-3 DEFINITIONS Except as otherwise provided in these Bylaws, the following definitions shall apply under this Article: (a) Body whose decision prompted the hearing" refers to the Medical Executive Committee in all cases where the Medical Executive Committee or authorized Medical Staff Officers took the action or rendered the decision which resulted in a hearing being requested. It refers to the Board in all cases where the Board or authorized Officers, directors or committees of the Board took the action or rendered the decision which resulted in a hearing being requested. (b) Medical disciplinary cause or reason" refers to a basis for disciplinary action involving an aspect of the competence or professional conduct of a Practitioner which is reasonably likely to be detrimental to patient safety or to the delivery of patient care. (c) Practitioner" refers to the Physician, dentist, podiatrist or psychologist who has requested a hearing pursuant to Article VII. (d) Date of receipt" of any notice or other communication shall be deemed to be the date it was delivered personally to the addressee or, if delivered by certified mail, five (5) days after it was deposited, postage prepaid, in the United States mail. 7.1-4 SUBSTANTIAL COMPLIANCE Hospital's and/or Medical Staff Members substantial compliance with the procedures set forth in these Bylaws shall constitute compliance. 7.2 GROUNDS FOR HEARING Except as otherwise specified in these Bylaws, any one or more of the following actions or recommended actions shall be deemed actual or potential adverse action and constitute grounds for a hearing, if recommended for a medical disciplinary cause or reason: (a) denial of initial Medical Staff appointment; (b) denial of requested advancement in Medical Staff membership status, or category; (c) denial of Medical Staff reappointment; (d) imposition of, or voluntary acceptance of, restrictions on Medical Staff Privileges or membership for a cumulative total of more than thirty (30) days in any twelve (12) month period; (e) revocation of Medical Staff membership; (f) denial of Clinical Privileges; (g) involuntary reduction of current Clinical Privileges; (h) summary suspension of Clinical Privileges for more than fourteen (14) days; (i) termination of all Clinical Privileges; or (j) temporary privileges. 7.3 REQUESTS FOR HEARING 7.3-1 NOTICE OF ACTION OR PROPOSED ACTION In all cases in which action has been taken or a recommendation made as set forth in Section 7.2, said person or body shall give the Practitioner written notice as soon as reasonable but not later than five (5) business days, via certified mail, return receipt requested, of: 1) the recommendation or final proposed action, 2) that such action, if finalized by the Governing Board, shall be taken and reported to the Florida Agency for Health Care Administration, within 30 days of the Boards action, but prior to final appeals, and 3) the right to request a hearing pursuant to Section 7.3-2, and that such hearing must be requested within thirty (30) days or such right shall be deemed waived. 7.3-2 REQUEST FOR HEARING The Practitioner shall have thirty (30) days following receipt of notice of such action to request a hearing. The request shall be in writing addressed to the President with a copy to the CEO. In the event the Practitioner does not request a hearing within the time and in the manner described, the Practitioner shall be deemed to have waived any right to a hearing and accepted the recommendation or action involved. 7.3-3 REVIEW COMMITTEE When a hearing is requested, the President (if the Medical Executive Committee initiated the action) or the CEO (if the Board initiated the action) shall appoint an ad hoc review committee consisting of at least three (3) Medical Staff Members, and alternates as appropriate, who shall be randomly picked from a list of ten (10) elected by the Medical Staff, at the Annual meeting in April, shall not have actively participated in the formal consideration of the matter at any previous level (i.e., they shall not have acted as an accuser, investigator, fact finder or initial decision-maker in the same matter), shall not be in direct economic competition with the affected Practitioner, and shall stand to gain no direct financial benefit from the outcome.� In determining whether a Practitioner or Board Member is in direct economic competition with the affected Practitioner, account shall be taken and documented of the types of practice, locations of practice and referral patterns. Practitioners practicing in the same community should not necessarily be deemed to be in direct economic competition but Practitioners in the same specialty will. Knowledge of the matter involved shall not preclude a Member of the Medical Staff from serving as a Member of the ad hoc review committee. In the event that it is not feasible to appoint an ad hoc review committee from the Review Committee, the President may appoint Members from other Staff categories or Practitioners who are not Members of the Medical Staff. Such appointment shall include designation of the chairman. Membership on an ad hoc review committee should not include, where feasible, an individual practicing the same specialty as the Practitioner. 7.3-4 NOTICE TO PRACTITIONER Together with the notice stating the place, time and date of the hearing, the President, or the CEO, on behalf of the body whose decision prompted the hearing, shall state clearly and concisely in writing the reasons for the adverse final proposed action taken or recommended, including the acts or omissions with which the Practitioner is charged and a list of the charts in question, where applicable. 7.3-5 TIME AND PLACE FOR HEARING Upon receipt of a request for hearing, the President shall schedule a hearing. As soon as reasonable but no later than five (5) days from the date of the receipt of the request for a hearing, the President shall give notice to the Practitioner of the time, place and date of the hearing. This notice shall include a list of hearing rights. Unless extended by the ad hoc review committee, upon mutual agreement of the Ad Hoc Committee, and the affected member, the date of the commencement of the hearing shall be set as soon as reasonable but no less than 30 and no more than 45 days, from the date of receipt of the request for a hearing; when the request is received from a Practitioner who is under summary suspension the hearing shall be held as soon as the arrangements may reasonably be made but no less than 30 and no more than 45 days so as to comply with the goal of completing any corrective action proceedings and also holding a single hearing. 7.3-6 FAILURE TO APPEAR OR PROCEED Failure without good cause of the Practitioner to personally attend and proceed at such a hearing in an efficient and orderly manner shall be deemed to constitute voluntary acceptance of the recommendations or actions involved. 7.3-7 POSTPONEMENTS AND EXTENSIONS Once a request for hearing is initiated, postponements and extensions of time beyond the times permitted in these Bylaws may not be unreasonably denied by the ad hoc review committee, or its chairman acting upon its behalf, within the discretion of the committee or its chairman, on a showing of good cause. 7.4 HEARING PROCEDURE 7.4-1 PREHEARING CONFERENCE/HEARING (a) At the request of either party, each party, at least ten (10) days prior to the hearing, shall furnish to the other a written list of the names and addresses of the individuals, so far as is then actually anticipated, who will give testimony or evidence in support of that party at the hearing.� The witness list shall be amended when additional witnesses are identified.� A failure to comply with this requirement is good cause to postpone the hearing. (b) The Practitioner shall have the right to inspect at his or her expense, any documents relevant to the charges, and shall also have the right to receive, at least twenty (20) business days prior to the hearing, a copy of the documents relevant to the charges. (c ) The body whose decision prompted the hearing shall have the right to inspect any documents or other evidence relevant to the charges in the possession or control of the Practitioner or his or her representative(s) within ten (10) business days after receiving the request. (d) The failure by either party to provide access to this information at least twenty (20) business days before the hearing shall constitute good cause for a continuance. The right to inspect and copy by either party does not extend to confidential information referring solely to individually identifiable Members, other than the Practitioner under review. (e) The presiding officer shall consider and rule upon any request for access to information and may impose any safeguards the protection of the peer review process and justice requires. In so doing, the hearing officer shall consider: whether the information sought may be introduced to support or defend the charges; the exculpatory or inculpatory nature of the information sought, if any; the burden imposed on the party in possession of the information sought, if access is granted; and any previous requests for access to information submitted or resisted by the parties to the same proceeding. (f) The body whose decision prompted the hearing may object to the introduction of the evidence that was not provided by the Practitioner during an appointment, reappointment or privilege application review or during corrective action, despite the requests of the peer review body for such information.� The information may be barred from the hearing by the presiding officer unless the Practitioner can reasonably show that he Previously acted diligently and could not have submitted the information. (g) At the request of either party, the parties must exchange documents that will be introduced at the hearing. The request must be made at least 20 days prior to the hearing, and the documents must be exchanged at least ten (10) days prior to the hearing.� A failure to comply with this rule is good cause for the presiding officer to grant a continuance.� Repeated failures to comply shall be good cause for the presiding officer to limit introduction of any documents not provided to the other side in a timely manner. (h) The Practitioner shall be entitled to a reasonable opportunity to question and challenge the impartiality of the ad hoc review committee Members and the hearing officer. Challenges to the impartiality of any ad hoc review committee Member or the hearing officer shall be ruled on by the hearing officer. (i) It shall be the duty of the Practitioner and the body whose decision prompted the hearing to exercise reasonable diligence in notifying the presiding officer of any pending or anticipated procedural disputes as far in advance of the scheduled hearing as possible, in order that decisions concerning such matters may be made in advance of the hearing. Objections to any prehearing decisions may be succinctly made at the hearing. 7.4-2 REPRESENTATION The Practitioner shall have the right, at his or her expense, to attorney representation at the hearing, and shall provide notice to the Hospital of the identity of any attorney(s) who will represent the Practitioner at the hearing. 7.4-3 THE HEARING OFFICER The President or affected Practitioner shall have the right to request that a Hearing Officer preside at the hearing. The hearing officer shall be an attorney at law appointed by the President qualified to preside over a quasi-judicial hearing, with experience in Medical Staff matters. The hearing officer shall not be an attorney regularly utilized by the Hospital for Medical Staff matters. The hearing officer shall be a bona fide neutral party, shall gain no direct financial benefit from the outcome, shall disclose any potential conflict of interest with either parties, and shall not act as a prosecuting officer or as an advocate. The hearing officer shall endeavor to assure that all participants in the hearing have a reasonable opportunity to be heard and to present relevant oral and documentary evidence in an efficient and expeditious manner, and that proper decorum is maintained. The hearing officer shall be entitled to determine the order of or procedure for presenting evidence and argument during the hearing and shall have the authority and discretion to make all rulings on questions which pertain to matters of law, procedure or the admissibility of evidence. If the hearing officer determines that either side in a hearing is not proceeding in an efficient and expeditious manner, the hearing officer may take such discretionary action as seems warranted by the circumstances. 7.4-4 THE PRESIDING OFFICER The presiding officer at the hearing shall be the hearing officer as described in Section 7.4-3.� The presiding officer shall act to assure that all participants in the hearing have a reasonable opportunity to be heard and to present all relevant oral and documentary evidence, and that proper decorum is maintained.� He or she shall be entitled to determine the order of or procedure for presenting evidence and argument during the hearing.� He or she shall have the authority and discretion, in accordance with these Bylaws, to grant continuances, to rule on disputed discovery requests, to decide when evidence may not be introduced, to rule on challenges to ad hoc review committee Members, to rule on challenges to himself or herself serving as a presiding officer, and to rule on questions which are raised prior to or during the hearing pertaining to matters of law, procedure, or the admissibility of evidence. 7.4-5 RECORD OF THE HEARING At the request of the Practitioner undergoing a Fair Hearing, or at the request of the body initiating the Fair Hearing, a court reporter shall be present to make a record of the hearing and proceedings. The cost of attendance of the court reporter shall be borne by the party requesting the court reporter, and the cost of the transcript, if any, shall be borne by the party requesting it. If a court reporter is not requested by either party, the proceeding will be audio recorded. The hearing officer may, but shall not be required to, order that oral evidence shall be taken only on oath, under penalties for perjury, administered by any person lawfully authorized to administer such oath. 7.4-6 RIGHTS OF THE PARTIES Within reasonable limitations, both sides at the hearing may call and examine witnesses for relevant testimony, introduce relevant exhibits or other documents, cross-examine or impeach witnesses who shall have testified orally on any matter relevant to the issues, and otherwise rebut evidence, as long as these rights are exercised in an efficient and expeditious manner. The Practitioner may be called by the body whose decision prompted the hearing and examined as if under cross-examination. 7.4-7 MISCELLANEOUS RULES Judicial rules of evidence and procedure relating to the conduct of the hearing, examination of witnesses, and presentation of evidence shall not apply to a hearing conducted under this Article. Any relevant evidence, including hearsay, shall be admitted if it is the sort of evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of such evidence in a court of law. The ad hoc review committee may interrogate the witnesses or call additional witnesses if it deems such action appropriate. At its discretion, the ad hoc review committee may request or permit both sides to file written arguments. 7.4-8 BURDENS OF PRESENTING EVIDENCE AND PROOF (a) At the hearing, the body whose decision prompted the hearing shall have the burden of initially presenting evidence to support the charges and its recommendation. The Practitioner may present evidence in response. (b) An applicant for Medical Staff Membership or Privileges, or for an increase in Privileges shall bear the burden of persuading the committee, by a preponderance of the evidence, of his/her qualifications by producing information which allows for adequate evaluation and resolution of reasonable doubts concerning his/her current qualifications for membership and Privileges. An applicant shall not be permitted to introduce information requested by the Medical Staff but not produced during the application process unless the applicant establishes that the information could not have been produced previously in the exercise of reasonable diligence. (c ) Except as provided above for applicants for new Membership or Clinical Privileges, or an increase in Privileges, throughout the hearing, the body whose decision prompted the hearing shall bear the burden of persuading the hearing committee by a preponderance of the evidence, that its action or recommendation is reasonable and warranted. 7.4-9 ADJOURNMENT AND CONCLUSION The presiding officer may adjourn the hearing and reconvene the same without special notice at such times and intervals as may be reasonable and warranted, with due consideration for reaching an expeditious conclusion to the hearing. Upon conclusion of the presentation of oral and written evidence, or the receipt of closing written arguments, if submitted, the hearing shall be closed. The hearing committee shall thereupon, outside of the presence of the parties, conduct its deliberations and render a decision and accompanying report.� Final adjournment shall not occur until the ad hoc review committee has completed its deliberations. 7.4-10 BASIS FOR DECISION The decision of the ad hoc review committee shall be based on the evidence introduced at the hearing, including all logical and reasonable inferences from the evidence and the testimony. 7.4-11 DECISION OF THE AD HOC REVIEW COMMITTEE Within thirty (30) days after closure of the hearing [or within fifteen (15) days if the Practitioner is currently under suspension], the ad hoc review committee shall render a decision which shall be accompanied by a report in writing. A copy of said decision shall be forwarded to the Medical Executive Committee, the President, and the Board. The Practitioner shall be informed via certified mail, return receipt requested. The report shall contain a concise statement of the reasons in support of the decision, including findings of fact and a conclusion articulating the nexus between the evidence produced at the hearing and the conclusion reached. Both the Practitioner and the body whose decision prompted the hearing shall be provided a written explanation of the procedure for appealing the decision. The decision of the ad hoc review committee shall be subject to such rights of appeal or review as described in these Bylaws. 7.5 APPEAL 7.5-1 TIME FOR APPEAL Within thirty (30) days after receipt of the decision of the committee, either the Practitioner or the body whose decision prompted the hearing may request an appellate review. A written request for such review shall be delivered to the President, the CEO and the other party in the hearing. If a request for appellate review is not requested within such period, both sides shall be deemed to have accepted the action involved and it shall thereupon become the final action of the Medical Staff.� Such final recommendation shall be considered by the Board as soon as reasonable but not later than forty-five (45) days.� The recommendation shall be given great weight, but shall not be binding on the Board. If the Board were to differ from the Medical Staff decision, it will document its reasons in writing and notify the President of the Medical Staff and the affected Practitioner and committee. 7.5-2 GROUNDS FOR APPEAL A written request for an appeal shall include an identification of the grounds for appeal and a clear and concise statement of the facts in support of the appeal. 7.5-3 TIME, PLACE AND NOTICE If an appellate review is to be conducted, the Board shall, after receipt of notice of appeal, schedule a review date and cause each side to be given notice of the time, place and date of the appellate review. The date of appellate review shall not exceed thirty (30) days, from the date of such notice, unless mutually agreed upon by the affected Member and the Hospital, provided however, that when a request for appellate review concerns a Member who is under suspension which is then in effect, the appellate review shall be held as soon as the arrangements may reasonably be made, but not to exceed fifteen (15) business days from the date of the notice. The time for appellate review may be reasonably extended by the Board only for good cause, which shall be documented. 7.5-4 APPEAL BOARD The Board may sit as the appeal board, or it may appoint an appeal board which shall be composed of not less than three (3) members of the Board. If the Board is unable to identify a sufficient number of members to constitute a 3-person appeal board, the Board may appoint ad hoc Board members from other boards directly related to the Hospital, solely for the purpose of serving as appeal board members. Knowledge of the matter involved shall not preclude any person serving as a member of the appeal board, so long as that person did not participate in the matter at any previous level, (e.g., as an accuser, investigator, fact finder, or initial decision-maker).� The Chairman of the Board may appoint a Hearing Officer to preside at the appellate hearing. The appeal Board members shall disclose any conflict of interest. 7.5-5 APPEAL PROCEDURE The proceeding by the appeal board shall be in the nature of an appellate hearing based on the record of the hearing before the ad hoc review committee, provided that the appeal board may accept additional oral or written evidence, subject to a foundational showing that such evidence could not have been made available to the ad hoc review committee in the exercise of reasonable diligence and subject to the same rights of cross-examination or confrontation provided at the ad hoc review hearing; or the appeal board may remand the matter to the ad hoc review committee for the taking of further evidence and for decision. Each party shall have the right to be represented by legal counsel or any other representative designated by that party in connection with the appeal, to present a written statement in support of his or her position on appeal, and to personally appear and make oral argument. The appeal board may thereupon conduct, at a time convenient to itself, deliberations outside the presence of the appellant and respondent and their representatives. The appeal board shall present to the Board its written recommendations as to whether the Board should affirm, modify, or reverse the ad hoc review committee decision, or remand the matter to the ad hoc review committee for further review and decision. 7.5-6 DECISION (a) Except as provided in Section 7.5-6(b) within thirty (30) days after the conclusion of the appellate review proceedings, the Board shall render a final decision. The Board shall give great weight to the recommendation of the ad hoc review committee and shall not act arbitrarily or capriciously. The Board is allowed, however, to exercise its independent judgment in determining whether a Practitioner was afforded a fair hearing, whether the decision is reasonable and warranted, and whether any Bylaws, Rule or Regulation relied upon by the ad hoc review committee in reaching its decision is reasonable and warranted. (b) Except when the matter is remanded for further review and recommendation, the final decision of the Board following the appeal procedures set forth in this Article shall be effective immediately and shall not be subject to further review.� If the matter is remanded to the ad hoc review committee, or any other body or person, said committee, body, or person shall promptly conduct its review and make its recommendations to the Board in accordance with the instructions given by the Board.� The time for a further review and report shall not exceed forty-five (45) business days, except as the parties may otherwise stipulate. (c) The decision shall be in writing, shall specify the reasons for the action taken, and shall be forwarded to the President, the Medical Executive Committee, and the subject of the hearing. 7.5-7 JOINT CONFERENCE COMMITTEE (a) The purpose of the Joint Conference Committee, as defined in Section 10.11, shall be to review and make recommendations to the Board with respect to matters regarding Medical Staff membership and Clinical Privileges, and corrective or disciplinary action, where the proposed final action of the Board is contrary to the recommendation of the Medical Executive Committee. Additionally, the Joint Conference Committee shall serve as an appeal board under this Article with respect to adverse action taken by the Board without prior recommendation by Medical Executive Committee, following all of the procedural rules as defined in Section 7.5-3, 7.5-4, 7.5-5 and 7.5-6. (b) If the Board's final action is not in accordance with the final recommendation of the Medical Executive Committee, such action of the Board shall not yet be effective, and the Board shall promptly refer the matter to the Joint Conference Committee for further review, which shall review and make such recommendation as soon as reasonable but not later than ten (10) business days. The Board shall give special written notice of such referral to the parties. At its next meeting after receipt of such Joint Conference Committee's recommendation, the Board shall take its final action, which may or may not be in accordance with that of either the Medical Executive Committee or the Joint Conference Committee, and which shall be effective immediately and not subject to further hearing or appeal. The Board's action on the matter following receipt of the Joint Conference Committee's recommendation shall constitute its final action. 7.5-8 RIGHT TO ONE HEARING No Practitioner shall be entitled to more than one evidentiary hearing and one appellate review on any matter which shall have been the subject of adverse action or recommendation. 7.6 EXCEPTIONS TO HEARING RIGHTS 7.6-1 TERMINATION OF TEMPORARY PRIVILEGES No Practitioner is entitled to the hearing or appeal rights provided in this Article by virtue of the expiration, non-renewal or termination of temporary Clinical Privileges, unless such action is expressly stated to be for a medical disciplinary cause or reason. 7.6-2 CLOSED STAFF OR EXCLUSIVE USE DEPARTMENTS, AND HOSPITAL CONTRACT PRACTITIONERS (a) The fair hearing provisions of this Article do not apply to new applicants whose application for Medical Staff membership and Privileges was denied because the Privileges he or she seeks are granted only pursuant to a closed Staff or exclusive use policy.� Such a Practitioner shall have the right, however, to request that the Board review the denial, and the Board shall have the discretion to determine whether to review such a request and, document its decision in writing, and if it decides to review the request, to determine whether the Practitioner may personally appear before and/or submit a statement in support of his or her position. (b) The fair hearing rights of this Article do not apply to Practitioners serving as Hospital contract Practitioners.� Removal of these Practitioners from office shall instead be governed by the terms of their individual contracts and agreements with the Hospital.� The hearing rights of this Article, however, shall apply to the extent that an action is taken which must be reported to the Florida Agency for Health Care Administration or National Practitioner Data Bank, and to the extent that Medical Staff membership status or Clinical Privileges which are independent of the Practitioner's contract are also removed or suspended. 7.6-3 AUTOMATIC SUSPENSION OR LIMITATION OF PRACTICE PRIVILEGES Practitioners whose Clinical Privileges are automatically suspended and/or limited for any of the reasons specified in ArticleVI of these Bylaws are not entitled to any hearing rights. 7.7 SEALING DISCIPLINARY ACTION RECORDS Upon petition, the Medical Executive Committee, in its sole discretion, may seal previous disciplinary action records upon a showing of good cause or rehabilitation. ARTICLE VIII. OFFICERS 8.1 OFFICERS OF THE MEDICAL STAFF The Officers of the Medical Staff shall be: (a) President (b) Vice President (c) Secretary-Treasurer (d) Past President or Chief of Staff (e) Member At Large 8.2 QUALIFICATIONS OF OFFICERS Officers, except for the Past President, shall be elected at the Annual Meeting of the Medical Staff. The outgoing President of the Medical Staff shall automatically assume the office of Past President when his/her successor assumes the office of the President. If the President is re-elected to an additional term, then a Chief of Staff shall be elected at the Annual Meeting of the Medical Staff. Officers shall be Members of the Active Staff at the time of nomination and election, and must remain Members in good standing during their term of office. Failure to maintain such status shall immediately create a vacancy in the office involved. 8.3 ELECTION OF OFFICERS (a) Officers shall be elected at the Annual Meeting of the Medical Staff. Only Members of the Active Staff shall be eligible to vote. Voting shall be by a show of hands unless a secret ballot is requested. If three (3) successive tie votes occur for any officer position, the voting for that position will be suspended, and will take place at the next regularly scheduled General Staff meeting, or at a special General Staff meeting called for that purpose. Officers will be elected in the even calendar years. Department Chiefs will be elected in the odd calendar years. In the event of a vacancy, the term of the Officer elected to fill the vacancy in the interim, will be in effect only until the next regularly-scheduled election. For the purpose of being eligible to run for a second successive term, completion of the interim term by the newly-elected Officer shall count as one term if the duration is 12 months or more, but shall not count as one term if the duration is less than 12 months. (b) The nominating committee shall consist of at least three Members of the Active Staff, appointed by the President. These members will be selected from ten (10) members elected by the Medical Staff at their Annual meeting in April prior to the year in which the elections are held. This committee shall offer one or more nominees for each Officer and shall present its nominations at the monthly meeting prior to the elections. The nominating committee is not barred from nominating one of its members. (c) Nominations may also be made from the floor at the time of the annual meeting. 8.4 TERM OF OFFICE All Officers shall serve for a term of two years, or until a successor is elected. Officers shall serve for no more than two successive terms in the same office. Officers shall take office on the first day of the Medical Staff year, May 1. No Physician can hold simultaneous Officer and/or Department Chief and/or Division Chief positions. 8.5 VACANCIES IN OFFICE (a) An Officer may resign at any time by giving written notice to the President of the Medical Staff. The Medical Staff President may resign at any time by giving written notice to the Medical Executive Committee. Such resignations shall become effective immediately on receipt unless otherwise stated in the notice. (b) An Officer may be removed from office by a two-thirds vote of the Medical Executive Committee subject to the approval of a simple majority of the Medical Staff. Grounds for such removal may include, but not be limited to, failure to perform functions of the position or failure to meet the qualifications for the position. All such grounds will be memorialized in writing. (c) Vacancies during the Medical Staff year shall be filled as follows: (1) President. If there is a vacancy in the office of President, the Vice President shall serve the term which remains. Past President or Chief of Staff, Vice President, Secretary/Treasurer, Member At Large vacancies shall be filed by a vote of the Medical Staff at the first regular meeting following the vacancy, or at a special meeting held for that purpose. For the purpose of being eligible to run for a second successive term, completion of the interim term by the newly-elected Officer shall count as one term if the duration is 12 months or more, but shall not count as one term if the duration is less than 12 months. (d) If an officer unexpectedly becomes unavailable and cannot perform his/her duties as an officer for a continuous period exceeding 60 calendar days, the officers position will be vacated. 8.6 DUTIES OF OFFICERS 8.6-1 PAST PRESIDENT or CHIEF OF STAFF (a) The Past President or Chief of Staff will have a seat with full voting rights on the Medical Executive Committee and shall be a Member ex officio of all committees of the Medical Staff. He shall serve as Chairman of the Credentials Committee. (b) The Past President shall serve as Chairman of the Credentials Committee. If a Chief of Staff is elected, who had not served as President of the Medical Staff in the last ten years, the Chairmanship of the Credentials Committee will remain with the most recent Past President. (c) The Past President or Chief of Staff shall serve in an advisory capacity during the two years following his tenure as President and shall have the authority of the President in the event that both the President and the Vice President are absent. (d) The Past President will serve as Chairman of the Clinical Quality Review Committee. If a Chief of Staff is elected, who had not served as President of the Medical Staff in the last ten years, the Chairmanship of the Clinical Quality Review Committee will remain with the most recent Past President. 8.6-2 PRESIDENT The President shall be elected by the Active Staff and serve as the Chief Administrative Officer of the Medical Staff to: (a) Act in coordination with the hospital CEO in all matters of mutual concern within the Hospital. (b) Call, preside and be responsible for the agenda of all meetings of the Medical Staff after having sought advice and covent of the Medical Staff. (c) Serve as Chairman of the Medical Executive Committee. (d) Serve as ex officio Member of all other Medical Staff committees. (e) Be responsible for the enforcement of the Medical Staff Bylaws and Rules and Regulations, for implementation of sanctions where these are indicated, and for the Medical Staff's compliance with procedural safeguards in all instances where corrective action has been requested against a Member of the Medical Staff. (f) Appoint committee Members to all standing, special and multidisciplinary Medical Staff committees except for the Medical Executive Committee. A willing staff member will not be unreasonably denied a right to serve on any committee of his/her choosing. (g) Serve as the individual responsible for the organization and conduct of the Medical Staff, with whom the Governing Board shall directly consult on all matters related to the quality of medical care provided to patients at the Hospital and other matters of mutual concern at each Governing Board meeting. 8.6-3 VICE PRESIDENT The Vice President shall be elected by the Active Staff. In the absence of the President, the Vice President shall assume all the duties and have the authority of the President. He shall automatically succeed the President when the latter fails to serve for any reason. He shall be a voting Member of the Medical Executive Committee. 8.6-4 SECRETARY-TREASURER The Secretary-Treasurer shall be elected by the Active Staff. The Secretary-Treasurer shall keep accurate and complete minutes of all Medical Staff meetings, call meetings at the request of the President, attend to all correspondence and perform other such duties as ordinarily pertain to his office. He may be assisted in his duties by a recording secretary who may be an employee of the Hospital. He shall also be responsible for the proper handling of Staff funds in accordance with the instructions from the Medical Staff. He shall be a voting Member of the Medical Executive Committee. MEMBER AT LARGE The Member At Large shall be elected by the Active Staff. The Member At Large shall primarily be responsible to represent the views of the Medical Staff and assist the President in keeping the Medical Staff apprised of Medical Executive Committee deliberations that affect the Medical Staff. The Member At Large will be a voting member of the Medical Executive Committee. 8.7 CONFLICT OF INTEREST All Officers of the Medical Staff shall execute the Flagler Hospital Acknowledgement and Certification With Respect to Conflicts of Interest Policy� on an annual basis. This statement will be signed and presented to the Medical Staff Services Department by June 1st of each year. Disclosures will be acknowledged at the first General Staff meeting and Medical Executive Committee meeting following the June 1st deadline. ARTICLE IX. CLINICAL DEPARTMENTS AND DIVISIONS 9.1 ORGANIZATION OF DEPARTMENTS There shall be clinical departments of Medicine, Surgery, Orthopedics, Pediatrics, Obstetrics/Gynecology, Family Medicine, Cardiology, Radiology and Emergency Medicine. A new Department may be formed upon the approval of the Medical Executive Committee and the Medical Staff after being approved by the parent Department from which it comes. The newly-formed Department will be set up on a provisional basis for one year at which point it will be re-evaluated by the Medical Executive Committee. Objectives for the first year will be defined by the prospective Department at the time of application for departmental status. Permanent Department status may be confirmed, or Provisional Departmental status may be extended or denied at the conclusion of the first year, at the discretion of the MEC. The MECs performance evaluation of the newly-formed Department, at the conclusion of the first year, will be based upon the progress the newly-formed Department made toward completing its objectives. During the Provisional Status of a Department, the Chief shall sit on the MEC, without a vote, or stipend. 9.2 QUALIFICATIONS, SELECTION AND TENURE OF DEPARTMENT CHIEFS Each Chief shall be a Member of the Active Medical Staff best qualified by training, experience and demonstrated ability for the position. Each Chief shall either be Board Certified in his/her appropriate specialty Board, or be deemed comparatively competent through the credentialing process. Each Chief shall be elected by his department at the first meeting at which a quorum is present, after the Annual Meeting of the Medical Staff. Commencing in 1999, each Chief shall serve for a term of two years, or until a successor is elected. Chiefs shall take office on May 1st. If the election takes place on May 2nd or later in the election year, then the Chief shall take office immediately following the election. A Department Chief may hold two consecutive two-year terms. If all Department Members belong to one professional medical group, upon unanimous agreement of Active Staff Members within that Department, a qualifying Active Staff Department Member serving as Chief may continue to serve as the Chief of the Department for an additional term(s). Officers will be elected in the even calendar years. Department Chiefs will be elected in the odd calendar years. In the event of a vacancy, the term of the Department Chief elected to fill the vacancy in the interim, will be in effect only until the next regularly-scheduled election. For the purpose of being eligible to run for a second successive term, completion of the interim term by the newly-elected Department Chief shall count as one term if the duration is 12 months or more, but shall not count as one term if the duration is less than 12 months. The most recent past Chief of the Department will be the Acting Chief of the Department at any time the current Chief of the Department is unavailable. In the event of a tie vote, the Department may consider any of the following options: a) continue to re-vote until the tie is broken, in accordance with Roberts Rules of Order, b) split the term with one Physician acting as Chief during the first year, and the other Physician acting as Chief during the second year. If the candidates choose to split the term, any time served as a Department Chief during that term will be counted as if the candidate served a full two-year term for purposes of running for a successive term. 9.3 VACANCY The Chief of a Department may resign at any time by giving written notice to the President of the Medical Staff. Such resignation shall become effective immediately on receipt unless otherwise stated in the notice. A Chief of a Department may be removed from office by a two-thirds vote of the Active Staff of the respective Department. Grounds for such removal may include failure to perform functions of the position or failure to meet the qualifications for the position. If a Chief unexpectedly becomes unavailable and cannot perform his/her duties as a Chief for a continuous period exceeding 60 calendar days, the Chiefs position will be vacated. If there is a vacancy in the position of Chief of a Department, the respective department shall elect a Chief at the first regular monthly meeting at which a quorum is present, following the vacancy, or at a special meeting held for that purpose. For the purpose of being eligible to run for a second successive term, completion of the interim term by the newly-elected Department Chief shall count as one term if the duration is 12 months or more, but shall not count as one term if the duration is less than 12 months. For the purpose of qualifying for voting and/or running for Chief of the Department, when a vacancy occurs, eligibility will be based on the immediate past Medical Staff Year attendance. In the event of a vacancy in the office, and there are less than two eligible candidates for a Chief, a Temporary Administrative Chief may be appointed by the Medical Staff President. The Temporary Administrative Chief will not have voting privileges on issues outside of their Department. Once a minimum of two Members of the Department become eligible, a special election will take place. If, during the election year, the current Chief has completed his/her maximum term, and there are no other eligible Members in the Department that wish to serve as Chief, the Department will be placed on a one year probationary status, and a Temporary Administrative Chief will be appointed by the Medical Staff President, upon approval of the Medical Executive Committee. 9.4 FUNCTIONS OF DEPARTMENT CHIEFS Each Chief shall: (a) Be accountable for all professional and administrative activities within his department. (b) Be a Member of the Medical Executive Committee, giving guidance on the overall medical policies of the Hospital, and making recommendations and suggestions regarding his own service in order to assure quality patient care. (c ) Maintain continuing review of the professional performance of all Practitioners with Clinical Privileges in his department and report thereon to the Medical Executive Committee. (d) Participate in measures to enforce the Bylaws and Rules and Regulations within his department and for preparing and annually revising the rules of his service. (e) Be responsible for implementation within his department of actions taken by the Medical Executive Committee of the Medical Staff. (f) Transmit to the Medical Executive Committee his department's recommendations concerning appointment, reappointment and the delineation of Clinical Privileges for all Practitioners in his department. (g) Be responsible for the orientation, teaching, education and research program in his department. (h) Participate in every phase of the administration of his department through cooperation with nursing service and administration in matters affecting resources, to include space, patient care, including personnel, supplies, special regulations, standing orders and techniques. (i) Assist in the preparation of such annual reports, including budgetary planning as may be required by the Medical Executive Committee. (j) Maintain a permanent record of the department's proceedings, findings and actions, and shall transmit these reports to the Medical Executive Committee of the Medical Staff. (k) Recommend to the Medical Staff the criteria for Clinical Privileges that are relevant to the care provided in the department. (l) Integrate the department or service into the primary functions of the organization. (m) Be responsible for all clinically related activities of the department. (n) Assess and recommend to the relevant Hospital authority off-site sources for needed patient care services not provided by the department or the organization. (o) Coordinate and integrate interdepartmental and intradepartmental services. (p) Develop and implement policies and procedures that guide and support the provision of services. (q) Recommend a sufficient number of qualified and competent persons to provide care or service. (r) Determine that qualifications and competence of department or service personnel who are not licensed independent Practitioners and who provide patient care services. (s) Maintain quality control programs, as appropriate. (t) Be responsible for continuous assessment and improvement of the quality of care and services provided within his department. 9.5 FUNCTIONS OF DEPARTMENTS Each clinical department shall establish its own criteria, consistent with the Policies of the Medical Staff and Board of Trustees, for the granting of Clinical Privileges in the service. Each department will develop criteria that reflects current knowledge and clinical experience relating to the care or service it provides. Such criteria will be used as a tool in the development of an ongoing program of the review of the quality of care provided by the Practitioners assigned to the department. The specific organization, scope and method of review will be devised by each department in accordance with the Hospitals overall Performance Improvement Plan. 9.6 ASSIGNMENT TO MULTIPLE DEPARTMENTS A physician may have membership in multiple Departments, as long as competence in each Department specialty is demonstrated. Criteria used by the individual Departments to determine eligibility may include residency/fellowship training, or board eligibility/certification. A physician may be Chairman of only one Department at any one time, and have only one vote on the Medical Executive Committee or at the General Staff meetings, at any one time. Therefore, no Physician can hold simultaneous Officer and/or Department Chief and/or Division Chief positions. Physicians can attend meetings in both Departments, but can only vote in one Department. If a Practitioner is granted membership in more than one Department, the Practitioner may serve on more than one ER Call rotation, but is not obligated to serve on more than one ER Call rotation. The Practitioner will be assigned to a primary ER call for the Department which would most benefit from that Practitioners clinical expertise. The primary Department assignment for ER Call purposes will be determined by the Medical Executive Committee. Any Member belonging to multiple Departments, will be allowed to qualify for voting privileges and election as Chief of any Department to which the Member belongs (pursuant to Sections 11.4 and 12.8). Any Member belonging to multiple Departments, will be allowed to qualify for voting at the General Staff meetings/hold an Officer position, by meeting the attendance requirement outlined in Section 11.4, for regular Medical Staff meetings, and meeting the attendance requirement outlined in Section 12.8 of the total meetings of each Departments to which the Member belongs. 9.7 ORGANIZATION OF DIVISIONS Each Department, at their discretion, shall have the option to propose the formation of a Division of Specialists within their Department. A division will be formed upon the recommendation of the applicable Department, the Medical Executive Committee and the approval of the Medical Staff. The newly-formed Division will be set up on a provisional basis for one year at which point it will be re-evaluated by the Department. Objectives for the first year will be defined by the prospective Division at the time of application for Division status. Permanent Division status may be confirmed, or Provisional Division status may be extended or denied at the conclusion of the first year, at the discretion of the Department. The Departments performance evaluation of the newly-formed Division, at the conclusion of the first year, will be based upon the progress the newly-formed Division made toward completing its objectives. At the conclusion of the extension, the Department must either recommend or reject the Divisions request to become a new Division. No new request from that Division can be made for a minimum of one year. 9.8 QUALIFICATIONS, SELECTION AND TENURE OF DIVISION CHIEFS Each Chief shall be a Member of the Medical Staff best qualified by training, experience and demonstrated ability for, and interest in, the position. Each Chief shall be elected by his Division at the first meeting at which a quorum is present, after the Annual Meeting of the Medical Staff. Elections will take place in the odd calendar years. Each Chief shall serve for a term of two years, but may serve for up to two successive two-year terms. Chiefs shall take office on May 1st. If the election takes place on May 2nd or later in the election year, then the Chief shall take office immediately following the election. If all Division Members belong to one professional medical group, upon unanimous agreement of Active Staff Members within that Division, a qualifying Active Staff Division Member serving as Chief may continue to serve as the Chief of the Division for an additional term(s). The Most recent past Chief of the Division will be the Acting Chief of the Division at any time the current Chief of the Division is unavailable. In the event of a tie vote, the Division may consider any of the following options: a) continue to re-vote until the tie is broken, in accordance with Roberts Rules of Order, b) split the term with one Physician acting as Chief during the first year, and the other Physician acting as Chief during the second year. If the candidates choose to split the term, any time served as a Department Chief during that term will be counted as if the candidate served a full two-year term for purposes of running for a successive term. 9.9 VACANCY The Chief of a Division may resign at any time by giving written notice to the Chief of the Department. Such resignation shall become effective immediately on receipt unless otherwise stated in the notice. A Chief of a Division may be removed from office by a two-thirds vote of the Medical Staff Practitioners in the respective Division. Grounds for such removal may include failure to perform functions of the position or failure to meet the qualifications for the position. If a Chief unexpectedly becomes unavailable and cannot perform his/her duties as a Chief for a continuous period exceeding 60 calendar days, the officers position will be vacated. If there is a vacancy in the position of Chief of a Division, the respective Division shall elect a Chief at the first regular monthly meeting at which a quorum is present, following the vacancy, or at a special meeting held for that purpose. For the purpose of being eligible to run for a second successive term, completion of the interim term by the newly-elected Division Chief shall count as one term if the duration is 12 months or more, but shall not count as one term if the duration is less than 12 months. For the purpose of qualifying for voting and/or running for Chief of the Division, when a vacancy occurs, eligibility will be based on the immediate past Medical Staff Year attendance. In the event of a vacancy in the office, and there are less than two remaining eligible candidates for a Chief, a Temporary Administrative Chief may be appointed by the Medical Staff President. The Temporary Administrative Chief will not have voting privileges on issues outside of their Division. Once a minimum of two Members of the Division become eligible, a special election will take place. If, during the election year, the current Chief has completed his/her maximum term, and there are no other eligible Members in the Division that wish to serve as Chief, the Division will be placed on a one year probationary status, and a Temporary Administrative Chief will be appointed by the Medical Staff President, upon approval of the Medical Executive Committee. 9.10 FUNCTIONS OF DIVISION CHIEFS Each Chief shall: Transmit to the Department Chief the Divisions recommendations regarding equipment, staffing, policies, etc., as appropriate. Maintain a permanent record of the Divisions proceedings, findings, and actions, and transmit these reports to the Department. Recommend to the Department the criteria for Clinical Privileges that are relevant to the care provided by the Division. Integrate the Division into the primary functions of the Department. Develop and implement policies and procedures that guide and support the provisions of the Division. Recommend to the Department a sufficient number of qualified and competent persons to provide care or service within the Division. 9.11 CONFLICT OF INTEREST All Department Chiefs shall execute the Flagler Hospital Acknowledgement and Certification with Respect to Conflicts of Interest Policy� on an annual basis. This statement will be signed and presented to the Medical Staff Services Department by June 1st of each year. Disclosures will be acknowledged at the first General Staff meeting and Medical Executive Committee meeting following the June 1st deadline. ARTICLE X. COMMITTEES PREAMBLE: Any interested Medical Staff Member may request attendance at any Committee, except MEC, peer review activities and credentialing activities, by requesting observer status from the Chair, the denial of which will be explained by the Chair at the next Medical Staff meeting. Observation status does not entitle the interested Medical Staff Member to participate in discussions at the Committee, unless invited to do so, by the Chair of the Committee. Interested Medical Staff Members may review agendas of Medical Staff meetings, on the date of the meeting, in the Medical Staff Office. 10.1 BYLAWS COMMITTEE 10.1-1 COMPOSITION The Bylaws Committee shall be composed of at least five Members of the Active Medical Staff, who shall serve staggered terms, appointed annually by the Medical Staff President. No individual should be allowed membership on the Bylaws Committee if within the past three years, he has had a curtailment of Privileges, suspension, or where an adverse decision has been rendered, but not yet resolved under the Fair Hearing Plan. Upon such adverse decision, an existing Member shall become an ex officio Member without vote, until a final decision is rendered by the Board. 10.1-2 DUTIES (a) Review the current Bylaws and General Rules and Regulations, and make all necessary proposed changes. (b) Submit any recommendation to the Medical Executive Committee for changes in these documents. 10.1-3 MEETINGS This Committee shall meet as often as necessary, at the call of its Chairman, but at least annually. It shall maintain a record of its proceedings, and should report it activities and recommendations to the Medical Executive Committee. 10.1-4 RECORDS A comprehensive written record will be maintained and will be made available for review upon request by a Medical Staff Member. 10.2 CANCER COMMITTEE 10.2-1 COMPOSITION This Committee shall be composed of all specialties in the hospital concerned with the care of, or the treatment of, the cancer patient. At a minimum, the Committee shall include at least one representative from Surgery, Medical Oncology, Radiation Oncology, Diagnostic Radiology and Pathology. The physician Cancer Liaison will also be a member of this Committee. There will also be representatives from Social Services, Oncology Nursing, Administration, Tumor Registry, Quality Management, Palliative Care and Clinical Research. Other disciplines may be added as necessary. 10.2-2 DUTIES The duties of the Cancer Committee shall be to provide leadership for the delivery and coordinated multidisciplinary approach to cancer patient management; develop annual clinical and programmatic goals; supervise the Tumor Registry; establish and implement a plan to evaluate the cancer registry data and activity; monitor cancer conference activity, community outreach activities, and the number and participation of patients accrued to cancer related clinical trials; coordinate the offering of a yearly educational program other than the cancer conference; and develop and disseminate an annual report. 10.2-3 MEETINGS The Cancer Committee shall meet at least quarterly, and shall maintain written reports of its activities. It shall make a record of its proceedings and actions which shall be reported to the Medical Executive Committee. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.2-4 RECORDS A Comprehensive written record will be maintained and will be made available for review upon request by a Medical Staff Member. 10.3 CARDIOVASCULAR COMMITTEE 10.3-1 COMPOSITION This committee shall consist of all Active Staff Cardiothoracic Surgeons, Vascular Surgeons, Invasive Cardiologists, and representation from Radiology and Emergency Medicine. Additionally, representatives from Administration, Nursing Services, and Cardiopulmonary/Cardiology Services shall be consulting members of the Committee. 10.3-2 DUTIES This committee shall provide medical direction to the Cardiovascular Program in accordance with established policies. 10.3-3 MEETINGS This committee shall meet at least quarterly, shall maintain a permanent record of its findings, proceedings and actions, and shall make a report thereof to the Medical Executive Committee of the Medical Staff. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.3-4 RECORDS A Comprehensive written record will be maintained and will be made available for review upon request by a Medical Staff Member. 10.4 CLINICAL QUALITY REVIEW COMMITTEE 10.4-1 COMPOSITION The Clinical Quality Review Committee shall be composed of one Physician representative from the Departments of Medicine, Family Medicine, Cardiology, Surgery, Orthopedic Surgery, OB/GYN, Radiology and Emergency Medicine to be nominated by their Department, and appointed by the President. A representative from the Department of Pediatrics will attend upon specific request. Additional Members of the Medical Staff may be appointed annually by the President. In addition, the Vice President of Nursing, the Quality Management Director, the Utilization Review Coordinator, and an administrative representative shall be consulting members of the committee. Ancillary service directors will be asked to attend meetings and participate as consulting members when appropriate. 10.4-2 DUTIES The Clinical Quality Review Committee shall be responsible for the following functions: (a) The review of the utilization of Hospital services. Such review shall address over-utilization, under-utilization and inefficient scheduling of resources. (b) Development, review and revision of the Hospital's utilization review plan (available for review in the Medical Staff Office). Any revisions, amendments will be communicated with the Medical Staff in writing. (c) Oversight of the review of the ongoing program of quality and appropriateness review conducted by the Hospital's ancillary and support services. In addition, the ongoing program includes reports from clinical quality teams, medical error reports, medication error reports, pertinent findings from significant/sentinel events,status reports of core measures and the national patient safety goals. Any revisions, amendments will be communicated with the Medical Staff in writing. (d) Conduct its proceeding in accordance with the current Performance Improvement Plan (available for review in the Medical Staff Office), approved by the Board of Trustees. 10.4-3 MEETINGS The Clinical Quality Review Committee shall meet at least every other month, and shall maintain a permanent record of its findings, proceedings, and actions, and shall transmit these reports to the MEC of the Medical Staff. 10.5 CONTINUING MEDICAL EDUCATION COMMITTEE 10.5-1 COMPOSITION This committee shall consist of at least three Members of the Medical Staff. Additionally, there shall be appropriate representation from Hospital management and Nursing Service, who shall be consulting members of the committee. 10.5-2 DUTIES (a) As part of its oversight for the Medical Library, this Committee shall: (1) recommend the acquisition, purchase or discarding of educational materials; (2) consider, and select Department recommendations for book and journals to be ordered; (3) recommend to the Medical Executive Committee an annual library/education budget; (4) establish rules and regulations for the use of the Medical Library. (b) As part of its oversight for Continuing Medical Education, this Committee shall: (1) solicit suggestions from the Medical Staff for topics of future CME programs; (2) consider, select and prioritize topics for CME programs; (3) work with the Quality Management Department to determine specific topics for additional physician education; (4) provide guidance to the Medical Staff Office, as needed, to implement CME activities; (5) work with the Hospital Staff Development Department in their endeavor to obtain CEUs for presentations offered under the physician CME program; (6) Consider activities as they relate, in part, to the type and nature of care, treatment, and services offered by Flagler Hospital. (c) The Chair of this Committee shall serve as the liaison with the Florida Medical Association for the purpose of obtaining CMEs and/or obtaining/maintaining accreditation by the Florida Medical Association. 10.5-3 MEETINGS This committee shall meet at least quarterly, shall maintain a permanent record of its findings, proceedings and actions, and shall transmit these reports to the Medical Executive Committee of the Medical Staff. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.5-4 RECORDS A Comprehensive written record will be maintained and will be made available for review upon request by a Medical Staff Member. 10.6 CREDENTIALS COMMITTEE 10.6-1 COMPOSITION The Credentials Committee shall consist of the current Past President who shall serve as Chairman, and the two most recent past Medical Staff Chiefs of Staff who are still appointees to the Active Staff (if one of the Past Presidents is unable to serve, the next most recent Past President shall serve), and the current Vice President and Secretary/Treasurer. If three Past Presidents are not available/willing to serve, members may be appointed to the Committee, as necessary, by the Medical Executive Committee, and the Medical Staff will be notified of such an addition. If any current member is not able to attend a meeting(s), a standing Alternate may be named by the President. The Alternate must be a previous member of the Credentials Committee or the MEC within the past 10 years. The Alternate will be allowed to vote in the absence of a Credentials Committee member, and will be counted in the quorum when necessary. If a Credentials Committee member cannot complete their term for any reason, the Alternate will automatically assume that position for the remainder of the departing members term; the President will then appoint another Alternate as described above. 10.6-2 DUTIES The function of the Credentials Committee shall be: (a) To review the credentials of all applicants, to make investigations of and to interview applicants as may be necessary and to make recommendations for appointment and the delineation of Clinical Privileges in compliance with these Bylaws. (b) To report to the Medical Executive Committee on each applicant for Medical Staff appointment and/or Clinical Privileges. (c) To review reports on specific persons holding appointments to the Medical Staff that are referred by the Medical Executive Committee, the Clinical Quality Review Committee and any other committees to the extent that those reports concern the Clinical Privileges of Medical Staff appointees and to make such recommendations as provided by these Bylaws. (d) In any instance where a member of the Credentials Committee has a conflict of interest in any matter involving an applicant or appointee to the Medical Staff which comes before the Credentials Committee, that member shall not participate in the discussion or voting on the matter and shall absent himself from the meeting during that time, although he may be asked to answer any questions concerning the matter before leaving. 10.6-3 MEETINGS The Credentials Committee shall meet at least every other month, unless there are no applications ready for review, but may hold an interim meeting to discuss an urgent� matter at the discretion of the Credentials Committee Chair to accomplish its duties and shall make a permanent record of its proceedings and actions and shall report its recommendations to the Medical Executive Committee. 10.7 CRITICAL CARE COMMITTEE 10.7-1 COMPOSITION This committee shall consist of no less than three Members of the Medical Staff, and will include Members from the Departments of Medicine and Surgery. Frequent users of the ICU shall be given preference. Additionally, representatives from Administration and Nursing Service shall be consulting members of the Committee. 10.7-2 DUTIES This committee shall provide medical direction to the Critical Care Unit in accordance with established Critical Care Unit policies. The Critical Care Committee shall develop, periodically review and receive reports from a program of quality management which monitors and evaluates the quality and appropriateness of care rendered in the Critical Care Unit(s). 10.7-3 MEETINGS This committee shall meet at least quarterly, shall maintain a permanent record of its findings, proceedings and actions, and shall make a report thereof to the Medical Executive Committee of the Medical Staff. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.7-4 RECORDS A Comprehensive written record will be maintained and will be made available for review upon request by a Medical Staff Member. 10.8 ETHICS COMMITTEE 10.8-1 COMPOSITION The Ethics Committee shall consist of the President of the Medical Staff (or designee); physician representation to include at a minimum one representative from the Surgery Department, Family Medicine Department, Medicine Department, and Anesthesia Service; the Chief Operating Officer of the Hospital; the Nursing Director of the ICU; the Risk Manager; and representatives from pastoral care and social services/ethics, and other members as needed. 10.8-2 DUTIES The Ethics Committee will have a functioning process available to staff, patients, families and other decision makers to provide for the review, assessment and resolution of dilemmas in patient care, and to assist in the development and implementation of processes concerning: patient rights and responsibilities advance directives resolution of conflict in care or treatment decisions withholding resuscitation and forgoing or withdrawing life-sustaining treatment pain management end of life care decisions 10.8-3 MEETINGS The Ethics Committee shall meet as often as necessary to meet its functions. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.8-4 RECORDS This committee shall maintain a permanent record of its findings, proceedings, and actions, and shall report to the Medical Executive Committee. 10.9 INFECTION CONTROL COMMITTEE 10.9-1 COMPOSITION The Infection Control Committee shall consist of at least three Members of the Medical Staff appointed annually by the President. In addition, the Infection Control Coordinator, Vice President of Nursing, Director of Pharmacy, a representative of the Laboratory and Administration shall be consulting members of the committee. 10.9-2 DUTIES This committee shall be responsible for the surveillance of inadvertent Hospital infection potentials, review and analysis of actual infections, promotion of preventative and corrective programs designed to minimize infection hazards, and the supervision of infection control in all phases of the Hospital's activity including: (a) Operating rooms, delivery rooms, recovery rooms, special care units. (b) Sterilization procedures by heat, gas, chemicals or otherwise. (c) Isolation procedures. (d) Prevention of cross-infection by anesthesia apparatus or respiratory therapy equipment. (e) Testing of Hospital personnel for carrier status. (f) Disposal of infectious materials. (g) Other situations as required by the Medical Executive Committee. 10.9-3 MEETINGS This committee shall meet at least quarterly, shall maintain a permanent record of its findings, proceedings, and actions, and shall transmit these reports to the Medical Executive Committee of the Medical Staff. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.9-4 RECORDS A Comprehensive written record will be maintained and will be made available for review upon request by a Medical Staff Member. 10.10 JOINT CONFERENCE COMMITTEE 10.10-1 COMPOSITION The Joint Conference Committee shall be a standing committee composed of the President of the Medical Staff, and one other member of the Medical Staff, appointed by the President, two members of the Board of Trustees and the Hospital CEO. The representatives of the Medical Staff shall include the President. The chairmanship shall be alternated between the Board of Trustees and the Medical Staff each year. Each member shall have one vote. 10.10-2 DUTIES The Joint Conference Committee shall conduct itself as a forum for the discussion of matters of Hospital policy and practice, especially those which pertain to efficient and effective patient care, and shall provide liaison with the Board of Trustees and the hospital CEO. The Joint Conference Committee will participate in the mediation process when there is disagreement on issues of significance between the Organized Medical Staff (OMS) and the Medical Executive Committee (MEC) and/or between the OMS/MEC and the Board of Trustees. The Joint Conference Committee shall also perform all duties requiring adjudication according to Articles VI and VII. 10.10-3 MEETINGS The Joint Conference Committee shall meet at least quarterly, and shall maintain written reports of its activities. 10.10-4 RECORDS A comprehensive written record will be maintained and, except for issues of credentialing, peer review, or quality management, will be made available for review upon request by a medical staff member. 10.11 MEDICAL EXECUTIVE COMMITTEE 10.11-1 COMPOSITION The Medical Executive Committee shall be a standing committee and shall consist of the Medical Staff Officers and Chiefs of the Departments of Surgery, Orthopedics, Medicine, Family Medicine, Cardiology, Pediatrics, OB/GYN, Radiology and Emergency Medicine. The Medical Staff Officer and Department Chief positions are elected by the Medical Staff; therefore, the mechanism to elect and remove MEC Members is described in Articles VIII and IX, respectively. No Physician shall have more than one vote on the Medical Executive Committee at any one time. The Hospital CEO shall be a Member ex officio of the Medical Executive Committee. The Medical Executive Committee may include other Licensed Independent Practitioners, at the Medical Executive Committees discretion. 10.11-2 DUTIES The duties of the Medical Executive Committee shall be: (a) To conduct all routine business for the Medical Staff and to represent and act on behalf of the Medical Staff, subject only to such limitations as may be imposed by these Bylaws. The Medical Staff shall review any decision of the Medical Executive Committee with the exception of decisions regarding credentials, the delineation of Clinical Privileges, and/or corrective action taken pursuant to Articles IV, V and VI. The Medical Executive Committee is empowered to act on behalf of the organized Medical Staff between meetings of the organized Medical Staff, to include implementing any Rule and Regulation, Policy and Procedure mandated by federal, state, local legislation or authoritative agency, to include accreditation agencies. If the MEC refers an item to a Department/Division, it is expected that the Department/Division respond within 90 days. Additional time may be requested by the Department/Division Chief. If the matter is urgent, at the discretion of the Medical Executive Committee, the time can be shortened. During this process, the Medical Staff President will have the authority to communicate with the appropriate Department/Division Chief about the issue. (b) To coordinate the activities and general policies of the various clinical departments and services. (c) To receive and act upon committee reports. (d) To implement policies of the Medical Staff not otherwise the responsibility of the services. (e) To provide liaison between the Medical Staff, Hospital CEO and the Board of Trustees. (f) To recommend action to the Hospital CEO on matters of a medico-administrative nature. (g) To make recommendations on Hospital management matters, equipment needs and long range planning to the Board of Trustees. (h) To report to the Board of Trustees the care rendered to patients in the Hospital. (i) To ensure that the Medical Staff is kept abreast of the accreditation program and informed of the accreditation status of the Hospital. (j) To provide for the preparation of all meeting programs, either directly or through delegation to a program committee. (k) To review the credentials of all applicants and to make recommendations for Staff membership, assignments to departments and delineation of Clinical Privileges. (l) To review and make recommendations on requests for corrective action pursuant to Article VI of these Bylaws. (m) To review periodically all information available regarding the performance and clinical competence of all Staff Members and other Practitioners with Clinical Privileges, and as a result of such reviews, to make recommendations for reappointments and renewal, or changes in Clinical Privileges. (n) To take all reasonable steps to ensure professionally ethical conduct and competent clinical performance on the part of all Members of the Medical Staff, including initiation of and/or participation in Medical Staff corrective or review measures when warranted. (o) Responsibility for the review and revision of the general Medical Staff Bylaws and Rules and regulations annually. (p) Assist with acquisition and maintenance of The Joint Commission accreditation (as it applies to the Medical Staff), for which purposes it shall form a sub-committee to include key Hospital personnel who are important to the implementation of the accreditation program. (q) Assist with development and maintenance of methods for the protection and care of Hospital patients and others at the time of internal or external disaster. It shall form subcommittees specifically to adopt and periodically review the written plan for the care, reception and evacuation of mass casualties, and shall assure that such plan is coordinated with the inpatient and outpatient services of the Hospital and that it adequately reflects developments in the Hospital community and the anticipated role of the Hospital in the event of disaster in nearby communities, and the plan is rehearsed by key personnel at least twice annually. (r) It shall report at each General Medical Staff meeting. Participate in any hospital deliberation affecting the Medical Staff. No Member shall vote on a question in which he has direct personal or pecuniary interest not common to other Members of the Medical Staff organization. (u) Review the composition of the Medical Staff to determine which specialties are over/under-staffed. 10.11-3 MEETINGS The Medical Executive Committee shall meet at least every other month and maintain a comprehensive permanent written record of its proceedings and actions. Its record will be available to any interested medical staff member in the Medical Staff Office upon reasonable request, except for peer review, credentialing and quality management information. 10.12 METABOLIC AND BARIATRIC SURGERY COMMITTEE 10.12-1 COMPOSITION The Metabolic and Bariatric Surgery Committee shall consist of the Metabolic and Bariatric Surgery Physician Director, all Metabolic and Bariatric Surgeons, the Metabolic and Bariatric Surgery Coordinator, Metabolic and Bariatric Surgery Reviewer and Administrative representatives, and other Physicians and healthcare providers as deemed necessary. 10.12-2 DUTIES The duties of the Metabolic and Bariatric Committee shall be to: Provide leadership for the delivery, with a coordinated multidisciplinary approach, to patient management. Develop and evaluate annual goals and objectives for the clinical, educational, and programmatic activities related to bariatric surgery. Supervise the Bariatric Program and its functions. Establish priorities, and assume responsibility for, a Performance Improvement program as it pertains to evaluating the bariatric program and the care of bariatric surgical patients. Prepare an annual comprehensive program evaluation report. Ensure compliance with the standards of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), to include: Quality control of MBSAQIP Registry Data Establish and implement a plan to evaluate the MBSAQIP data registry twice yearly with the semiannual SAR report Quality Improvement Peer Review Process for all adverse events Mortality reports submitted/reviewed by MBS committee Community Outreach Monitor community outreach 10.12-3 MEETINGS The Metabolic and Bariatric Committee shall meet at least quarterly, and shall maintain written reports of its activities. It shall make a record of its proceedings and actions which shall be reported to the Medical Executive Committee. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.12-4 RECORDS A comprehensive written record will be maintained and will be made available for review upon request by a Medical Staff Member 10.13 PHARMACY AND THERAPEUTICS COMMITTEE 10.14-1 COMPOSITION The Pharmacy and Therapeutics Committee shall consist of at least four Members of the Medical Staff plus one representative each from administration, nursing, and pharmacy, who shall be consulting members of the committee. Each member shall have one vote. 10.13-2 DUTIES The Pharmacy and Therapeutics Committee shall have the following functions: (a) Review of all significant untoward drug reactions. (b) Review and approval of policies and procedures related to the selection, distribution, handling, use and administration of drugs. (c) Evaluate the use of investigational or experimental drugs. (d) Review the prophylactic, therapeutic, and empiric use of drugs. The selection of drugs to be monitored should be based on the following: (1) The drug has known or suspected potential for adverse reactions or for interactions with other drugs, and may, therefore, present a significant risk of adverse reaction. (2) The drug is used in patients with a high risk of adverse reaction. (3) The drug has been identified for monitoring by another aspect of the Hospital's quality management program. (4) The drug is one of the most frequently prescribed. (5) Review and advise on the content of the Hospitals drug Formulary and special purpose drug lists. 10.13-3 MEETINGS This committee shall meet at least quarterly, shall maintain a permanent record of its findings, proceedings and actions, and shall transmit these reports to the Medical Executive Committee of the Medical Staff. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.13-4 RECORDS A Comprehensive written record will be maintained and will be made available for review upon request by a medical staff member. 10.14 PROFESSIONAL PRACTICE COMMITTEE 10.14-1 COMPOSITION The Professional Practice Committee (PPC) shall be composed of 14 voting members who are Active Members of the Medical Staff and who have continuous Flagler Hospital patient contacts and have an active practice in the community from the following specialties:� Four Members from Adult Medicine (one Internal Medicine, one Cardiologist, one Medicine Subspecialist, one Family Medicine); four Members from Surgery (one General Surgery, one Orthopedics, and two additional Surgical Members); one Member from each of the following specialties:� OB/GYN, Emergency Medicine, Anesthesiology, Pediatrics, Radiology, and one Intensivist. Additional voting Staff Members may be appointed to the PPC upon the recommendation of the Medical Staff President, and approval by the MEC, if deemed necessary. Practitioners from other specialties may be invited to the meeting as needed. Current Department Chiefs and voting MEC members are not eligible to be PPC members. The Vice President of the Medical Staff shall be an ex officio member, without vote. In addition, the Vice President of Performance Improvement, the Quality Management Director and case review quality support staff as determined by the Chair are ex-officio members of the PPC. 10.14-2 DUTIES The Professional Practice Committee shall be responsible for the following functions: Define Practitioner relevant performance measures and targets for the Practitioner General Competencies in collaboration with the appropriate specialties. Evaluate Practitioner performance and compliance with these indicators via either case review or aggregate data for patterns and trends and determine if improvement opportunities exist. Assure accountability for the development of improvement plans when appropriate. Oversee any Medical Staff specialty specific peer review activities. Conduct its proceeding in accordance with the current Performance Improvement Plan (available for review in the Medical Staff Services Department), approved by the Board of Trustees. 10.14-3 MEETINGS The PPC will meet at least 10 times per year. A quorum for purposes of making final determinations or recommendations for individual case reviews or improvement opportunities based on aggregate data will require the presence of 50% of the voting PPC members at a regularly scheduled meeting. A majority will consist of a majority of voting PPC members present. 10.15 STROKE COMMITTEE 10.15-1 COMPOSITION The Stroke Committee shall be an interdisciplinary group consisting of the Neurology Medical Director, Emergency Care Center (ECC) Medical Director, ECC Administrative Director, ECC QA nurse, neurosurgery representative, internal medicine physician representative, Directors of the MICU/SICU/CVS, Director of the Neurology Nursing Unit, Pharmacy Director, Laboratory Director, Quality Management representatives including the Chief Medical Officer, Chief of the Radiology Department or his/her designee, Radiology Administrative Director, representatives from Rehab Services and Social Services and Cardio-Pulmonary services, Neuro certified Nurses (CNSN) and representatives from the nursing staff. Other representatives may be asked to attend as necessary such as St. Johns County EMS Services, Marketing & Strategic Planning, etc. 10.15-2 DUTIES Provides leadership for stroke patient management with a coordinate multidisciplinary approach. Develops and evaluates annual goals and objectives for the clinical, community outreach, quality improvement, and programmatic activities related to stroke. Oversees the Stroke Coordinators function and role particularly in the gathering of stroke data. Reviews the stroke core measure data on a quarterly basis to discern opportunities for improvement. Ensures compliance with the standards of The Joint Commission. Revises the written stroke protocols/order sets as necessary. Evaluates the patients perception of the quality of care of the Flagler Hospital stroke program. Increases knowledge of prevention and management of stroke to the St. Johns County community, Flagler Hospital staff and professionals. 10.15-3 MEETINGS The Stroke Committee shall meet at least quarterly, and shall maintain written reports of its activities. 10.15-4 RECORDS It shall make a record of its proceedings and actions which shall be reported to the Medical Executive Committee. 10.16 TRANSFUSION COMMITTEE 10.16-1 COMPOSITION The Transfusion Committee shall be composed of at least four members of the Medical Staff to include a Pathologist and representatives from the Surgery, Medicine and OB/GYN Departments. There shall be consulting members from Quality Management, Laboratory, Nursing Services and the Blood Bank. 10.16-2 DUTIES The Transfusion Committee will perform the following function: Blood Review The evaluation of the appropriateness of transfusions. The evaluation of all transfusion reactions. The development and approval of policies relating to the distribution, handling, use, and administration of blood and blood components. The review of the adequacy of the transfusion services. The review of ordering practices for blood and blood products. 10.16-3 MEETINGS This committee shall meet quarterly, shall maintain a permanent record of its findings, proceedings, and actions, and shall report to the Executive Committee. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.17 UTILIZATION REVIEW COMMITTEE 10.17-1 COMPOSITION The Utilization Review Committee will consist of a minimum of three Active Staff members. The Vice President of Quality Management and at least one Utilization Review nurse shall be non-voting members 0.17-2 DUTIES The Utilization Review Committee will review admissions and appropriate criteria, and will educate the Medical Staff in this area. These reviews will involve the review of medical records. The committee may request additional information directly from physicians providing care to these patients. The committee will report to the Medical Executive Committee, and will provide a quarterly synopsis to the Clinical Quality Review Committee. 10.17-3 MEETINGS The Utilization Review Committee ordinarily will meet at least quarterly. A quorum shall constitute those present, with a minimum of three voting Practitioner Committee members. 10.17-4 RECORDS This committee shall maintain a permanent record of its findings, proceedings, and actions, and shall report to the Medical Executive Committee. ARTICLE XI. MEDICAL STAFF MEETINGS 11.1 REGULAR MEETINGS (a) Staff meetings shall be held at least every other month to review and approve the action recommended by the Medical Executive Committee of the Medical Staff. The meetings will be business and educational. (b) The monthly Staff meeting occurring in April, the month preceding the start of the Medical Staff year, shall be the Annual Staff Meeting at which election of Officers for the ensuing period shall be conducted. Every other year at the Annual Staff Meeting (the same year Department Chiefs are elected) there will be an election of the Pool of 10. Medical Staff Officers, Department Chiefs and Division Chiefs are ineligible to serve on the Pool of 10. Vacancies in the Pool of 10 will be filled by election at the next regularly-scheduled General Staff meeting. (c) The Medical Executive Committee shall, by standing resolution designate time and place for all regular Staff meetings. Notice of the original resolution and any changes thereto shall be given to each Member of the Staff in the same manner as provided in Section 11.2(b) of this Article XI for notice of a special meeting. (d) The agenda and supporting document of the Medical Staff meeting, will be available electronically two (2) business days in advance. 11.2 SPECIAL MEETINGS (a) The President of the Medical Staff, the Medical Executive Committee or not less than one-fourth of the Members of the Active Medical Staff may, at any time, file a written request with the President that a special meeting of the Medical Staff be called, within seven days of the filing of the request. (b) Written or electronic notice stating the place, day and hour of any special meeting of the Medical Staff shall be sent to each Member of the Medical Staff, not less than three nor more than seven days before the date of such meeting, by or at the direction of the President. If mailed, the notice of the meeting shall be deemed delivered when deposited, postage prepaid, in the United States mail, addressed to each Staff Member at his address as it appears on the records of the Hospital. Notice may also be sent to other Medical Staff groups who have so requested. The attendance of a Member of the Medical Staff at a meeting shall constitute a waiver of notice of such meeting. No business shall be transacted at any special meeting except that stated in the notice calling the meeting. 11.3 QUORUM The presence of forty (40) Active Staff Physicians at the beginning of any meeting shall constitute a quorum for all actions during that meeting including amendment of these Medical Staff Bylaws, Rules and Regulations. 11.4 ATTENDANCE REQUIREMENTS Each Member of the Active and Provisional Active Staff shall be required to attend, in person, at least forty percent of all regular Medical Staff meetings each year. At any time a Member is on an approved Leave of Absence, the Members attendance requirements will be suspended and the Members absence from meetings during that time frame shall not affect the Members attendance record for that Medical Staff year. The failure to meet the foregoing annual attendance requirement shall result in loss of voting rights for the next election of Officers or Department Chief or Division Chief, and loss of eligibility to run for Office, as an Officer or Department Chief or Division Chief, in the next election. Attendance at Medical Staff meetings will be monitored and recorded on a yearly basis beginning at the start of each Medical Staff year, and will be expunged at the end of each Medical Staff year. New attendance monitoring will begin with each Medical Staff year, and will be counted for whichever election (Officers or Department Chief or Division Chief) is scheduled to take place at the election meeting that year. 11.5 AGENDA 11.5-1 SPECIAL MEETING The agenda at any special meeting shall be: (a) Reading of the notice calling the meeting. (b) Transaction of the business for which the meeting was called. (c) Adjournment. (d) The order of procedure for all regular and special meetings of the Medical Executive Committee and Medical Staff shall be governed by the most recently amended "Roberts Rules of Order". If discrepancy occurs between Roberts Rules of Order and these Bylaws, these Bylaws shall take precedence. 11.6 MEDICAL EXECUTIVE COMMITTEE RECOMMENDATIONS Any action recommended by the Executive Committee, excluding credentialing related activity, will take effect upon either: 1) An affirmative majority vote of those present and eligible to vote, at which a quorum is present, and at which the initial presentation is made, or 2) A majority of members eligible to vote at the next meeting, (whether or not there is a quorum) following two consecutive meetings, at which a quorum was not present. A quorum must be present to discuss or vote upon proposed changes to the Medical Staff Bylaws, Rules & Regulations. ARTICLE XII. COMMITTEE AND DEPARTMENT AND DIVISION MEETINGS 12.1 REGULAR MEETINGS Each committee and clinical department and division shall be required to meet as stipulated in these Bylaws, and on such other occasions as may be considered necessary to meet their responsibility. Clinical Departments and Divisions shall meet at least quarterly. 12.2 SPECIAL MEETINGS A special meeting of any committee or clinical department or division may be called by or at the request of the Chair/Chief, by the President of the Medical Staff, or by one-third of the respective group's Members, but not less than two. 12.3 NOTICE OF MEETINGS Written or oral notice stating the time, day and place of any special meeting or of any regular meeting not held pursuant to resolution shall be given to each member of the committee or clinical department or division, not less than three days before the time of such meeting by the person or persons calling the meeting. If mailed, the notice of meeting shall be deemed delivered when deposited in the United States mail addressed to the Member at his address at it appears in the Hospital's records, postage prepaid. The attendance of a Member at a meeting shall constitute a waiver of notice of such meeting. An agenda and supporting documents for any meeting will be available electronically two (2) business days prior to the meeting. 12.4 QUORUM Quorum requirements will be determined by each individual Department/Division and documented in the Departments Rules and Regulations. The presence of one fourth (1/4th) but not less than three voting Medical Staff Members, of a committee at the beginning of the meeting shall constitute a quorum, unless stated otherwise in these Bylaws. Election of a Department or Division Chief shall require a quorum of a minimum of fifty percent (50%) of eligible voters. The vote may take place at a regularly-scheduled meeting of the Department or Division, or at an interim meeting of the Department or Division, as long as all eligible voters are notified, in writing, at least seven (7) calendar days in advance of the interim meeting, and providing the notice clearly states that the election of the Department or Division Chief will take place at that meeting. If an eligible voter cannot attend the election meeting, but wishes to cast a vote for a candidate, the eligible voting Member may present to the Medical Staff Services Department, between 8:00 am � 4:30 pm, Monday � Friday, during the week immediately preceding the election meeting, and complete an official ballot, which the Member will place in an envelope and seal. The ballot will remain sealed and will be kept in the possession of the Medical Staff Services Department until the election meeting, at which time it will be counted. At the time the written ballot is completed, the Member will sign a document stating they did vote; each voting Member will only be allowed one vote, either by ballot as noted above, or at the election. The presence of at least three voting Medical Staff members shall constitute a quorum at any Task Force meeting or Ad Hoc meeting of the Medical Staff. Any Member of an official division shall not count as part of the quorum at the department meeting, unless the individual is present. 12.5 MANNER OF ACTION The action of a majority of the Members present at a meeting at which a quorum is present shall be the action of a committee or clinical department or division. Action may be taken without a quorum with a unanimous consent in writing (setting forth the action so taken), signed by each Member entitled to vote thereat. If, after two meetings within four consecutive months, there is no quorum for a vote, the members will be notified electronically by the Medical Staff Office, that the issue will be read at the next meeting for a third time, and will be subject to a vote of a simple majority of voting members present. In matters requiring prompt action or approval by Departments/Committees, the membership in attendance at the second reading, may exercise a fast-track� option if there is no quorum at the second reading. The fast-track� option provides that a simple majority present at the second reading, may call for an electronic vote of all voting members of Departments/Committees to dispose of the votable issue within five business days. If the majority of voting members of Departments/Committee members wish to abort the fast-tract� process, they must respond within the five business day voting period, to stop the process. Their response must be electronic and must stipulate Abort Fast-Track�. All voting and responses must be submitted to the Medical Staff Office electronically, thereby documenting date and time of response automatically. All votable issues in the email system shall be entitled CALL FOR VOTE�. 12.6 RIGHTS OF EX OFFICIO MEMBERS Persons serving under these Bylaws as ex officio members of a committee shall have all rights and Privileges of regular members except they shall not be counted in determining the existence of a quorum and shall have no vote. 12.7 MINUTES Minutes of each regular and special meeting of a Committee or clinical department or division shall be prepared and shall include a record of attendance of Members and the results of the vote taken on each matter. Minutes shall be signed by the presiding officer and forwarded to the appropriate committees. Each committee and clinical department and division shall maintain a permanent file of the minutes of each meeting. 12.8 ATTENDANCE REQUIREMENTS Each department or division Member shall be required to attend at least fifty percent of all meetings of his department or division during the previous Staff year. At any time a Member is on an approved Leave of Absence, the Members attendance requirements will be suspended and the Members absence from meetings during that time frame shall not affect the Members attendance record for that Medical Staff year. On the request of a Member, with the consent of the Chief/Chairman, a Member may attend via teleconference calling if adequate and timely pre-arrangements have been made with the Medical Staff Services Department. Division members may attend both their division and department meetings. To qualify for voting rights and eligibility to run for an office, attendance at either a division meeting or a department meeting shall count as attendance toward their meeting requirement for that division or department. The failure to meet the foregoing annual department or division meeting attendance requirements shall result in loss of voting rights for the next election of Officers or Department Chief or Division Chief, and loss of eligibility to run for Office, as an Officer or Department Chief or Division Chief, in the next election. Departments and Divisions are considered separate entities for voting eligibility purposes; a Department Member must meet the Department meeting attendance requirements to be eligible to vote for, and/or run for, Chief of the Department. A Division Member must meet the Division meeting attendance requirements to be eligible to vote for, and/or run for, Chief of the Division. Voting eligibility for the Department or Division does not automatically grant voting eligibility in the other. Attendance at Medical Staff department or division meetings will be monitored and recorded on a yearly basis beginning at the start of each Medical Staff year, and will be expunged at the end of each Medical Staff year. New attendance tracking will begin with each Medical Staff year, and will be counted for whichever election (Officers or Department Chief or Division Chief) is scheduled to take place at the election meeting that year. 12.9 MEETING CANCELLATION DUE TO LACK OF CHAIR If the Chairman of a Committee or Chief of a Department or Division, or the designated Chairman of a Committee or Chief of a Department or Division is not present within fifteen minutes (15) of the official start-time of a meeting, the meeting may be cancelled, if the majority of voting members present at the time agree to cancel the meeting. The attendance will be recorded for those present at the time the meeting is canceled, and will count toward eligibility of voting/election of Officers/Chiefs. ARTICLE XIII. IMMUNITY AND RELEASES 13.1 AUTHORIZATION AND CONDITIONS By applying for or exercising Clinical Privileges within this Hospital, an applicant: (a) authorizes representatives of the Hospital and the Medical Staff to solicit, provide, and act upon information bearing on, or reasonably believed to bear on, the applicant's professional ability and qualifications; (b) authorizes persons and organizations to provide information concerning such Practitioner to the Medical Staff; (c) agrees to be bound by the provisions of this Article and to waive all legal claims against any representative of the Medical Staff or the Hospital who acts in accordance with the provisions of this Article; and (d) acknowledges that the provisions of this Article are express conditions to an application for Medical Staff membership, the continuation of such membership, and to the exercise of Clinical Privileges at this Hospital. 13.2 CONFIDENTIALITY OF INFORMATION 13.2-1 GENERAL Only those sections of records and proceedings of all Medical Staff committees having the responsibility of evaluation and improvement of quality of care rendered in this Hospital, including, but not limited to, meetings of the Medical Staff, meetings of the Medical Executive Committee, meetings of Departments, meetings of committees established under ArticleX, and meetings of special or ad hoc committees created by the Medical Executive Committee pursuant to Article VI, including information regarding any Member or applicant to this Medical Staff, shall, to the fullest extent permitted by law, be confidential, only if they contain specific reference to a particular Practitioner(s) by name. 13.2-2 BREACH OF CONFIDENTIALITY Inasmuch as effective peer review and consideration of the qualifications of Medical Staff Members and applicants to perform specific procedures must be based on free and candid discussions, any breach of confidentiality of the discussions or deliberations of Medical Staff committees, except in conjunction with other Hospital, professional society, or licensing authority, is outside appropriate standards of conduct for this Medical Staff and will be deemed disruptive to the operations of the Hospital. If it is determined that such a breach has occurred, the Medical Executive Committee may undertake such corrective action as it deems appropriate and document in writing including the rationale for such an action. 13.3 IMMUNITY FROM LIABILITY 13.3-1 FOR ACTION TAKEN Each representative of the Medical Staff and Hospital shall be exempt, only to the fullest extent permitted by law, from liability to an applicant or Member for damages or other relief for any action taken or statements or recommendations made within the scope of duties exercised as a representative of the Medical Staff or Hospital. 13.3-2 FOR PROVIDING INFORMATION Each representative of the Medical Staff and Hospital and all third parties shall be exempt, only to the fullest extent permitted by law, from liability to an applicant or Member for damages or other relief by reason of providing information to a representative of the Medical Staff or Hospital concerning such person who is, or has been, an applicant to or Member of the Staff or who did, or does, exercise Clinical Privileges or provide services at this Hospital. 13.4 ACTIVITIES AND INFORMATION COVERED The confidentiality and immunity provided by this Article shall apply to all acts, communications, reports, recommendations or disclosures performed or made in connection with this or any health care facility's or organization's activities concerning, but not limited to: (a) application for appointment, reappointment, or clinical Privileges; (b) corrective action; (c) hearings and appellate reviews, (d) quality assessment and improvement and utilization review; (e) other committee or Medical Staff activities related to monitoring and maintaining; (f) quality patient care and appropriate professional conduct; (g) peer review organizations, Florida Board of Medicine and similar reports; and (h) activities of the Physician's Aid Committee. 13.5 RELEASES Each Medical Staff Member shall, upon request of the Medical Staff or Hospital, execute general and specific releases in accordance with the express provisions and general intent of this Article. Execution of such releases shall not be deemed a prerequisite to the effectiveness of this Article. ARTICLE XIV. GENERAL PROVISIONS 14.1 RULES AND REGULATIONS The Medical Staff shall initiate and adopt such Rules and Regulations as it may deem necessary for the proper conduct of its work and shall periodically review and revise its Rules and Regulations to comply with current Medical Staff practice. Recommended changes to the General Rules and Regulations shall be submitted to the Bylaws Committee and Medical Executive Committee for review and evaluation prior to presentation for consideration by the Medical Staff as a whole under such review or approval mechanism as the Medical Staff shall establish. Department-specific Rules and Regulations will be created, and revised as necessary, upon recommendation of the specific Department and the MEC, prior to presentation to the Medical Staff as a whole. A rule or regulation shall be deemed adapted upon approval by 2/3 of Members present at the meeting in which the rule or regulation is considered, provided a quorum is present. Following adoption such Rules and Regulations shall become effective following approval of the Board, which approval shall not be withheld unreasonably. Applicants and Members of the Medical Staff shall be governed by such Rules and Regulations as are properly initiated and adopted. If there is a conflict between the Bylaws and the Rules and Regulations, the Bylaws shall prevail. The mechanism described herein shall be the sole method for the initiation, adoption, amendment, or repeal of the Medical Staff Rules and Regulations. 14.2 DUES OR PRIVILEGES AND REGULATORY MAINTENANCE FEES The Medical Executive Committee shall have the power to recommend the amount of annual dues or assessments, if any, for each category of Medical Staff membership, subject to the approval of the Medical Staff, and to determine the manner of expenditure of such funds received. The Medical Executive Committee shall have the power to recommend the amount of Privileges and Regulatory Fees, if any, for each category of Medical Staff membership, subject to the approval of the Medical Staff. These fees will be set aside for disbursement for Medical Staff needs (eg legal fees for the collective Medical Staff). These funds will be under the control of the MEC and will be disbursed by a majority affirmative vote by the MEC. 14.3 CONSTRUCTION OF TERMS AND HEADINGS The captions or headings in these Bylaws are for convenience only and are not intended to limit or define the scope of or affect any of the substantive provisions of these Bylaws. These Bylaws apply with equal force to both sexes wherever either term is used. 14.4 AUTHORITY TO ACT Any Member or Members who act in the name of this Medical Staff without proper authority shall be subject to such disciplinary action as the Medical Executive Committee may deem appropriate. 14.5 EFFECTIVE DATE OF PROVISIONS These Bylaws shall take effect on May 16, 2002; the effective date of any amendments made after May 16, 2002 shall take effect on the respective dates of approval by the Board of Trustees. 14.6 UNIFICATION/DISUNIFICATION The Medical Staff can be included in a unified medical staff of any health system in which the Hospital participates only after: * Six months� prior written notice to all Medical Staff Members describing the proposed unification, setting forth its risks, benefits, and effects to the Medical Staff and its Members; * The Medical Executive Committee concurs (based on favorable recommendations from two-thirds of all Departments that report to the Medical Executive Committee,) following review and study; and * No less than two-thirds of all Medical Staff Members with voting rights who hold clinical privileges to practice on-site at the hospital cast votes in favor of unification. The Medical Executive Committee shall determine whether the Medical Staff votes: At a special meeting called for that purpose, or Via confidential mail or electronic balloting * If the Medical Staff votes to accept unification, these Medical Staff Bylaws will remain in effect to the Members, until the Medical Staff Bylaws are amended or new Medical Staff Bylaws are adopted pursuant to the terms of these Bylaws. The Medical Staff shall disunify from any system-unified medical staff only after: * No less than two-thirds of all Medical Staff Members with voting rights who hold clinical privileges to practice on-site at the Hospital cast votes in favor of disunification. * A motion to opt out of the unified medical staff shall be made at a regular or specially called meeting of the Hospitals Medical Staff, with the notice being given at least 14 days in advance of the meeting. * The vote to disunify will take place at either a special meeting called for that purpose, or via confidential mail or electronic balloting. There must be at least a 14 day advance notice of the date of the vote. * The Medical Staff shall be the unique Medical Staff of the Hospital effective immediately upon an affirmative vote to disunify. The unique Medical Staff will operate under the Medical Staff Bylaws that were in effect immediately prior to unification. Special elections shall be called immediately to elect Officers, Department Chiefs and other Medical Staff leadership consistent with the Medical Staff Bylaws in effect immediately prior to unification. ARTICLE XV. ADOPTION AND AMENDMENT OF BYLAWS 15.1 PROCEDURE On the request of the President, the Medical Executive Committee, or upon timely written petition signed by at least (10%) of the Members of the Medical Staff who are entitled to vote, consideration shall be given to the amendment or repeal of these Bylaws. Such action may be taken at a regular or special meeting provided: (a) Proposed Bylaws change (or new Bylaw) will be made available to the Medical Staff at least 20 days before the regular or special meeting, during which a vote is to be taken. (b) A proposed Bylaws change (or new Bylaw) must be presented for discussion at a regular or special meeting at least 10 days before the meeting at which a vote is to be taken. (c) Ordinarily a Bylaws change will be published with the agenda for a regularly-scheduled Medical Staff meeting, and voted on at a subsequent Staff meeting. 15.2 QUORUM AND ACTION ON BYLAW CHANGE If a quorum is present for the purpose of enacting a Bylaw change, the change shall require an affirmative vote of a super majority of 2/3rd (66.66%) or more of the Members voting in person. In the alternative, if a quorum of the Medical Staff is not present, the vote shall be conducted by written ballot, which may be sent by first class mail written receipt requested or by facsimile copier or by hospital electronic mail and documentation of such mailing will be maintained. 15.3 APPROVAL Bylaw changes adopted by the Medical Staff shall become effective following approval by the Board, which approval shall not be withheld unreasonably. In its consideration of such Bylaw changes, the Board shall give great weight to the recommendations of the Medical Staff. 15.4 ULTIMATE AUTHORITY OF BOARD In recognition of the ultimate legal and fiduciary responsibility of the Board, the organized Medical Staff acknowledges, in the event the Medical Staff has unreasonably failed to exercise its responsibility and after Notice from the Board to such effect including a reasonable period of time for response, the Board may impose conditions on the Medical Staff that are required for continued state licensure, approval by accrediting bodies, or to comply with a court judgment. In such event, Medical Staff recommendations and views shall be carefully considered by the Board in its actions. Any conflict between the decision by the Board and the Medical Staff will trigger a Joint Conference meeting as described above under Section 10.11. 15.5 EXCLUSIVITY The mechanism described herein shall be the sole method for the initiation, adoption, amendment, or repeal of the Medical Staff Bylaws. EDITORIAL CHANGES Editorial changes (e.g., punctuation marks, correction of spelling errors) may be made to these Bylaws, Rules and Regulations, without Medical Staff/Board approval, providing they do not change the content or intent of the document. ARTICLE XVI. ALLIED HEALTH PROFESSIONALS 16.1 ALLIED HEALTH PROFESSIONALS ALLIED HEALTH PROFESSIONALS ("AHPs") are qualified persons exercising clinical privileges within the scope of their licensure and professional competence, either as employees of the Hospital or pursuant to an independent contract, and who are qualified to render direct or indirect patient care subject to the supervision of a Practitioner. AHPs shall submit applications for clinical privileges pursuant to the provisions of these Bylaws. AHPs include: advanced registered nurse Practitioners ("ARNPs") licensed and certified under Chapter 464, Florida Statutes; Physician Assistants ("PAs") licensed and certified under Section 458.347 or 459.022, Florida Statutes; and other Allied Health Professionals approved by the Medical Executive Committee. For the purposes of this definition, clinical privileges do not include the privilege of admitting patients or the privilege of membership on the Medical Staff. 16.2 SPECIAL CONDITIONS FOR CLINICAL PRIVILEGES OF AHPs Requests for clinical privileges from AHPs shall be processed in the manner specified in these Bylaws and in any applicable Rules and Regulations of the Medical Staff, provided that in the event of any conflict between these Bylaws and the Rules and Regulations, these Bylaws shall control. AHPs may, subject to any licensure requirements or other legal limitations, exercise independent judgment within the areas of their professional competence, and may participate directly in the medical management of patients under the supervision of a Physician who has been accorded Privileges to provide such care and who has ultimate responsibility for the patient's care. Such AHPs shall have had the required training and education appropriate for their Clinical Privileges, obtained the necessary license, and shall serve within the scope of their recognized professional qualifications and skill. Responsibilities and limitations thereto are placed on all AHPs and shall include the following: (a) AHPs may not admit or discharge patients, except as may be permitted by the Hospital's Rules and Regulations and protocols, or as required by law. (b) When requested by a patient's Physician, AHPs may and shall make appropriate entries on the patient's chart and complete all necessary clinical records, as controlled by licensure and statute and these Bylaws and Rules and State Regulations. (c) The extent of services shall be determined by the attending Physician or, in the case of an AHP employed by a Member of the Medical Staff, by the Physician employer, who has total responsibility for the patient; however, the services of every AHP shall be controlled by the specific Privileges granted at the time of appointment and at reappointment by the Board. (d) All Physician's Assistants and Orthopedic Assistants shall be in the employment of and under the supervision of a Member of the Medical Staff; all other AHPs shall be appropriately supervised by a Member of the Medical Staff; or, in the case of AHPs acting in the consultant capacity, are responsible to the Physician who requested their services. Certified Nurse Midwives must be on the Clinical Staff and have a Supervising Physician on the Active Medical Staff who is in their same medical practice group. (e) AHPs are not Members of the Medical Staff and shall not be entitled to the procedural rights provided in Article VII. 16.3 ELIGIBILITY Qualified AHPs who are duly licensed or certified as required by state law and satisfy the qualification requirements of these Bylaws and any other applicable policies established by the Board shall be eligible to apply for clinical privileges in the Hospital. 16.4 QUALIFICATIONS AHPs shall document their qualifications, status, clinical competence, training, demonstrated ability and physical and mental health condition with sufficient adequacy to demonstrate that (a) they can exercise judgment within their areas of competence, although a Staff Member may be ultimately responsible for patient care; (b) they may participate directly in patient care within the scope authorized by law and the Hospital; and (c) they are qualified to provide a needed service in the Hospital. AHPs must be determined, on the basis of documented references, to adhere strictly to the ethics of their respective professions and to work cooperatively with others; may be individually assigned to an appropriate clinical department; and shall carry out their activities subject to the policies, procedures, rules and regulations of the Hospital and these Bylaws. Additionally, AHPs shall furnish evidence of professional liability insurance coverage in the same amount required of the Physicians. 16.5 APPLICATION FOR PRIVILEGES An AHP shall submit to the President or his designee an application for clinical privileges on a form provided by the Hospital accompanied by a fee, the amount of which is to be determined by the Board of Trustees. If employed by a Member of the Medical Staff, the form shall be signed by the AHP and the Medical Staff Member. The President or his designee shall seek to collect or verify the references, licensure, and other qualifications evidence submitted, but the AHP shall have the burden of resolving any doubts about his qualifications. When collection or verification is accomplished, the President or his designee shall transmit the AHP's application and supporting materials to the Credentials Committee. Employment and/or clinical privileges of AHPs may be terminated at will by the Hospital and shall not be covered by other provisions of these Bylaws relating to denying, granting, modifying, suspending, curtailing or revoking Staff membership or the Clinical Privileges of Practitioners. 16.6 PREROGATIVES An AHP may: (a) exercise clinical privileges either independently or solely under the supervision or direction of a Staff Physician, as authorized by law and these Bylaws, (b) write orders only to the extent permitted by law and the Board and in any event not beyond the scope of the AHPs license or certificate; (c) serve on committees; (d) attend department meetings when invited; (e) if granted Clinical Privileges, furnish such professional services at the Hospital as provided under the grant of such Clinical Privileges; and (f) exercise such other prerogatives as may be approved by the Medical Staff or any department or committee with the approval of the Medical Executive Committee. AHPs may be accorded disparate treatment based on qualifications, abilities and competence, subject to requirements of law. 16.7 RESPONSIBILITIES Each AHP shall retain appropriate responsibility within his area of professional competence for the care and supervision of each patient in the Hospital for whom he is providing services; participate as appropriate in quality management activities required of the Medical Staff and in discharging other Medical Staff functions as may be required from time to time as a result of regulatory or credentialing requirements placed on the Medical/Clinical Staff or Hospital, upon timely written notice; and attend all meetings of departments and committees as may be required. 16.8 APPROVAL OF CLINICAL PRIVILEGES Except as specifically permitted in Section 16.3, no AHP shall be granted Clinical Privileges in the Hospital until the AHP has been approved by the Board. (a) First, the AHPs application shall be reviewed by the Credentials Committee, on a form provided by the Hospital, outlining sufficient information on the applicant's qualifications and abilities. The Credentials Committee may interview both the AHP applicant and supervising Member of the Medical Staff. The Credentials Committee shall promptly review and evaluate the application, make any investigation it may deem necessary, including the appointment of a Department or ad hoc committee to make a report on the application, and shall make a recommendation to the Medical Executive Committee. If the recommendation is favorable, it shall include a recommendation as to the scope of activities which the AHP will be permitted to undertake, the department assignment and any restrictions or limitations. (b) After prior review by the Medical Executive Committee, the Medical Executive Committee shall promptly consider recommendations of the Credentials Committee and, if the Medical Executive Committee considers it necessary or appropriate, may request additional information from or interview the applicant. The Medical Executive Committee shall make a recommendation to the Board. If the recommendation is favorable, it shall include a recommendation as to the scope of activities which the AHP will be permitted to undertake, the department assignment and any restrictions or limitations. (c) The Board shall promptly thereafter consider the Medical Executive Committee recommendation and shall approve or disapprove the application. If the AHP is approved, the Board shall approve the scope of activities which the AHP may undertake, the department assignment and any restrictions or limitations. If approved, the AHP shall be permitted to render clinical services, subject to the prerogative of the Board to modify, limit, restrict, suspend or revoke such approval at any time. Written notice of the Board's approval or disapproval shall be provided to the AHP and the supervising Physician. Employment and/or Clinical Privileges of AHPs may be terminated at will by the Hospital and shall not be covered by other provisions of these Bylaws relating to denying, granting, modifying, suspending, curtailing or revoking Staff membership or the Clinical Privileges of Practitioners. 16.9 PROVISIONAL NATURE OF APPROVAL The Board's initial approval of Clinical Privileges for an AHP shall be provisional in nature. Prior to the end of the provisional period the person appointed by the Credentials Committee shall submit a report and recommendation, which shall be considered at the next meeting of the Credentials Committee, which shall make a recommendation to the Medical Executive Committee concerning the AHP. The Medical Executive Committee shall consider the recommendation and shall thereafter make its recommendation concerning the AHP to the Board. The Board shall promptly review the Medical Executive Committee's recommendation and (a) the AHP may be granted Clinical Privileges for a period up to three (3) years, subject to the right of the Board to modify, limit, restrict, suspend or terminate such approval at any time, or (b) the AHP's approval shall be terminated. . No less than 15 patient contacts per reappointment cycle shall be required with the exception of those AHPs whose Supervising Physician is exempted from the 15 patient contact requirement, per Section 4.4 of these Bylaws. 16.10 TEMPORARY PRIVILEGES The CEO may grant an AHP temporary Clinical Privileges in the Hospital in the same manner granted to Medical Staff Members, and may grant temporary Privileges for a period not to exceed thirty (30) days, unless extended by the CEO for up to two additional thirty (30) day intervals [for a total of ninety (90) days]. In such cases, the recommending Staff Member shall be responsible for supervising the AHP. Such action may be taken on the basis of information then available which may reasonably be relied on as to the competence and qualifications of the AHP. The President or his designee shall, however, in such cases verify the AHP's current licensure or certification and shall obtain current information as to the AHP's professional liability insurance coverage if currently required by the Board of Trustees and any pending professional liability actions or proceedings. Any denial of such a request shall be final and nonappealable. 16.11 EFFECT OF SUPERVISING PHYSICIAN The Board shall determine the scope of activities which each AHP may undertake. Such determination shall be furnished in writing to the AHP and shall be final and not appealable. Any Clinical Privileges granted to an AHP who is employed by a Member of the Medical Staff shall be valid only so long as the AHP remains an employee of the Physician and the Physician remains on the Staff in good standing. The person appointed by the Credentials Committee shall oversee the activities of the AHP. 16.12 BI-ANNUAL REVIEW Each AHP shall submit a renewal application for Clinical Privileges on a form provided and approved by the Hospital. The procedure for review shall be the same as the procedure for review of the initial application. The AHPs review will coincide with their primary Supervising Physicians reappointment. The review shall also include the AHPs activities in the Hospital, performance, compliance with these Bylaws and the Rules and Regulations, ethics and conduct, relations with Staff Members and the Administration, clinical and/or technical skills, as indicated in part by the results of quality management activities, and such other information as may be appropriate. Applicants for reappointment must have required documented patient contacts as outlined in Section 4.4, unless the AHP works with a Locum Tenens Physician, Community Staff, Dentists/Oral-Maxillofacial Surgeons, Dermatologists, Allergists, Rheumatologists or Radiation Oncologists. All Physician Assistants, Advanced Registered Nurse Practitioners, Certified Registered Nurse Anesthetists and Midwifes will undergo an annual review in addition to any review conducted at reappointment time. 16.13 SUPERVISION All activities of AHPs who are required by law or by Hospital rules, regulations or protocols to provide care under the supervision or direction of a Practitioner shall be under the direct and immediate supervision of a Medical Staff Member, but such supervision shall not require the physical presence of the Staff Member unless otherwise required by law. To provide for continuous supervision, the AHP must have either: 1) A primary and secondary Medical Staff Member in good standing as their supervising Physicians, or 2) a primary supervising Physician, and the agreement of another Medical Staff Member to accept care of all patients under the direction of the AHP should that AHPs primary supervising Physician be unavailable (eg, out of town). In the latter case, it is the responsibility of the AHP to notify the Medical Staff Services Department of the dates the supervising Physician is unavailable. If any other Hospital employee reasonably questions the authority or instructions of an AHP either to act or to issue instructions outside of the presence of the supervising Medical Staff Member, the Hospital employee may delay acting until the supervising Practitioner has validated the order or instructions of the AHP. 16.14 INDEMNITY Each Practitioner who supervises or directs an AHP, who is not employed by the Hospital and who provides patient care, shall indemnify the Hospital and hold the Hospital harmless from and against all currently existing or subsequently arising actions, causes of action, claims, damages, costs and expenses, including reasonable attorneys fees, resulting from, caused by or arising from any act or omission of such AHP, including, without limitation, the negligence of such AHP or the failure of such AHP to satisfy the standards of proper care of patients. 16.15 GENERAL PROVISIONS 16.15-1 EXHAUSTION OF REMEDIES If adverse action described below is taken or recommended, the applicant or Allied Health Practitioner agrees to follow and complete the procedures set forth in these Bylaws, before attempting to obtain judicial relief related to any issue or decision which may be subject to a hearing or appeal under this Article. 16.15-2 DEFINITIONS Except as otherwise provided in these Bylaws, the following definitions shall apply under this Article: (a) "Body whose decision prompted the hearing" refers to the Medical Executive Committee in all cases where the Medical Executive Committee or authorized Medical Staff Officers took the action or rendered the decision which resulted in a hearing being requested. It refers to the Board in all cases where the Board or authorized Officers, directors or committees of the Board took the action or rendered the decision which resulted in a hearing being requested. (b) "Medical disciplinary cause or reason" refers to a basis for disciplinary action involving an aspect of the competence or professional conduct of an Allied Health Practitioner which is reasonably likely to be detrimental to patient safety or to the delivery of patient care. (c) "Date of receipt" of any notice or other communication shall be deemed to be the date it was delivered personally to the addressee or, if delivered by certified mail, five (5) days after it was deposited, postage prepaid, in the United States mail. 16.15-3 SUBSTANTIAL COMPLIANCE Hospital's and/or the Allied Health Professionals substantial compliance with the procedures set forth in these Bylaws shall constitute compliance. 16.16 GROUNDS FOR HEARING Except as otherwise specified in these Bylaws, any one or more of the following actions or recommended actions shall be deemed actual or potential adverse action and constitute grounds for a hearing, if recommended for a medical disciplinary cause or reason: (a) denial of initial appointment; (b) denial of reappointment; (c) imposition of, or voluntary acceptance of, restrictions on Privileges for a cumulative total of more than thirty (30) days in any twelve (12) month period; (d) denial of Privileges; (e) involuntary reduction of current Privileges; (f) summary suspension of Privileges for more than fourteen (14) days; or (g) termination of all Privileges. 16.17 REQUESTS FOR HEARING 16.17-1 NOTICE OF ACTION OR PROPOSED ACTION In all cases in which action has been taken or a recommendation made as set forth in Section 16.16, said person or body shall give the Allied Health Practitioner written notice as soon as possible but not later than five (5) business days, via certified mail, return receipt requested, of: 1) the recommendation or final proposed action, 2) the right to request a hearing pursuant to Section 7.3-2, and that such hearing must be requested within thirty (30) days or such right shall be deemed waived. 16.17-2 REQUEST FOR HEARING The Allied Health Practitioner shall have thirty (30) days following receipt of notice of such action to request a hearing. The request shall be in writing addressed to the President with a copy to the CEO. 16.17-3 REVIEW COMMITTEE When a hearing is requested, the President (if the Medical Executive Committee initiated the action) or the CEO (if the Board initiated the action) shall appoint a committee consisting of the President, the CEO, the respective Department Chief and the Allied Health Practitioners Supervision Physician(s) 16.17-4 NOTICE TO ALLIED HEALTH PRACTITIONER Together with the notice stating the place, time and date of the hearing, the President, or the CEO, on behalf of the body whose decision prompted the hearing, shall state clearly and concisely in writing the reasons for the adverse final proposed action taken or recommended, including the acts or omissions with which the Allied Health Practitioner is charged and a list of the charts in question, where applicable. 16.17-5 TIME AND PLACE FOR HEARING Upon receipt of a request for hearing, the President shall schedule a hearing and, as soon as possible but no later than twenty (20) business days give notice to the Allied Health Practitioner of the time, place and date of the hearing 16.17-6 FAILURE TO APPEAR OR PROCEED Failure without good cause of the Allied Health Practitioner to personally attend and proceed at such a hearing in an efficient and orderly manner shall be deemed to constitute voluntary acceptance of the recommendations or actions involved. 16.18 HEARING PROCEDURE 16.18-1 HEARING (a) The Allied Health Practitioner shall have the right to inspect at his or her expense, any documents relevant to the charges. (b) The body whose decision prompted the hearing shall have the right to inspect any documents or other evidence relevant to the charges in the possession or control of the Allied Health Practitioner within ten (10) business days after receiving the request. 16.18-2 REPRESENTATION The Allied Health Practitioner shall have the right, at his or her expense, to attorney representation at the hearing, and shall provide notice to the Hospital of the identity of any attorney(s) who will represent the Practitioner at the hearing 16.18-3 THE PRESIDING OFFICER The presiding officer at the hearing shall be the President, who shall act to assure that all participants may in the hearing have a reasonable opportunity to be heard and to present all relevant oral and documentary evidence, and that proper decorum is maintained.� He or she shall be entitled to determine the order of or procedure for presenting evidence and argument during the hearing.� He or she shall have the authority and discretion, in accordance with these Bylaws, to grant continuances, to rule on disputed discovery requests, to decide when evidence may not be introduced, and to rule on questions which are raised prior to or during the hearing. 16.18-4 RECORD OF THE HEARING A written record of the hearing shall be kept. 16.18-5 BURDENS OF PRESENTING EVIDENCE AND PROOF (a) At the hearing, the body whose decision prompted the hearing shall have the burden of initially presenting evidence to support the charges and its recommendation. The Allied Health Practitioner may present evidence in response. An applicant for Privileges, shall bear the burden of persuading the committee, by a preponderance of the evidence, of his/her qualifications by producing information which allows for adequate evaluation and resolution of reasonable doubts concerning his/her current qualifications 16.18-6 ADJOURNMENT AND CONCLUSION The presiding officer may adjourn the hearing and reconvene the same without special notice at such times and intervals as may be reasonable and warranted, with due consideration for reaching an expeditious conclusion to the hearing. Upon conclusion of the hearing, the committee shall thereupon, outside of the presence of the parties, conduct its deliberations and render a decision and accompanying report 16.18-7 BASIS FOR DECISION The decision of the committee shall be based on the evidence introduced at the hearing, including all logical and reasonable inferences from the evidence and the testimony. 16.18-8 DECISION OF THE COMMITTEE Within thirty (30) days after closure of the hearing the committee shall render a decision which shall be accompanied by a report in writing. A copy of said decision shall be forwarded to the Medical Executive Committee, the President, and the Board. The Allied Health Practitioner shall be informed via certified mail, return receipt requested. The report shall contain a concise statement of the reasons in support of the decision, including findings of fact and a conclusion articulating the nexus between the evidence produced at the hearing and the conclusion reached. 16.18-9 BOARD ACTION The Board shall consider the report of the committee at its next regularly scheduled meeting, and shall make a determination. The Boards decision shall be final. 16.19 APPEAL 16.19-1 RIGHT TO ONE HEARING No Practitioner shall be entitled to more than one evidentiary hearing. 16.20 EXCEPTIONS TO HEARING RIGHTS 16.20-1 TERMINATION OF TEMPORARY PRIVILEGES No Allied Health Practitioner is entitled to the hearing or appeal rights provided in this Article by virtue of the expiration, non-renewal or termination of temporary Privileges, unless such action is expressly stated to be for a medical disciplinary cause or reason. 16.21 LEAVE OF ABSENCE If military duty or medical emergency (an unplanned medical condition, not considered an impairment�) arises, a Clinical Staff member may request an immediate leave of absence, which will be granted by the Medical Executive Committee designee (the President), and ratified by the Medical Executive Committee and the Board of Trustees at a subsequent meeting. The leave may not exceed twelve (12) months, provided that an additional twelve (12) months may be recommended by the Medical Executive Committee, and approved by the Board of Trustees, for good cause in writing. If during the term of the Leave of Absence the Clinical Staff member becomes due for reappointment, the reappointment material shall be forwarded via certifiable mail to his last known address, for completion. Failure without good cause to submit the completed application in the normal manner shall be considered as indicating a desire not to be reappointed, and the Clinical Staff member shall not be entitled to the procedural rights provided in. A Clinical Staff member may request reinstatement after military duty/medical leave if their Supervising Physician still has a professional relationship with the Clinical Staff member. The Clinical Staff member shall submit an official document attesting to their activation to, and their deactivation from, military duty, and/or a medical release from their personal physician. Return from a leave of absence may be granted by the Medical Executive Committee designee (President) and the Hospital designee (CEO), on a temporary basis. The formal return from a leave of absence will occur when ratified by the Medical Executive Committee and the Board of Trustees, at each of their next meetings. If a Clinical Staff members primary Supervising Physician goes on a Leave of Absence, the Clinical Staff member must immediately cease all practice activity within Flagler Hospital until such time they can provide documentation of a new primary Supervising Physician Agreement by a Practitioner in Good Standing at Flagler Hospital. If said documentation is not produced within 30 days of the Clinical Staffs primary Supervising Physicians beginning Leave of Absence date, it will be accepted as a voluntary resignation by the Clinical Staff member. This will not be considered a disciplinary action, and therefore will not be reportable or be a qualifying event for a Fair Hearing process. 16.22 INTERVENTION PROJECT FOR NURSES If an Allied Health Practitioner (AHP) is enrolled, or becomes enrolled, in the Intervention Project for Nurses (IPN) or a comparable organization (approved by the MEC), at any time when the AHP is on the Clinical Staff at Flagler Hospital, the AHP will be required to have the IPN/organization submit a good standing� letter to the Medical Staff Services Department at least annually, or more frequently than annually if requested by the MEC or the Board, for as long as the AHP is enrolled in the IPN/organization. Failure to have the IPN/organization submit a good standing� letter at the required frequency may result in a loss of membership on the Clinical Staff. This will be considered a voluntary resignation for not meeting required qualifications, and will not be considered an adverse action. Therefore, the AHP will not be entitled to procedural rights under Section 16.15. Once the AHP has satisfactorily completed their contract with the IPN/organization, the Hospital reserves the right to request pertinent random testing, without notice to the AHP, for the duration of up to three times the term of the initial IPN/organization contract. SIGNATURE PAGE TO FOLLOW INITIALLY ADOPTED by the Medical Staff on May 14, 2002. LAST REVISED: (See footer at bottom of page) SIGNATURE ON FILE ____________________________________________________________ President, Medical Staff INITIALLY APPROVED by the Board on May 16, 2002. LAST REVISED: (See footer at bottom of page) SIGNATURE ON FILE ____________________________________________________ Chairman, Board of Trustees EXHIBIT A� SINCE 15-MILE RULE WAS ELIMINATED: 2008 EXHIBIT B� RULES & REGULATIONS See individual Department, Service and General Staff Rules and Regulations. EXHIBIT C� EXCLUSIVE CONTRACTS ANESTHESIOLOGY EMERGENCY MEDICINE PATHOLOGY RADIOLOGY CARDIOTHORACIC SURGERY BARIATRIC SURGERY RADIATION THERAPY NICU HOSPITALISTS INTENSIVISTS EXHIBIT D� PHYSICIAN BILL OF RIGHTS The right to care for patients without compromise; The right to freely advocate for patient safety; The right to be compensated for providing care; The right to be evaluated by unbiased peers who are actively practicing physicians in the community and specialty; The right to care for our own well-being; The right to full due process when privileges are challenged; The right to privacy; The right of medical staffs to be self-governed and independently advised; The right of freedom from personal loss or liability for adverse outcomes relating to medical practice based on compassion and good judgment within community standards; The right to fair market and transparent economic competition; Because physicians are created equal, all physicians have the right to equal treatment; Because physicians are the primary patient care decision makers, all physicians have the right to make decisions, without undue influence, abuse or harassment; Because physicians have a duty to their patients, all physicians have the right to quality medical care above financial considerations; Because physicians seek the best outcome, all physicians have the right to have their orders carried out correctly.   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