The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of

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1 June 22, 2018 NOTICE The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 5:45PM on Monday June 25, 2018 in the Kaweah Delta Medical Center Blue Room {Mineral King Wing 400 West Mineral King Avenue}. The Board of Directors of the Kaweah Delta Health Care District will meet in a closed Board of Directors meeting at 5:46PM on Monday June 25, 2018 in the Kaweah Delta Medical Center Blue Room {Mineral King Wing 400 West Mineral King Avenue} pursuant to Health and Safety Code 32155, & Safety Code The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 6:00PM on Monday June 25, 2018 in the Kaweah Delta Medical Center Blue Room {Mineral King Wing 400 West Mineral King Avenue}. All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings (special meetings are posted 24 hour prior to meetings) in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room. The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page KAWEAH DELTA HEALTH CARE DISTRICT Nevin House, Secretary/Treasurer Cindy Moccio - Board Clerk / Executive Assistant to CEO DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff West Mineral King Avenue Visalia, CA (559)

2 KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS Kaweah Delta Medical Center {Blue Room} 400 West Mineral King Avenue, Visalia Monday, June 25, 2018 OPEN MEETING AGENDA {5:45PM} Call to order Approve agenda Public / Medical Staff participation Members of the public or the medical staff may comment on agenda items before action is taken and after the item has been discussed by the Board. Each speaker will be allowed five minutes. Members of the public wishing to address the Board concerning items not on the agenda and within the subject matter jurisdictions of the Board are requested to identify themselves at this time. 1. Approval of Closed Agenda as follows: Closed Meeting Agenda 5:46PM 1.1. Credentialing - Medical Executive Committee (June 2018) requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and Harry Lively, MD, Chief of Staff 1.2. Approval of closed meeting minutes May 30, 2018 and June 12, Adjourn CLOSED MEETING AGENDA {5:46PM} Call to order 1. Credentialing - Medical Executive Committee (June 2018) requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and Harry Lively, MD, Chief of Staff 2. Approval of closed meeting minutes May 30, 2018 and June 12, 2018 Action Requested: Approval of the May 30, 2018 and June 12, 2018 closed meeting minutes. Adjourn OPEN MEETING AGENDA {6:00PM} Call to order Approve agenda Public / Medical Staff participation Members of the public or the medical staff may comment on agenda items before action is taken and after the item has been discussed by the Board. Each Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III David Francis Zone IV Nevin House Zone V Board Member President Board Member Board Member Secretary/Treasurer

3 speaker will be allowed five minutes. Members of the public wishing to address the Board concerning items not on the agenda and within the subject matter jurisdictions of the Board are requested to identify themselves at this time. Closed Session Action Taken Report on actions taken in closed session. 1. Approval of Board of Directors meeting open meeting minutes May 30, 2018 and June 12, Action Requested: Approval of the May 30, 2018 and June 12, 2018 open meeting minutes. 2. Recognitions Herb Hawkins 2.1. Presentation of Resolution 1999 to Christy Kennedy, Registered Nurse, Ambulatory Surgery Center for the Service Excellence Award June Consent Calendar (All matters under the Consent Calendar will be approved by one motion, unless a Board member request separate action on a specific item). Recommended Action: Approve the June 25, 2018 Consent Calendar /2019 Annual Operating and Capital Budget Presentation and request for approval of the 2018/2019 annual operating and capital budget as reviewed and recommend for approval by the Board of Director s Finance, Property Services and Acquisition Committee Malinda Tupper Vice President & Chief Financial Officer Recommended Action Approval of the 2018/2019 annual operating and capital budget. 5. Kaweah Delta Health Care District Risk Profile Review of Risk Management Goals and Profile of Accomplishements and Goals Ed Hirsch, MD, Vice President & Chief Medical / Quality Officer & Evelyn McEntire, Director of Risk Management Recommended Action Approval of the Kaweah Delta Health Care District Risk Management Profile Accomplishments and Goals. 6. Board of Directors Bylaws Review and request for approval of the revisions to the Board of Directors Bylaws as reviewed and recommended for approval by the Board of Directors Governance and Legislative Affairs Committee Gary Herbst, Chief Executive Officer Rcommended Action Approval of the Board of Directors Bylaws dated June 25, Quality Report Infection Prevention Annual review of key quality of care indicators and actions related to the prevention of infections Shawn Elkin, RN, Manager of Infection Prevention, Sandy Volchko, RN, Director of Quality and Patient Safety, and Daniel Boken, M.D., Medical Director of Infection Prevention 8. Strategic Plan Element Report - Information Management and Integration across the continuum Implement an integrated suite of clinical and revenue cycle solutions, Identify information technologies pertaining to population health - Doug Leeper, Vice President & Chief Information Officer 9. Credentialing Medical Executive Committee requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff Monday June 25, 2018 Page 2 of 3 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III David Francis Zone IV Nevin House Zone V Board Member President Board Member Board Member Secretary/Treasurer

4 membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval Harry Lively, MD, Chief of Staff Recommended Action: Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the medical staff scheduled for reappointment, Whereas the basis for the recommendations now before the Board of Trustees regarding initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff be approved or reappointed (as applicable), as attached, to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member s letter of initial application approval and reappointment from the Board of Trustees and within their individual credentials files. 10. Chief of Staff Report Update from the Chief of Staff relative to Medical Staff issues - Harry Lively, MD, Chief of Staff 11. Chief Executive Officer Report Report relative to current events and issues - Gary Herbst, Chief Executive Officer Kaweah Delta Medical Center Seismic Analysis Update Community Engagement Initiatives Update Kaweah Delta Events: Service Awards Luncheon Visalia Convention Center Tuesday June 26th at Noon 2018 Cancer Survivor Event SRCC Maynard Faught Conference Room Wednesday June 27 th 11am 30 th Annual Kaweah Delta Golf Classic Friday August 3, Board President Report Report from the Board President relative to current events and issues Lynn Havard Mirviss, Board President Adjourn In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors meeting. Monday June 25, 2018 Page 3 of 3 Herb Hawkins Zone I Lynn Havard Mirviss Zone II John Hipskind, MD Zone III David Francis Zone IV Nevin House Zone V Board Member President Board Member Board Member Secretary/Treasurer

5 BOARD OF DIRECTORS MEETING CLOSED SESSION KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS MEETING MONDAY JUNE 25, 2018 CLOSED MEETING SUPPORTING DOCUMENTS PAGES

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16 MINUTES OF THE OPEN MEETING OF THE KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS HELD MONDAY MAY 30, :30PM, IN THE KAWEAH DELTA MEDICAL CENTER MINERAL KING WING BLUE ROOM, LYNN HAVARD MIRVISS PRESIDING PRESENT: Directors Havard Mirviss, Hawkins Hipskind, House, & Francis &; G. Herbst, Chief Executive Officer; T. Rayner, VP & COO, M. Tupper, VP & CFO; H. Lively, MD, Chief of Staff; E. Hirsch, VP & CMO/CQO; D. Leeper, VP & CIO, D. Lynch, Legal Counsel; C. Moccio, Board Clerk The meeting was called to order at 5:30PM by Director Havard Mirviss. Director Havard Mirviss asked for approval of the agenda. MMSC (Hawkins/Hipskind) to approve the agenda. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, House, Hipskind, and Francis Public participation none Director Havard Mirviss called for the approval of the closed agenda. Approval of Closed Agenda as follows: Closed Meeting Agenda 5:31PM 1.1. Conference with Legal Counsel Anticipated Litigation Significant exposure to litigation pursuant to Government Code (d)(2) 14 Cases - Dennis Lynch, Legal Counsel & Ben Cripps, Compliance Officer 1.2. Credentialing - Medical Executive Committee (May 2018) requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and Harry Lively, MD, Chief of Staff 1.3. Approval of closed meeting minutes - April 23, 2018 and May 17, 2018 MMSC (Francis/Hawkins) to approve the closed agenda. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, Hipskind, House, & Francis Adjourn - Meeting was adjourned at 5:31PM Lynn Havard Mirviss, President Kaweah Delta Health Care District and the Board of Directors Thereof ATTEST: Nevin House, Secretary/Treasurer Kaweah Delta Health Care District Board of Directors

17 MINUTES OF THE OPEN MEETING OF THE KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS HELD MONDAY MAY 30, :00PM, IN THE KAWEAH DELTA MEDICAL CENTER MINERAL KING WING BLUE ROOM, LYNN HAVARD MIRVISS PRESIDING PRESENT: Directors Havard Mirviss, Hawkins Hipskind, House, & Francis &; G. Herbst, Chief Executive Officer; T. Rayner, VP & COO, M. Tupper, VP & CFO; H. Lively, MD, Chief of Staff; E. Hirsch, VP & CMO/CQO; D. Leeper, VP & CIO, D. Lynch, Legal Counsel; C. Moccio, Board Clerk The meeting was called to order at 6:00pm by Director Havard Mirviss. Director Havard Mirviss entertained a motion to approve the agenda. MMSC (Hawkins/House) to approve the agenda. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, Hipskind, House, and Francis Public/Medical Staff participation None. Closed Session Action Taken: Director Mirviss announced that at the April 23rd closed Board meeting: The Board approved Resolution 1995 approving the acquisition of 515 West Acequia Avenue and 535 W. Acequia Avenue, Visalia, County of Tulare, California, from Thomas F. Mitts, Trustee for the cost up to but not exceeding $680, to be funded from cash reserves. During today s closed meeting the Board took action to approve the closed minutes from April 23rd and May 17th. Approval of Board of Directors meeting open meeting minutes April 23, 2018 and May 17, 2018 Director Havard Mirviss entertained a motion to approve the open minutes from April 23rd and May 17th A correction has been made at the top of page six of the open minutes from the 6:00pm - open meeting on April 23rd to change the meeting location from the Blue Room to the SRCC Maynard Faught Conference Room. MMSC (Francis/Hawkins) to approve the open minutes from April 23rd and May 17th with the correction noted at the top of page six of the open minutes from the 6:00pm - open meeting on April 23rd to change the meeting location from the Blue Room to the SRCC Maynard Faught Conference Room. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, Hipskind, House, and Francis Recognitions Director House presented the following resolutions; Resolution 1991 to Bradley Donabedian - Service Excellence Award April 2018 Presentation of Resolution 1996 to Maria Marquez, RN - Service Excellence Award May 2018 Resolution 1992 to Javier Lara - inaugural Patient Safety Hero of the Year Award. Even-Year Board of Directors Election Request approval of resolution #1997 ordering even-year board of directors election for Zone 2 and Zone 4 (copy attached to the original of these minutes and considered a part thereof) Dennis Lynch, Legal Counsel MMSC (Hipskind/House) to approve Resolution 1997 a resolution ordering even-year board of director s election; consolidation of elections; and specification of the election order. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, Hipskind, House, and Francis

18 Consent Calendar Director Havard Mirviss entertained a motion to approve the consent calendar with the correction made to page five of the Finance Report (4.1D) correction the percentage of change in the operating margin to reflect a positive number vs. a negative number (copy attached to the original of these minutes and considered a part thereof). MMSC (Hawkins/Frances) to approve the consent calendar with the correction made to page five of the Finance Report (4.1D) correction the percentage of change in the operating margin to reflect a positive number vs. a negative number. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, Hipskind, House, and Francis Quality Report National Surgical Quality Improvement Program (NSQIP) Review of key quality of care indicators and actions for the surgical patient population(copy attached to the original of these minutes and considered a part thereof) J.P. Manuele, MD, NSQIP surgeon champion and Cindy Conley, RN, Surgical Strategic Plan Element Report - Medical Staff Hospital/Physician alignment strategies Gary Herbst, Chief Executive Officer Sierra View hospital has recently been invited to join Sequoia Integrated Health (SIH). We are working with Blue Shield to create an Accountable Care Organization (ACO). We are working with Sierra View to create a Joint Powers Authority (JPA) to help eliminate duplication and redundancy of service for both organizations and help drive down costs. Implementation of Cerner Millennium a single integrated health record. SIH has purchase the Cozenva System which will allow us to track and trend treatment and outcomes of patients in the system. Kaweah Delta Medical Foundation was started two years ago. It has been marginally successful we had hoped for a greater increase in physician recruitment than we have experience thus far. Local Agency Formation Commission (LAFCO) Call to Vote Vote for the appointment of an independent special district representative to the countywide Redevelopment Agency Dissolution (RDA) Oversight Board (copy attached to the original of these minutes and considered a part thereof). Following a discussion relative to the need for the requested vote, Mr. Herbst recommended that the Board vote for Daniel Smith Sierra View Local Health Care District. Entertain a motion to vote for one of four candidates 1. Alberto Aguilar Tulare Public Cemetery District 2. Vicki Gilson Tulare Public Cemetery District 3. Leo Gonzalez Orosi Memorial District 4. Daniel Smith Sierra View Local Health Care District MMSC (Hipskind/Hawkins) to vote for Daniel Smith Sierra View Local Health Care District as the independent special district representative to the countywide Redevelopment Agency Dissolution (RDA) Oversight Board. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, Hipskind, House, and Francis Board of Directors Meeting - Open Page 2 of 5

19 Credentialing Harry Lively, MD Chief of Staff - Medical Executive Committee request that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval. Director Havard Mirviss requested a motion for the approval of the credentials report excluding the Emergency Medicine providers highlighted on Exhibit A {copy attached to the original of these minutes and considered a part thereof}. MMSC (House/Hipskind) Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provisional status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the medical staff scheduled for reappointment, Whereas the basis for the recommendations now before the Board of Trustees regarding initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff, excluding Emergency Medicine Providers as highlighted on Exhibit A (copy attached to the original of these minutes and considered a part thereof), be approved or reappointed (as applicable), to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member s letter of initial application approval and reappointment from the Board of Trustees and within their individual credentials files. Vote: Director Havard Mirviss, House, Hawkins, Francis & Hipskind Yes. Director John Hipskind, MD left the room for the vote on the credentials, for the Emergency Medicine providers as highlighted on Exhibit A {copy attached to the original of these minutes and considered a part thereof}. MMSC (Hawkins/Francis) Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provisional status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the Emergency Medicine providers scheduled for reappointment. Whereas the basis for the recommendations now before the Board of Trustees regarding initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff Emergency Medicine providers be approved or reappointed (as applicable), to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member s letter of initial application approval and reappointment from the Board of Board of Directors Meeting - Open Page 3 of 5

20 Trustees and within their individual credentials files. Vote: Director Havard Mirviss, House, Francis & Hawkins Yes. Director Hipskind Absent CHIEF OF STAFF REPORT Report from Harry Lively, MD, Chief of Staff: Cerner rollout started out rough, however we have weathered the storm and it is settling down, most of the staff are learning how to use the system. There is still work to be done, the Medical Staff is committed to making it work. CHIEF EXECUTIVE OFFICER REPORT Report from Gary Herbst, Chief Executive Officer: Tulare Regional Medical Center - letter of support for State funding o Kaweah Delta received a request from the President of the Tulare Regional Medical Center (TRMC) board for a letter of support relative to TRMC s request to the State for $22 million to reopen and operationalize TRMC. Mr. Herbst recommended that our Board should submit a letter of support to the State for the funding request by TRMC. The TRMC board will be sending out an RFP to parties potentially interested in affiliating with them. He and Nevis House will be meeting with a group from TRMC on Friday at the request of TRMC. MMSC (Hawkins/Francis) for management to draft a letter for Board signature to submit to the State in support of TRMC s request for funding. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, Hipskind, House, and Francis Grand Jury Response o In March 2018 Kaweah Delta received a letter from the Grand Jury regarding a complaint from a patient relative to the timeliness of receiving care in the Kaweah Delta Emergency Department (ED). We have submitted the response to their findings and provided them an update relative to our ED expansion plans. KD*Hub Update o Each week things are improving; there are still issues to overcome. o Nursing is doing well; there are challenges relative to patient movement which can impact patient care. o Challenges relative to lab and specimen collection. o Pharmacy has done well right from the start. o Larger challenge is related to patient charges; however, the system is improving every day. Claims are undergoing a 100% audit to ensure that they being processed correctly. Cardiovascular Services and Cleveland Clinic Affiliation o We are evaluating, along with our cardiac surgery team, to determine if we are going to affiliate with the Cleveland Clinic. o We have demonstrated to the Cleveland Clinic that we would be a good affiliate; however, we have not made our decision yet. We are currently conducting a feasibility study. o Potential launch in September which will need Board action to move forward. We will ask for Board action at the June or July Board of Directors meeting. Legislative Updates no updates. Kaweah Delta Medical Center Seismic Analysis Update Board of Directors Meeting - Open Page 4 of 5

21 o On June 4th a group from Visalia will be going to Sacramento to meet with Bob David who is the head of OSHPD. We will meet to discuss potential options and the challenges of hospitals in Tulare County. Community Engagement Initiatives Update o All of the groups are now up and running. Kaweah Delta Events: o Unveiling of Rupi Malli Plaque 202 Willow Lobby o Nursing Celebration Breakfast Blue Room, Cousteau, South Campus Cafeteria June 8th o Hospital Week BBQ Kaweah Park (By Kaweah Kids Center) June 13th 11am-2pm o Graduate Medical Education (GME) Graduation June 13th 5:30PM o Visalia Chamber Award Dinner June 14th 6:00PM o Hospital Week BBQ Exeter Health Clinic June 20th Noon-1:30PM o Hospital Week BBQ Visalia Medical Clinic East Lawn June 22nd 11:30-2:00PM Moody s Credit Review o This Friday Kaweah Delta will undergo their bi-annual credit review with Moody s. We are currently A3 stable and believe we will be able to maintain that rating. BOARD PRESIDENT REPORT Report from Lynn Havard Mirviss, Board President Director Havard Mirviss noted that relative to her recent hospital stay, the care she received was excellent, however that is not the case relative to the food that is served to our patients. We are not going to improve our patient satisfaction scores unless we can improve the quality of the food being served to our patients. Mr. Herbst noted that this has been a long standing issue contributed by the lack of leadership at the director level for our food services division. We have a new chef, however, we need to have a leader, the director of food services, to ensure we establish and sustain good quality meals for our patients. Director Francis noted that we should set a baseline expectation for the quality of the food service to patients and establish guidelines that keep us from dropping below this expectation. Mr. Rayner and Mr. Herbst both noted that this is, and will continue to be, a top priority to improve the food being served to our patients. Adjourn - Meeting was adjourned at 7:55PM Lynn Havard Mirviss, Board President Kaweah Delta Health Care District and the Board of Directors Thereof ATTEST: Nevin House, Secretary/Treasurer Kaweah Delta Health Care District Board of Directors Board of Directors Meeting - Open Page 5 of 5

22 MINUTES OF THE SPECIAL OPEN MEETING OF THE KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS HELD TUESDAY JUNE 12, :00AM, IN THE KAWEAH DELTA MEDICAL CENTER ACEQUIA WING EXECUTIVE OFFICE CONFERENCE ROOM, LYNN HAVARD MIRVISS PRESIDING PRESENT: Directors Havard Mirviss, Hawkins Hipskind, House, & Francis; G. Herbst, Chief Executive Officer; T. Rayner, VP & COO, R. Sawyer, VP & CNO; E. Hirsch, VP & CMO/CQO; D. Leeper, VP & CIO, D. Lynch, Legal Counsel; C. Moccio, Board Clerk The meeting was called to order at 11:05AM by Director Havard Mirviss. Director Havard Mirviss asked for approval of the agenda. MMSC (House/Hipskind) to approve the agenda. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, House, Hipskind, and Francis Public participation none Director Havard Mirviss called for the approval of the closed agenda. Approval of Closed Agenda as follows: Closed Meeting Agenda 11:00AM Report involving trade secrets {Health and Safety Code 32106} Discussion will concern a proposed new services/programs estimated date of disclosure is 09/01/18 Gary Herbst, Chief Executive Officer, Board of Directors and Dennis Lynch, legal counsel MMSC (Francis/Hipskind) to approve the closed agenda. This was supported unanimously by those present. Vote: Yes Havard Mirviss, Hawkins, Hipskind, House, & Francis Chief Executive Officer Report On Monday, June 4 th, a group from Visalia including myself, Doug Leeper, Julieta Moncada, Mike Williams, Nevin House, Bill Kitchen, and Randy Groom (Visalia City Manager), Judd Williams and Luis from kpff went to Sacramento to meet with the heads of the OSHPD Bob David, Paul Coleman, and Chris Tokas, in addition to a few of their engineers. We provided them a brief history up to our failed bond measure in We believe that their general sense of the matter is that they are very unsure that the Mineral King Wing could pass the shake test, and even if it did we have other issues that could prevent us from meeting compliance relative to the NPC requirements in the Mineral King Wing. This was reviewed with the Community Advisory Council Hospital of the Future group late last week and their general consensus was that we should consider other alternatives, we would end up spending a lot of money of this testing for nothing. Adjourn - Meeting was adjourned at 11:19AM Lynn Havard Mirviss, President Kaweah Delta Health Care District and the Board of Directors

23 Nominated By: Maria Howell Comments: Service Excellence June 2018 Christy Kennedy, RN (16 Years) BEHAVIORAL STANDARDS OF PERFORMANCE: - Compassionate Service: KIND AND CARING TO ALL PATIENTS AND FAMILY - Respect: CONSIDERATE OF COWORKERS AND PATIENTS PRIVACY - Communication: COMPLETE AND THOROUGH COMMUNICATOR - Commitment to Colleagues: CHRIS CHECKS ON HER DAYS OFF TO BE SURE WE ARE STAFFED, OFTEN COMES IN EXTRA TO HELP I have worked with Christy Kennedy for many years and her passionate commitment to patients, patient families and coworkers is exemplary. She has helped direct our ASC team throughout our remodel transition, as we move floors and manage patients through their surgical process. She is calm and competent in a critical situation. She has been a good friend and coworker for many years, for this I am very thankful! Thank you for your tremendous kind and compassionate care! DIRECTOR/MANAGER: Christine Aleman & Benton Duckett BOARD MEMBER: Herb Hawkins

24 KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS - CONSENT CALENDAR Kaweah Delta Medical Center - Blue Room 400 West Mineral King Avenue, Visalia Monday June 25, :00PM NOTE: All items listed on the Consent Calendar are considered to be routine by the District Board of Directors, and will be enacted by one motion. There will be no separate discussion of these items unless a Board Member so requests, in which event, the item will be removed from the Consent Calendar and considered in its normal sequence on the regular agenda Reports A. Medical Staff Recruitment B. Environment of Care C. Cardiology Service Line {Interventional Radiology, Cath lab} and Surgery D. Financials E. Endoscopy F. Non-Invasive Cardiology 3.2. Policies: A. ADMINISTRATIVE 1. Patient Safety Plan AP175 Revised 2. Quality Improvement Plan AP41 Revised 3. Travel, Per Diem, and Other Employee Reimbursement AP19 Revised 4. Risk Management Plan AP45 Reviewed B. RISK MANAGEMENT 1. Reporting and Investigation of Sentinel or Adverse Events RM06 Delete C. HUMAN RESOURCES Approval of Human Resources policies as reviewed by the Human Resources Committee {06/19/19}. 1. Employee Benefits Overview HR.128 Revised 2. Reporting Fraud and Abuse HR.192 Delete 3. Educational Leave of Absence HR.150 Delete 4. Confidential Information HR.194 Delete D. EMPLOYEE HEALTH Approval of Human Resources policies as reviewed by the Human Resources Committee {06/19/19}. 1. Hepatitis A Exposure EH10 Revised 2. Influenza Prevention and Immunization EH05 Revised Consent Calendar June 25, 2018 Page 1 of 2

25 3.3. Recommendations from the Medical Executive Committee June A. Medical Staff Bylaws June 2018 revision as reviewed and approved by the general Medical Staff. B. MERP Annual Review C. Medical Staff Policies & Procedures 1. MS 45 Focused Professional Practice Evaluation 2. MS 47 Code of Conduct for Medical Staff & Advanced Practice Providers 3. MS 49 Practitioner Health Policy 4. MS 02 Medical Staff Well Being Committee 5. MS 33 Reporting Guidelines for (CA Business Professional Code) MS 25 Rescinded/Lapsed Membership and/or Privileges 6. MS 29 Documenting Current Clinical Competence (Co-Manage/Co-Admit) 7. MS 11 Disruptive Medical/Advanced Practice Provider Staff Member Policy 8. MS 30 Proctoring Policy D. Privilege forms Revised 1. Adult Hospitalist Medicine 2. Advanced Practice Provider Emergency Medicine/Urgent Care 3. Cardiothoracic Surgery 4. Cardiovascular Medicine 5. Critical Care 6. Vascular Surgery 3.4. Kaweah Delta Board of Directors Committee Mission and Purpose statements. a. Human Resources Reviewed and approved by the Human Resources Committee June 19, b. Governance & Legislative Affairs Reviewed and approved by the Governance Legislative Affairs Committee June 19, Consent Calendar June 25, 2018 Page 2 of 2

26 Golden State Cardiac & Thoracic Surgery Mineral King Radiology Medical Group Cardiac & Thoracic Surgery 1 Interventional Radiology 1 Horizon Critical Care Sequoia Radiation Oncology Medical Associates Intensivist 2 Radiation Oncologist 1 IQ Surgical Associates Valley Children's Health Care GI Hospitalist 3 Maternal Fetal Medicine 2 Pediatric Hospitalist 3 Kaweah Delta Medical Foundation Adult Primary Care 2 Valley Hospitalist Medical Group Dermatology 2 Hospitalist - Nights 1 ENT 1 Gastroenterology 2 Vituity - Family Medicine Clinic General Surgery 1 Family Medicine Core Faculty 1 OB/GYN 3 Orthopedic Surgery - Adult Reconstruction 1 Other Recruitment Pediatrics 1 Palliative Medicine 2 Podiatry 1 Rheumatology 1 Urology (1- physician; 1-APP) 2 Kaweah Exeter Medical Group Adult Primary Care 3 OB/Gyn 1 Pediatrics 1 Kaweah Delta Physician Recruitment Open Position Snapshot - June 2018 Prepared by: Brittany Taylor, Physician/Leadership Recruiter btaylor@kdhcd.org - (559) Date prepared: 6/12/2018

27 Candidate Activity Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status Adult Primary Care - Family Medicine Kaweah Delta Medical Foundation Christiansen, M.D. Christopher 07/18 American Board of Family Medicine, Eligible CA Licensed; Current Kaweah Delta Resident; Direct candidate. Offer accepted Cardiology - Pediatrics Valley Children's Hospital Sykes, M.D. Michelle 08/18 American Board of Pediatrics, Certified; American Board of Pediatrics - Pediatric Cardiology, Certified CA Licensed; Presented by VCH on 3/21/18. Site visit: 4/3/18; Offer accepted. Cardiology, Invasive/Non- Interventional Endocrinology Gastroenterology Gastroenterology General Surgery Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Kaweah Delta Medical Foundation Said, M.D. Sarmad 08/18 Saif, M.D. Noman 02/18 Tariq, M.D. Hassan 08/19 Hsueh, M.D. William 08/19 Machado, M.D. Carol 08/18 General Surgery IQ Surgical Associates Kirkpatrick, M.D. Vincent 07/18 American Board of Internal Medicine, Certified; American Board of Internal Medicine - Cardiovascular Disease, Eligible American Board of Internal Medicine, Certified; American Board of Internal Medicine - Endocrinology, Certified American Board of Internal Medicine, Certified American Board of Internal Medicine, Certified American Board of Surgery - General Surgery, Certified American Board of Surgery - General Surgery, In progress CA Licensed; Presented on 7/13/17 by Physician Empire. CA licensed; Currently practicing in Longview, TX; Brother is moving to Fresno. Presented by Cejka on 2/1/17. Presented by Puzzle Piece Solutions on 4/5/18. No CA license; Presented by Fidelis Partners on 7/25/17. CA licensed; Currently practicing in Fresno, CA; Candidate reached out directly on 5/8/18. CA Licensed; Presented by Fidelis Partners on 11/6/17. Site visit: 9/22/17; Offer accepted. Site Visit: 3/9/17; Offer accepted, Start Date: 7/9/2018 Currently under review Site visit: 11/10/17; Offer accepted. Phone Interview: 5/11/18; Site Visit: 6/7/18; Offer Accepted. Tentative start date: 8/2018, pending credentialing Site Visit: 12/15/17; Offer accepted; Start Date: 8/2018 1

28 Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status GME Family Medicine Faculty (full-time) Vituity Parungao, M.D. Jodi 09/18 American Board of Family Medicine, Eligible No CA license; Candidate information rec'd on 9/11/17. Site visit: 9/19/17; Offer accepted; tentative start date: 8/2018 Hospitalist Valley Hospitalist Group Legesse, M.D. Ashenafi 01/18 American Board of Internal Medicine, Eligible CA Licensed; Candidate is currently practicing in Fresno; Candidate reached out directly on 9/18/17. Offer extended Hospitalist Valley Hospitalist Group Saadabadi, M.D. Zohreh 08/18 American Board of Family Medicine, Eligible No CA License; Currently completing Geriatric Medicine Fellowship; Candidate referred by Dr. Onsy Said on 3/5/18. Site Visit 3/20/18; offer extended Hospitalist - Critical Care Horizon Critical Care Yousef, M.D. Peter 08/18 American Board of Internal Medicine, Eligible CA Licensed; Presented by Puzzle Piece Solutions on 4/5/18. Site Visit: 5/4/18; Offer extended Hospitalist Valley Hospitalist Group Patel, M.D. Naresh TBD American Board of Family Medicine, Certified CA Licensed; Candidate is currently practicing in Site Visit: 11/1/17; Offer Bakersfield; Candidate accepted. rec'd directly from Salient MD on 10/23/17. Hospitalist Valley Hospitalist Group Tedaldi, M.D. Michael 07/19 American Board of Internal Medicine, Eligible CA Licensed; Spouse is currently PGY 1 with KDHCD General Surgery program; Candidate reached out directly on 11/10/17. Site visit: 11/14/17; Offer accepted Hospitalist Valley Hospitalist Group Chen, M.D. David Peng 07/18 American Board of Internal Medicine, Eligible Completing residency in Peoria, IL; Wife accepted Site visit: 12/12/17; offer an NP position in accepted; Anticipated start Porterville. Candidate date: August 2018 reached out directly on 10/9/17. Hospitalist Valley Hospitalist Group Gumaste, M.D. Purva 08/18 American Board of Internal Medicine, Eligible No CA license; Husband is joining local Nephrology group; Candidate reached out directly on 7/6/17. Site visit: 9/11/17; Offer accepted. Anticipated start date: 8/29/18 2

29 Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status Hospitalist Valley Hospitalist Group. Howard, M.D. Ryan 07/18 American Board of Family Medicine, Eligible No CA License; Completing residency in AZ; also considering Hospitalist position; Candidate reached out directly on 7/10/17. Site visit: 11/3/17; Offer accepted with Valley Hospitalist Medical Group. Anticipated start date: August 2018 Intensivist Horizon Critical Care Psihos, D.O. Peter John 08/18 American Osteopathic Board of Internal Medicine, Certified; Critical Care Medicine, Eligible (2018); Pulmonary Medicine, Eligible (2017) No CA License; Presented by Medical Puzzle Piece Solutions on 7/14/17. Site visit: 8/11/17; Offer accepted. Anticipated start date: July 2018 Intensivist Horizon Critical Care Elias, D.O. George 06/18 Intensivist Horizon Critical Care Sagar, M.D. Ala Eddin 08/19 Interventional Radiology Interventional Radiology Neonatology Orthopedic Surgery - Adult Reconstruction Otolaryngology Mineral King Radiology Group Mineral King Radiology Group Valley Children's Hospital Orthopaedic Associates Kaweah Delta Medical Foundation Sabatelli, M.D. Frank TBD Palaniappun, M.D. Senthil TBD Soares, M.D. Fernando TBD Kim, D.O. Jun 08/19 Giese, M.D. Rachel 01/19 CA licensed; Presented American Osteopathic by Medical Puzzle Piece Board of Surgery, eligible Solutions on 3/2/18. American Board of Internal Medicine, Certified; Pulmonary Medicine, Certified American Board of Radiology, Certified American Board of Radiology, Certified; American Board of Radiology - IR/DR, Certified American Board of Pediatrics, Certified; American Board of Pediatrics - Neonatal- Perinatal Medicine, American Board of Orthopedic Surgery, Eligible American Board of Otolaryngology, certified No CA License; Presented by Medical Puzzle Piece Solutions on 5/15/18. Presented by Fidelis Partners on 4/2/18. CA Licensed; Presented by Fidelis Partners on 4/18/18. No CA License; Referred by Dr. Jose Dosado. Presented by VCH on 4/9/18. No CA license; Direct candidate referred by Dr. Bruce Le on Site visit: 3/23/18; offer pending Site visit pending, July 2018 Working locums interview: 6/2018 Currently under review Site Visit 4/23/18; Offer pending Site visit: 3/1/18; offer accepted 12/11/17. No CA license; Completing Head and Neck research Site visit pending fellowship; Presented by references. Fidelis Partners on 6/4/18. 3

30 Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status Palliative Medicine Independent Tickoo, M.D. Roma TBD American Board of Internal Medicine, Certified; American Board of Geriatric Medicine, Certified; American Board of Hospice and Palliative Medicine, Certified; American Board of Psychiatry & Neurology Pain Med, Certified No CA License; Presented by Fidelis Partners on 5/24/18. Site visit: 6/11/18 Pediatric - Outpatient Kaweah Delta Medical Foundation Khalid, M.D. Saba 05/18 American Board of Pediatrics, Certified CA licensed; Provided locum coverage at VMC. Offer accepted Pediatric Hospitalist Valley Children's Hospital Jacob, M.D. Saul 09/18 American Board of Pediatrics, Eligible Spouse is Dr. Reetu Site visit: 3/26/18; Offer Malhotra, Pediatric accepted (.25 FTE at KDH & Hospitalist; Presented by.75 FTE at VCH). Start date: VCH on 3/14/18. 9/4/2018 Pediatric Hospitalist Valley Children's Hospital Ganesan, M.D. Thiyagu TBD American Board of Pediatrics, Certified CA Licensed; Presented by VCH on 5/22/18. Site Visit: 6/13/18 Pediatric Hospitalist Pediatric Hospitalist Urology Valley Children's Hospital Valley Children's Hospital Kaweah Delta Medical Foundation Malhotra, M.D. Reetu 09/18 Kaur, M.B.B.S. Resham TBD Ford, M.D. Joseph 07/18 American Board of Pediatrics, Eligible American Board of Pediatrics, Certified Spouse is Dr. Saul Jacob, Pediatric Hospitalist; Presented by VCH on 3/14/18. NO CA license; Presented by VCH on 2/6/18. No CA License; Completing Oncology fellowship ; Presented by Fidelis Partners on 6/14/17. Site visit: 3/26/18; Offer accepted (.25 FTE at KDH &.75 FTE at VCH). Start date: 9/4/2018 Site visit: 2/16/18; Offer accepted. Start Date: 7/30/2018 Site Visit: 7/7/17; Offer accepted 4

31 Environment of Care 1 st Quarter Report January 1, 2018 through March 31, 2018 Presented by Rob DiBernardo, Director of Facility Operations and Support Services Maribel Aguilar, Safety Officer 1 Please contact Rob DiBernardo with any questions (559)

32 Kaweah Delta Healthcare District Performance Monitoring 1 st Quarter 2018 EOC Component: Performance Standard: Evaluation: There were 77 Occupational Safety & Health Administration (OSHA) reportable injuries during the 1 st quarter This is a annualized increase of 29% over 1 st quarter We review the departments that have had over 3 OSHA recordable injuries in a quarter and send to managers. 3 North (4), Acute Rehab (3), Surgery (6), Environmental Services (6). Report sent on 4/9/18. Provided 17 ergonomic evaluations in 1 st quarter to prevent cumulative trauma injuries/claims. Goal was not met for this quarter. SAFETY Employee Health: The objective is to reduce Occupational Safety & Health Administration (OSHA) recordable work related injuries/illness cases by 10% from the year Goal: Reduce OSHA Recordable Injuries by 10% in No more than 214 recordable injuries in Minimum Performance Level: Reduce OSHA Recordable Injuries by 10% in Type of injury YTD Totals Annualized Totals Annualized % change Q1 Q2 Q3 Q4 Total Accidents % OSHA report % Lost time cases % Lost time days % Strain/sprain % Cum Trauma % Sharps Exp % BBF Splash % Laceration na Bruise/ Contusion % Plan for Improvement Identify employees with more than 3 Occupational Safety % Health Administration recordable injuries in last 2 years. Discuss with Managers to determine if prevention is possible with education and/or re-training. Timely- same day on-site incident investigation and follow-up with manager for prevention. Review and discuss OSHA recordable injuries with department manager/ director for quarter. Identify education needs with manager. OSHA reportable injuries and illnesses are as follows: Fatalities, regardless of the time between the injury and death or the length of the illness. Any case, other than a fatality that resulted in lost workdays. Cases that did not have lost workdays but where the employee was transferred to another job or was terminated. Cases that required medical treatment other than first aid. Cases that involve loss of consciousness or restriction of work or motion (this includes any diagnosed occupational illnesses that are reported but not classified as fatalities or lost workdays). 2

33 EOC Component: Performance Standard: Evaluation: ). Forty-one departments were surveyed in the 1 st quarter. In all departments surveyed staff where able to verbalize their role during an internal disaster, which resulted in a 100% compliance rate. 95% minimum performance level was met for this quarter. EMERGENCY PREPAREDNESS During routine hazardous surveillance rounds employees will be queried regarding their role during various internal disasters ie. nurse call failure, oxygen outage, medical vacuum failure etc. Goal: 100% Compliance. Minimum Performance Level: Employees able to answer correctly 95% of the time. 100% 80% 60% 40% 20% 0% Internal Disaster Response 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Correct Responses Threshold Plan for Improvement: In each department visited there was knowledge of internal disaster procedures. Employees have been able to verbalize their role during an internal disaster including nurse call, oxygen, medical vacuum etc. We will continue to monitor through hazard surveillance rounding and during the quarterly mini drills. EOC Component: Performance Standard: Evaluation: There were 43 non-patient safety reports filed during the 1 st quarter 2018 which is higher than the 38 in the 1 st quarter Zero serious injuries were sustained. Goal is currently being met. SAFETY Risk Management: Non-patient injuries will be monitored to identify the need for further training and/or procedural changes on completing occurrence reports. Goal: Reporting of non-patient safety related events will increase by 10% by the end of Minimum Performance Level: Increase by 10% from baseline. Risk Management Non-Patient Safety Reports Filed District Except TLC TLC Event Report Plan for Improvement: This performance standard is being met or exceeded. Risk Management will continue to conduct a trend analysis of all visitor falls and injuries that have occurred to identify trends. TLC Types of Events: Falls related to basketball, treadmill District Type of Events: Fainting Self-trips 3

34 EOC Component: Performance Standard: Evaluation: All employees, physicians and support staff assigned to work in the Emergency Department or the Kaweah Delta Mental Health Hospital have received training in Non-violent Crisis Intervention. Organization leaders and select departments have also received Non-violent Crisis Intervention training and are part of the Workplace Violence Response Team. (Calendar year 2017) Acute Psych Hospital Average patient days = 1,422 Total year assaults = 105 We had 27 assault in 1 st quarter 2017 compared to 28 in 1 st quarter Goal is not met for this quarter. Emergency Department Total emergency department visits = 91,441 Total mental health patients seen = 3,563 Average monthly mental health census = 514 Total year assaults = 72 We had 21 assaults in 1 st quarter 2018 compared to 12 in Goal is not met for this quarter. SECURITY Kaweah Delta has adopted the Non-Violent Crisis Intervention training from the Crisis Prevention Institute in response to the Cal/OSHA Workplace Violence mandate. The Security Department is tracking assaultive incidents that originates from the Emergency Department and the Acute Psych Hospital to determine effectiveness of crisis intervention program with the goal of proactively being able to identify early warning signs of aggressive behavior and early intervention to decrease preventable assaults. Goal: Decrease assaults by 5% from previous year Acute Psych Hospital goal of or less assaults, less than 24 per quarter. Emergency Department goal of 68.4 or less assaults, less than 17 per quarter Goal currently being met 12 Acute Psych Hospital Assaults Goal currently being met Q1 Q2 Q3 Q4 Emergency Department Assaults Q1 Q2 Q3 Q Assaults 2018 Assaults 2017 Assaults 2018 Assaults Plan for Improvement: Acute Psych: Implement Non-violent Intervention Crisis training, proactively manage difficultaggressive patients. Emergency Department: A task force has been developed and assault incidents data review being conducted along with Emergency Department leadership. 4

35 EOC Component: Performance Standard: SAFETY Risk Management: No patient death or serious disability* associated with a fall while being cared for in a KDHCD facility. Goal: 100% Compliance. Minimum Performance Level: 100% Compliance. Evaluation: There were no incidents of patient death or serious disability associated with a fall while being cared for in a KDHCD facility. The Minimum Performance Level was met for this standard. *Serious disability means physical or mental impairment that substantially limits one or more of the major life activities of an individual, or the loss of bodily function if the impairment lasts more than seven (7) days, or is still present at the time of discharge, or loss of a body part. Plan for Improvement: Hazardous Surveillance inspections of all KDHCD facilities conducted on a scheduled basis. Safety issues identified are resolved by Department Manager. Continue to monitor. EOC Component: UTILITIES MANAGEMENT Performance Standard: Critical utility systems preventive maintenance will be performed on a regular basis. Goal: 100% of critical utility systems will be serviced and/or inspected quarterly. Minimum Performance Level: 100% of critical utility systems will be serviced and/or inspected quarterly. Evaluation: There were 148/148 critical utility preventative maintenance work orders completed. The compliance rate for the 1 st quarter was 100%. The Minimum Performance Level was met. 100% 80% 60% 40% 20% 0% Critical PM Completion Rate All Campuses 100% 1 Q 18 2 Q 18 3 Q18 4 Q % Plan for Improvement: Maintenance management will be monitoring the completion of critical utility preventive maintenance each month to insure completion as scheduled on a quarterly basis. Continue to monitor. Critical Preventive Maintenance % Completed Minimum Performance Level = 100% 5

36 EOC Component: Performance Standard: Evaluation: During the 1 st quarter 2018 hand hygiene performance achieved a 92% compliance rate. SAFETY Infection Prevention: Overall reduce healthcare-associated Infections by improving hand hygiene compliance on patient-related units. Patient-related units will submit a minimum (i.e., 30, etc. depending on size/function) observations per month to the Infection Prevention Office. 100% compliance with Hand Hygiene submissions. Performance Level Goal: 90% compliance with Hand Hygiene. Overall District Hand Hygiene Compliance 2018 Minimum Performance Level was met. Plan for Improvement: 1. Monthly data sent to managers and to directors as needed. 2. Evaluation of automated hand hygiene system. 3. Infection Prevention weekly rounding on units. 4. Infection Prevention intensive focus on inpatient units. EOC Component: Performance Standard: Evaluation: Forty-one departments were surveyed in the 1 st quarter. In 2 of the departments inspected supplies were found to be stored too close to the ceiling (18 clearance required). This resulted in an 95% compliance rate. Minimum Performance Level was not achieved during this Quarter. FIRE PREVENTION/LIFE SAFETY Equipment and supply storage compliance will be monitored during hazard surveillance inspections. Supplies are not to be stored on the floor. There also needs to be a clearance of 18 to the ceiling in sprinklered rooms and 24 in nonsprinklered rooms per California Fire Code & The Joint Commission requirements. Goal: 100% of departments inspected will be compliant. Minimum Performance Level: 100% of department inspected will be compliant. 100% 80% 60% 40% 20% 0% 95% Supply Storage 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr Compliant Departments Plan for Improvement: We will continue to monitor through hazard surveillance and report to appropriate director and VP. Non compliant departments will be sent reminder regarding storage and proper clearance. Continue to monitor through rounding during hazard surveillance 6

37 EOC Component: HAZARDOUS MATERIALS Performance Standard: Evaluation: Forty-one departments were surveyed in the 1st Qtr. Of the departments checked 41/41 departments were compliant. This resulted in a 100% compliance rating. 95% Minimum 40% Performance Level was 20% met for this Quarter. 0% Plan for Improvement: Employee should be able to respond with the correct steps to take when there is a chemical spill and be able to locate the chemical in the Maxcom binder or online system. During routine hazardous surveillance employees will be queried regarding their knowledge in using the SDS program. Goal: 100% compliance with response to chemical spill. Minimum Performance Level: 95% compliance with response to chemical spill. 100% 80% 60% Hazardous Materials 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr All employees were required to review this performance measure during our annual competency in May. We will continue to monitor and educate during hazard surveillance rounding. Safety Data Sheet 7

38 Kaweah Delta Health Care District Annual Report to the Board of Directors Cardiac and Vascular Surgery, Cath Lab, and Surgical Services Benton Duckett, MBA, BSN, RN, Director of Cardiac and Surgical Services June 2018 Summary Issue/Service Considered Continue to provide personal, professional and compassionate care for our patients, families, physicians, staffs, customers and team. Maintain highest quality care, compliance and profitability while sustaining an ideal work environment. Financial/Statistical Data Cardiothoracic Surgery: The cardiothoracic (CT) surgery program experienced a 30% increase in surgical volume as compared to last year. Part of this growth is based on an increase of cardiologists who have joined the Kaweah Delta Team. We also increased marketing efforts to physicians and the community highlighting our stellar program. Despite the increase in direct costs, the net revenue has improved. A major contributor to the cost increase is associated with an increase of the radial artery for coronary arterial bypass. This procedure increases surgical time and needed supplies, but is beneficial for the patient improving recovery. Continuous focus areas for the CT program: Partner with Case Management to move the patient through the continuum. Evaluate surgical work-up time. Continuously maintain and/or improve Society of Thoracic Surgeons (STS) outcomes. o Post-operative extubation within 24hrs after surgery o Decrease pump runs (Heart Lung Machine) o Decrease blood usage Achievements: Our program received two Heathgrades Awards this past year. We were awarded America s 50 Best in Cardiac Surgery Programs and Top 100 for Cardiac Care. Financial/Statistical Data Cath Lab:

39 The Cath Lab performance remains strong, with a Contribution Margin of 1M more than the previous year. The Cath Lab performed better in net revenue per case compared to cost per case. Quality/Performance 2017 Initiatives: Increased Radial Access vs the Femoral approach for percutaneous coronary intervention (PCI). Leading to improved patient outcomes: o Faster recovery and early mobility o Length of stay reduction o Decreased risk of bleeding o Improved patient experience Decreased Door to Balloon (D2B) time: o Throughput of the patient from the Emergency Department to the Cath Lab sooner when needing a PCI Improvement in Cath lab staffing levels have increased room utilization leading to improved staff, physician, and patient satisfaction. o Increased number of cases per day. o Reduced working hours o Reduction in hospital length of stay New Initiatives for 2018: The Transcatheter Aortic Valve Repair (TAVR) program is ready to launch with the first patient receiving the procedure on July 17, This minimally invasive surgical procedure repairs the valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve's place. The surgery may be called a transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI). It is performed by the Cardiologist and CT Surgeon in the Cath Lab. Development of a dedicated Interventional Radiology Team. This service line is growing and becoming more specialized. Our 6 th Cath Lab is up and running. Completed Cleveland Clinic implementation of improvement and efficiency projects. Begin Lean process on Cath Lab turnover times. We continue to strive to meet the goals of the (ACC) American College of Cardiology. These metrics include all interventional and non-interventional procedures, pacemakers, internal defibrillators, and how we compare to like facilities. This information is reported to the Department of Cardiovascular Service and PROSTAFF.

40 Surgery: Vascular, Orthopedics, Neurosurgery, Robotics and other Service Lines Financial/Statistical Data This has been an exciting year for Surgery. We have completed approximately 500 more cases this past year, with an increase in Contribution Margin of $1.5M. Neurosurgery rejoined the surgical service lines in November of We are awaiting the arrival of two full-time surgeons joining the group in July and September Quality/Performance Accomplishments: We maintain a certification as a Center of Excellence in both Minimally Invasive and Gynecological Surgery and Robotics awarded to us by the Surgical Review Board (SRC). We were awarded the Orthopedic Surgery Excellence Award 2018 by Healthgrades. We were a Five Star Recipient for both Hip and Knee replacement 2018 through Healthgrades. Our new Surgery Center opened in February of We completed construction and will be opening a new surgeons lounge in June Goals for the coming year: Redesign surgery block schedules to meet the current increased demand and accommodate for the new surgeons joining the team. Upgrade orthopedic equipment which is currently in the capital budget. Upgrade the Neurosurgical equipment to perform new procedures such as aneurysm clipping and tumor removal. Continue the lean process to improve turnover times to be more efficient and productive. Support the new Anesthesiologist Residency. Recommendations/Next Steps Continue to evaluate quality, and opportunities for improvement in conjunction with Infection Protection, and Quality Improvement teams. Continue to perform with in the National Surgical Quality Improvement Program (NSQIP). NSQIP results are reported to PROSTAFF. Continue to review profitability, direct costs, and contribution margins to identify opportunities for volume growth and cost containment in all areas of the cardiac and main operating rooms. Maintain and increase geographic patient access (market share) for all surgical cases, capturing any outmigration. Continue to explore new technologies.

41 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Cardiac Surgery Benton Duckett ( ) June 2018 Service Line Report Data: Fiscal Year 2017 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Cardiac Surgery 227 $13,956,678 $13,530,098 $426,580 $3,065,193 ($2,638,613) Grand Total 227 $13,956,678 $13,530,098 $426,580 $3,065,193 ($2,638,613) Service Line Report Data: Fiscal Year 2016 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Cardiac Surgery 273 $14,652,846 $14,168,014 $484,832 $3,531,003 ($3,046,171) Grand Total 273 $14,652,846 $14,168,014 $484,832 $3,531,003 ($3,046,171) Increase (Decrease) (46) ($696,168) ($637,916) ($58,252) ($465,810) $407,558 Net Revenue Per Case This Year Last Year $46,000 $50,000 $54,000 $58,000 $62,000

42 $, $, $, $, $,

43 Direct Cost Per Case This Year Last Year $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 Contribution Margin Per Case This Year Last Year $0 $1,000 $2,000 $3,000 $4,000 Last Year This Year Net Revenue Per Case $53,673 $61,483 Direct Cost Per Case $51,897 $59,604 Contribution Margin Per Case $1,776 $1,879

44 Cardiac Catheterization Benton Duckett ( ) June 2018 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Service Line Report Data: Fiscal Year 2017 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Cardiac Cath Procedures - I/P 1,257 $27,334,301 $17,981,701 $9,352,600 $4,117,079 $5,235,521 Cardiac Cath Procedures - O/P 3,170 $23,711,003 $15,737,965 $7,973,038 $3,412,905 $4,560,133 Grand Total 4,427 $51,045,304 $33,719,666 $17,325,638 $7,529,984 $9,795,654 Service Line Report Data: Fiscal Year 2016 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Cardiac Cath Procedures - I/P 1,320 $26,855,325 $18,587,938 $8,267,387 $4,512,940 $3,754,447 Cardiac Cath Procedures - O/P 3,367 $24,901,059 $16,759,456 $8,141,603 $3,883,418 $4,258,185 Grand Total 4,687 $51,756,384 $35,347,394 $16,408,990 $8,396,358 $8,012,632 Increase (Decrease) (260) ($711,080) ($1,627,728) $916,648 ($866,374) $1,783,022

45 Net Revenue Per Case This Year Last Year $9,000 $9,500 $10,000 $10,500 $11,000 $11,500 Direct Cost Per Case This Year Last Year $6,400 $6,600 $6,800 $7,000 $7,200 $7,400 $7,600 $7,800 Contribution Margin Per Case This Year Last Year $2,500 $3,000 $3,500 $4,000 Last Year This Year Net Revenue Per Case $11,043 $11,530 Direct Cost Per Case $7,542 $7,617 Contribution Margin Per Case $3,501 $3,914

46 Annual Report to the Board of Directors Financial & Statistical Information Surgical Services Benton Duckett ( ) June 2018 Service Line Report Data: Fiscal Year 2017 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Inpatient: General Surgery 1,026 $21,297,236 $15,011,735 $6,285,501 $4,292,730 $1,992,771 Orthopedics** 1,374 28,062,040 20,632,756 7,429,284 4,346,136 3,083,148 Thoracic Surgery 34 2,138,014 1,603, , ,817 75,374 Vascular Surgery 205 3,853,776 3,039, , ,946 (9,072) Gynecology 125 1,325, , , , ,833 Urology , , , ,848 (50,030) Surgery in other service lines ,137,834 8,508,107 2,629,727 2,304, ,931 Robotics Surgery , , , ,092 32,380 Total Inpatient 3,287 $ 69,569,455 $ 50,979,449 $ 18,590,006 $ 12,900,671 $ 5,689,335 *Note: During FY 2017, Orthopedic Service Line cases increased 7.3%, ALOS declined by 8.7%, and Direct Cost per Case declined by 5.1%. In addition to the LOS-related cost savings, significant supply savings was found to be a large contributing factor in the cost savings during FY Outpatient: Surgery 5,188 $ 19,858,934 $ 20,812,441 $ (953,507) $ 5,695,725 $ (6,649,232) Robotics ,437 1,331,500 (445,063) 503,461 (948,524) Total Outpatient 5,376 $ 20,745,371 $ 22,143,941 $ (1,398,570) $ 6,199,186 $ (7,597,756) *Note: Deep dive analysis into the Outpatient Surgery loss has been completed and presented. Biggest issues are: 1.) Heavy and growing Medi-Cal Managed Care payor mix and 2.) High level of ED Observ. hrs/costs impacting this service. Grand Total 8,663 $90,314,826 $73,123,390 $17,191,436 $19,099,857 ($1,908,421) Service Line Report Data: Fiscal Year 2016 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Inpatient: General Surgery 1,084 $22,067,170 $15,282,429 $6,784,741 $4,637,777 $2,146,964 Orthopedics 1,280 26,871,999 22,095,151 4,776,848 4,502, ,857 Thoracic Surgery 35 4,110,693 2,727,274 1,383, , ,161 Vascular Surgery 212 4,218,281 3,201,363 1,016, ,851 82,067 Gynecology 181 2,062,857 1,160, , , ,933 Urology 107 1,504,408 1,266, , ,905 (154,945) Surgery in other service lines 343 9,121,657 7,577,708 1,543,949 2,110,692 (566,743) Robotics Surgery , , , ,860 5,943 Total Inpatient 3,306 $ 70,919,362 $ 54,026,577 $ 16,892,785 $ 13,998,548 $ 2,894,237 Outpatient: Surgery 4,620 $ 15,960,402 $ 16,640,735 $ (680,333) $ 4,504,130 $ (5,184,463) Robotics ,846 1,145,374 (431,528) 439,458 (870,986) Total Outpatient 4,764 $ 16,674,248 $ 17,786,109 $ (1,111,861) $ 4,943,588 $ (6,055,449) Grand Total 8,070 $87,593,610 $71,812,686 $15,780,924 $18,942,136 ($3,161,212)

47 Increase (Decrease) 593 $2,721,216 $1,310,704 $1,410,512 $157,721 $1,252,791 Inpatient Net Revenue Per Case This Year Last Year $18,000 $19,000 $20,000 $21,000 $22,000 Inpatient Direct Cost Per Case $14,000 $14,500 $15,000 $15,500 $16,000 $16,500 $17,000 Inpatient Contribution Margin Per Case This Year Last Year $4,000 $4,500 $5,000 $5,500 $6,000 INPATIENT ONLY Last Year This Year Net Revenue Per Case $21,452 $21,165 Direct Cost Per Case $16,342 $15,509 Contribution Margin Per Case $5,110 $5,656 Source: SLR Surgical 7420 & 7421 by Service Line.rpt

48 CFO Financial Report June 19, 2018

49 500 Average Daily Census Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun FY 2016 FY 2017 FY 2018 Budget FY18

50 Inpatient Statistical Results: Monthly Comparison May 2018 May 2017 Change % Change Average Daily Census % Inpatient Revenue % 51.6% 50.5% 1.1% 2.2% Acute ALOS % KDHCD Patient Days: Medical Center 9,062 8,047 1, % Acute I/P Psych 1,341 1,474 (133) (9.0%) Sub-Acute % Rehab % TCS-Ortho TCS (118) (21.6%) NICU % Nursery (44) (7.7%) Total KDHCD Patient Days 13,824 12,558 1, % TCS-Ortho services were temporarily discontinued to use beds for overflow ambulatory surgery.

51 Financial Results: May Comparison (000 s) May 2018 May 2017 Change % Change Operating Revenue Net patient service revenue $48,498 $48,292 $ % Supplemental Gov't Programs 2,656 2, % Prime Program Premium revenue 2,777 2, % Management services revenue 2,599 2, % Other Revenue 1,669 1, % Other operating revenue 9,700 8,322 1, % Total Operating Revenue 58,198 56,614 1, % Operating Expenses Salaries and wages 21,910 21, % Employee benefits 5,902 4,466 1, % Total Employment Expenses 27,812 25,648 2, % Medical and other supplies 9,240 8, % Medical and other fees 8,319 6,595 1, % Purchased services 3,549 3, % Repairs and maintenance 2,232 2, % Utilities (13) (2.8%) Rents and leases % Depreciation and amortization 2,522 2, % Interest Expense % Other Expenses 2, , % Management Services Expenses 2,592 2, % Total Operating Expenses 59,875 52,561 7, % Operating Margin ($1,677) $4,053 ($5,730) (141.4%) Nonoperating Revenue % Excess Margin ($1,115) $4,517 ($5,632) (124.7%) Operating Margin % (2.9%) 7.2% Excess Margin % (1.9%) 8.0%

52 Financial Results: Budget Comparison (000 s) May 2018 May Budget Variance % Change Operating Revenue Net patient service revenue $48,498 $47,489 $1, % Supplemental Gov't Programs 2,656 2,717 (61) (2.2%) Prime Program - 1,154 (1,154) (100.0%) Premium revenue 2,777 2, % Management services revenue 2,599 2, % Other Revenue 1,669 1, % Other operating revenue 9,700 10,626 (925) (8.7%) Total Operating Revenue 58,198 58, % Operating Expenses Salaries and wages 21,910 22,325 (414) (1.9%) Employee benefits 5,902 6,055 (154) (2.5%) Total Employment Expenses 27,812 28,380 (568) (2.0%) Medical and other supplies 9,240 8, % Medical and other fees 8,319 6,939 1, % Purchased services 3,549 2, % Repairs and maintenance 2,232 2, % Utilities (41) (8.5%) Rents and leases % Depreciation and amortization 2,522 2,700 (177) (6.6%) Interest Expense % Other Expenses 2,049 1, % Management Services Expenses 2,592 2, % Total Operating Expenses 59,875 56,581 3, % Operating Margin ($1,677) $1,534 ($3,211) (209.3%) Nonoperating Revenue % Excess Margin ($1,115) $1,996 ($3,111) (155.8%) Operating Margin % (2.9%) 2.6% Excess Margin % (1.9%) 3.4%

53 Inpatient Statistical Results: YTD Comparison YTD 2018 YTD 2017 Change % Change Average Daily Census % Inpatient Revenue % 52.6% 52.2% 0.4% 0.8% Acute ALOS % KDHCD Patient Days: Medical Center 95,362 89,197 6, % Acute I/P Psych 15,577 15,704 (127) (0.8%) Sub-Acute 10,380 10, % Rehab 6,229 6, % TCS-Ortho 4,148 3, % TCS 5,371 5,847 (476) (8.1%) NICU 4,173 4,269 (96) (2.2%) Nursery 6,256 6, % Total KDHCD Patient Days 147, ,963 6, %

54 Financial Results: Year to Date Comparison (000 s) YTD 2018 YTD 2017 Change % Change Operating Revenue: Net patient service revenue $521,840 $488,860 $32, % Supplemental Gov't Programs 28,941 22,400 6, % Prime Program 17,091 15,617 1, % Premium revenue 29,328 25,097 4, % Management services revenue 26,585 24,876 1, % Other Revenue 17,370 15,094 2, % Other operating revenue 119, ,083 16, % Total Operating Revenue 641, ,943 49, % Operating Expenses: Salaries and wages 244, ,071 17, % Employee benefits 66,239 68,438 (2,199) (3.2%) Total Employment Expenses 310, ,509 14, % Medical and other supplies 101,731 89,812 11, % Medical and other fees 80,900 72,437 8, % Purchased services 35,130 29,445 5, % Repairs and maintenance 21,835 20,330 1, % Utilities 5,014 4, % Rents and leases 5,238 4, % Depreciation and amortization 22,558 21,214 1, % Interest Expense 4,507 5,012 (505) (10.1%) Other Expenses 12,591 11,417 1, % Management Services Expenses 26,074 24,314 1, % Total Operating Expenses 625, ,274 46, % Operating Margin $15,244 $12,669 $2, % Nonoperating Revenue 3,204 2, % Excess Margin $18,448 $14,950 $3, % Operating Margin % 2.4% 2.1% Excess Margin % 2.9% 2.5%

55 Budget Results: Year to Date Comparison (000 s) YTD Actual YTD Budget Variance % Change Operating Revenue Net patient service revenue $521,840 $512,662 9, % Supplemental Gov't Programs 28,941 29,883 (942) (3.2%) Prime Program 17,091 12,698 4, % Premium revenue 29,328 29, % Management services revenue 26,585 26,839 (255) (0.9%) Other Revenue 17,370 16, % Other operating revenue 119, ,355 3, % Total Operating Revenue 641, ,017 13, % Operating Expenses Salaries and wages 244, ,250 2, % Employee benefits 66,239 65, % Total Employment Expenses 310, ,685 3, % Medical and other supplies 101,731 90,558 11, % Medical and other fees 80,900 74,991 5, % Purchased services 35,130 31,926 3, % Repairs and maintenance 21,835 21, % Utilities 5,014 5,148 (134) (2.6%) Rents and leases 5,238 5, % Depreciation and amortization 22,558 29,173 (6,616) (22.7%) Interest Expense 4,507 5,298 (790) (14.9%) Other Expenses 12,591 14,610 (2,019) (13.8%) Management Services Expenses 26,074 26,344 (270) (1.0%) Total Operating Expenses 625, ,436 14, % Operating Margin $15,244 16,580 ($1,336) (8.1%) Nonoperating Revenue 3,204 5,007 (1,803) (36.0%) Excess Margin $18,448 $21,587 ($3,139) (14.5%) Operating Margin % 2.4% 2.6% Excess Margin % 2.9% 3.4%

56 Kaweah Delta Health Care District CONSOLIDATED INCOME STATEMENT SUMMARY Fiscal Year 2018 Income Statement Average Equiv Net Mgmt Other Mgmt Daily OP Patient Services Operating Contract Employee Depreciation Interest Services Census Census Revenue Revenue Revenue Payroll Labor Benefits Expense Expense Expense July ,156 $ 48,230,073 $ 2,211,182 $ 4,670,590 $ 22,049,818 $ 575,620 $ 4,914,452 $ 1,997,288 $ 405,981 $ 2,142,677 August ,720 $ 48,238,183 $ 2,569,270 $ 5,057,986 $ 21,311,920 $ 579,900 $ 5,657,463 $ 1,973,972 $ 405,516 $ 2,558,509 September ,504 $ 46,009,412 $ 2,254,768 $ 5,335,119 $ 20,964,051 $ 648,394 $ 6,337,098 $ 1,974,564 $ 410,858 $ 2,171,516 October ,459 $ 49,107,558 $ 2,450,526 $ 12,588,184 $ 22,097,330 $ 580,344 $ 6,342,663 $ 1,997,256 $ 398,858 $ 2,424,990 November ,607 $ 53,030,465 $ 2,675,295 $ 4,259,543 $ 22,558,858 $ 480,051 $ 6,391,348 $ 1,992,631 $ 404,178 $ 2,641,497 December ,446 $ 52,067,365 $ 2,150,859 $ 4,172,802 $ 22,356,446 $ 584,444 $ 4,529,471 $ 1,991,285 $ 442,819 $ 2,096,033 January ,372 $ 53,468,997 $ 2,564,714 $ 4,658,182 $ 22,988,509 $ 833,802 $ 6,089,325 $ 2,016,137 $ 388,184 $ 2,527,095 February ,290 $ 49,019,042 $ 2,122,160 $ 4,802,536 $ 20,945,377 $ 781,145 $ 6,527,153 $ 1,990,100 $ 344,105 $ 2,054,345 March ,700 $ 51,864,946 $ 2,553,919 $ 5,277,624 $ 23,435,601 $ 1,047,968 $ 7,657,420 $ 2,007,237 $ 345,501 $ 2,528,080 April ,878 $ 48,591,858 $ 2,433,354 $ 8,520,640 $ 23,476,765 $ 964,546 $ 5,891,015 $ 2,094,956 $ 379,551 $ 2,336,855 May ,945 $ 51,153,529 $ 2,598,537 $ 4,445,955 $ 21,910,273 $ 1,037,182 $ 5,901,502 $ 2,522,335 $ 581,777 $ 2,591,913 June 2018 Year-to-date , ,781,428 26,584,585 63,789, ,094,948 8,113,396 66,238,911 22,557,762 4,507,329 26,073,508 Budget , ,544,890 26,839,466 58,632, ,249,562 3,102,192 65,435,137 29,173,452 5,297,589 26,343,849 Variance 9 (764) $ 8,236,538 $ (254,881) $ 5,156,818 $ 2,845,387 $ 5,011,205 $ 803,774 $ (6,615,690) $ (790,260) $ (270,341) Current month ,945 $ 51,153,529 $ 2,598,537 $ 4,445,955 $ 21,910,273 $ 1,037,182 $ 5,901,502 $ 2,522,335 $ 581,777 $ 2,591,913 Budget ,385 50,205,647 2,483,652 5,425,679 22,324, ,068 6,055,192 2,699, ,225 2,437,789 Variance $ 947,882 $ 114,885 $ (979,725) $ (414,314) $ 750,113 $ (153,690) $ (177,298) $ 91,552 $ 154,124

57 Kaweah Delta Health Care District CONSOLIDATED INCOME STATEMENT SUMMARY Fiscal Year 2018 Income Statement Chargeable Nonchargeable Other Total Pharmacy Supplies Supplies Operating Operating Operating Investment Net Income w/o Net GOB Expense Expense Expense Expense Expense Income Income** GOB, PF & IC Revenue Net Income July 2017 August September October November December January February March April May $ 2,312,503 $ 2,033,632 $ 4,013,490 $ 11,961,191 $ 52,406,654 $ 2,705,191 $ 406,281 $ 3,111,472 $ 85,796 $ 3,197,268 $ 2,250,857 $ 2,483,328 $ 4,170,744 $ 12,804,515 $ 54,196,725 $ 1,668,713 $ 372,435 $ 2,041,148 $ 89,831 $ 2,130,979 $ 2,295,942 $ 1,950,484 $ 4,125,784 $ 12,698,789 $ 53,577,480 $ 21,819 $ 765,349 $ 787,169 $ 89,831 $ 877,000 $ 2,468,596 $ 2,310,189 $ 4,129,360 $ 13,634,514 $ 56,384,100 $ 7,762,168 $ 288,174 $ 8,050,341 $ 89,831 $ 8,140,173 $ 3,065,885 $ 2,447,415 $ 4,140,484 $ 13,833,086 $ 57,955,432 $ 2,009,871 $ 451,212 $ 2,461,083 $ 89,831 $ 2,550,914 $ 2,122,447 $ 2,842,218 $ 4,803,413 $ 13,658,485 $ 55,427,061 $ 2,963,965 $ (415,966) $ 2,547,999 $ 89,831 $ 2,637,830 $ 2,889,293 $ 2,941,244 $ 4,841,053 $ 13,532,469 $ 59,047,110 $ 1,644,783 $ 521,749 $ 2,166,532 $ 89,831 $ 2,256,364 $ 2,521,046 $ 1,798,971 $ 4,892,006 $ 13,347,556 $ 55,201,804 $ 741,935 $ 575,824 $ 1,317,758 $ 89,831 $ 1,407,589 $ 2,830,303 $ 2,280,438 $ 4,582,082 $ 16,022,328 $ 62,736,960 $ (3,040,470) $ (1,710,347) $ (4,750,817) $ 89,831 $ (4,660,986) $ 2,346,305 $ 1,971,623 $ 4,629,960 $ 15,011,414 $ 59,102,991 $ 442,861 $ 492,947 $ 935,808 $ 89,831 $ 1,025,639 $ 2,432,113 $ 2,108,619 $ 4,698,865 $ 16,090,275 $ 59,874,853 $ (1,676,833) $ 472,151 $ (1,204,682) $ 89,831 $ (1,114,850) June 2018 Year-to-date Budget Variance 27,535,291 25,168,162 49,027, ,594, ,911,170 15,244,004 2,219,808 17,463, ,108 18,447,919 28,098,699 22,202,699 40,256, ,276, ,436,493 16,580,205 4,022,753 20,602, ,437 21,587,396 $ (563,408) $ 2,965,463 $ 8,770,336 $ 2,318,212 $ 14,474,677 $ (1,336,202) $ (1,802,945) $ (3,139,147) $ (329) $ (3,139,476) Current month Budget Variance $ 2,432,113 $ 2,108,619 $ 4,698,865 $ 16,090,275 $ 59,874,853 $ (1,676,833) $ 472,151 $ (1,204,682) $ 89,831 $ (1,114,850) 2,600,178 2,054,578 3,725,266 13,906,175 56,580,690 1,534, ,255 1,906,542 89,494 1,996,037 $ (168,065) $ 54,041 $ 973,599 $ 2,184,100 $ 3,294,163 $ (3,211,120) $ 99,896 $ (3,111,224) $ 337 $ (3,110,887)

58 Kaweah Delta Health Care District CONSOLIDATED INCOME STATEMENT SUMMARY Fiscal Year 2018 Payroll Net Patient Net Patient & Contract Net Revenue Revenue Labor as a Operating Income Gross Deductions Per Cost Per Per Cost Per % of Net pat I/P Margin w/o GOB Patient from DFR & Adjusted Adjusted Adjusted Adjusted and Other Op I/P Revenue % % Revenue Revenue Bad Debt % Discharge Discharge Patient Day Patient Day Revenue Revenue % July 2017 August September October November December January February March April May 4.9% 5.6% $ 167,760,145 $ 119,530, % $ 9,510 $ 10,334 $ 1,918 $ 2, % $ 86,669, % 3.0% 3.6% $ 174,792,902 $ 126,554, % $ 8,934 $ 10,037 $ 1,891 $ 2, % $ 87,628, % 0.0% 1.4% $ 159,848,080 $ 113,838, % $ 8,903 $ 10,367 $ 1,850 $ 2, % $ 79,461, % 12.1% 12.5% $ 177,001,209 $ 127,893, % $ 9,817 $ 11,272 $ 1,944 $ 2, % $ 89,701, % 3.4% 4.1% $ 177,079,724 $ 124,049, % $ 10,466 $ 11,438 $ 2,144 $ 2, % $ 93,971, % 5.1% 4.4% $ 185,424,142 $ 133,356, % $ 10,566 $ 11,248 $ 2,042 $ 2, % $ 102,200, % 2.7% 3.5% $ 190,788,896 $ 137,319, % $ 10,629 $ 11,738 $ 1,995 $ 2, % $ 102,704, % 1.3% 2.3% $ 174,069,570 $ 125,050, % $ 10,719 $ 12,071 $ 1,947 $ 2, % $ 95,995, % -5.1% -8.2% $ 188,414,159 $ 136,549, % $ 10,001 $ 12,098 $ 2,039 $ 2, % $ 101,765, % 0.7% 1.6% $ 179,703,282 $ 131,111, % $ 10,234 $ 12,447 $ 1,915 $ 2, % $ 95,600, % -2.9% -2.1% $ 183,595,949 $ 132,442, % $ 10,303 $ 12,059 $ 1,911 $ 2, % $ 94,810, % June 2018 Year-to-date Budget Variance 2.4% 2.7% 1,958,478,059 1,407,696, % 9,989 11,352 1,963 2, % $ 1,030,510, % 2.6% 3.3% 1,838,485,507 1,295,940, % 9,842 11,091 1,950 2, % 953,864, % $ 119,992,552 $ 111,756, % $ 147 $ 260 $ 13 $ % $ 76,645, % Current month Budget Variance -2.9% -2.1% $ 183,595,949 $ 132,442, % $ 10,303 $ 12,059 $ 1,911 $ 2, % $ 94,810, % 2.6% 3.3% 170,128, ,922, % 9,842 11,091 1,950 2, % 88,268, % $ 13,467,440 $ 12,519, % $ 461 $ 968 $ (40) $ % $ 6,542, %

59 Kaweah Delta Health Care District CONSOLIDATED INCOME STATEMENT SUMMARY Fiscal Year 2018 Average FTEs per O/P Daily Adjusted O/P Revenue I/P Occupied Acute Days in Days in Days Cash Total Revenue % Revenue Bed ALOS A/R (Net) A/R (Gross) on Hand Surplus Cash July 2017 August September October November December January February March April May $ 81,090, % $ 6, $ 267,353,335 $ 87,164, % $ 6, $ 256,733,495 $ 80,386, % $ 6, $ 240,867,284 $ 87,299, % $ 7, $ 242,706,678 $ 83,107, % $ 7, $ 276,714,938 $ 83,223, % $ 7, $ 275,941,248 $ 88,084, % $ 7, $ 279,549,279 $ 78,073, % $ 6, $ 278,973,306 $ 86,648, % $ 7, $ 260,364,803 $ 84,102, % $ 7, $ 247,678,611 $ 88,785, % $ 6, $ 251,374,637 June 2018 Year-to-date $ 927,967, % $ 6, Budget 884,621, % 6,610 Variance $ 43,346, % $ 377 Current month $ 88,785, % Budget 81,860, % Variance $ 6,924, %

60 KAWEAH DELTA HEALTH CARE DISTRICT STATEMENT OF REVENUE AND EXPENSES FISCAL YEAR 2018 May Year To Date FY18 FY17 $ Change % Change FY18 FY17 $ Change % Change OPERATING REVENUE: Net patient service revenue $ 51,153,529 $ 50,403,009 $ 750, % $ 550,781,428 $ 511,259,935 $ 39,521, % Other operating revenue 7,044,492 6,211, , % 90,373,746 80,683,198 9,690, % Total operating revenue 58,198,020 56,614,273 1,583, % 641,155, ,943,133 49,212, % OPERATING EXPENSES: Salaries and wages 21,910,273 21,182, , % 244,094, ,070,734 17,024, % Employee benefits 5,901,502 4,465,508 1,435, % 66,238,911 68,438,115 (2,199,204) -3.2% Total employment expenses 27,811,775 25,648,204 2,163, % 310,333, ,508,849 14,825, % Medical and other supplies 9,239,597 8,578, , % 101,730,693 89,812,233 11,918, % Medical and other fees 8,318,882 6,595,118 1,723, % 80,900,104 72,437,341 8,462, % Purchased services 3,549,118 3,245, , % 35,129,802 29,444,995 5,684, % Repairs and maintenance 2,232,261 2,137,531 94, % 21,835,067 20,330,496 1,504, % Utilities 435, ,448 (12,587) -2.8% 5,013,612 4,816, , % Rents and leases 542, , , % 5,238,405 4,965, , % Depreciation and amortization 2,522,335 2,010, , % 22,557,762 21,214,175 1,343, % Interest Expense 581, , , % 4,507,329 5,012,259 (504,931) -10.1% Other Expenses 2,048, ,364 1,480, % 12,591,029 11,416,906 1,174, % Management Services Expenses 2,591,913 2,419, , % 26,073,508 24,314,274 1,759, % Total operating expenses 59,874,853 52,560,944 7,313, % 625,911, ,274,160 46,637, % OPERATING MARGIN (1,676,833) 4,053,329 (5,730,161) % 15,244,004 12,668,973 2,575, % NONOPERATING REVENUE: Investment Income 472, ,950 93, % 2,219,808 1,352, , % Net GOB Revenue 89,831 84,747 5, % 984, ,518 55, % Total nonoperating revenue 561, ,697 98, % 3,203,916 2,281, , % EXCESS MARGIN $ (1,114,850) $ 4,517,026 $ (5,631,876) % $ 18,447,919 $ 14,950,187 $ 3,497, %

61 KAWEAH DELTA HEALTH CARE DISTRICT RATIO ANALYSIS REPORT MAY 31, 2018 LIQUIDITY RATIOS June 30, Current Prior Moody's Month Month Audited Median Benchmark Value Value Value Aa A Baa Current Ratio (x) Accounts Receivable (days) Cash On Hand (days) Cushion Ratio (x) Average Payment Period (days) CAPITAL STRUCTURE RATIOS Cash-to-Debt 105.3% 103.6% 109.6% 225.6% 160.6% 112.1% Debt-To-Capitalization 34.8% 34.7% 35.5% 27.6% 33.9% 43.5% Debt-to-Cash Flow (x) Debt Service Coverage Maximum Annual Debt Service Coverage (x) Age Of Plant (years) PROFITABILITY RATIOS Operating Margin 2.4% 2.9% 2.4% 4.0% 3.2% 1.1% Excess Margin 2.7% 3.2% 2.7% 7.5% 6.1% 3.4% Operating Cash Flow Margin 6.6% 7.0% 6.8% 9.7% 10.0% 7.8% Return on Assets 2.3% 2.7% 2.2% 5.4% 4.6% 2.8% *For Moody's Reporting Purposes, bad debt is reflected as an operating expense

62 12.0% 11.0% 10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% (1.0%) (2.0%) (3.0%) (4.0%) (5.0%) (6.0%) (7.0%) (8.0%) (9.0%) Kaweah Delta Health Care District Kaweah Delta Health Care District 13.0% EXCESS MARGIN FY 2018 FY 2017 Budget Benchmark FY 2018 YTD Avg 13.0% 12.0% 11.0% 10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% (1.0%) (2.0%) (3.0%) (4.0%) (5.0%) (6.0%) OPERATING MARGIN FY 2018 FY 2017 Budget Benchmark FY 2018 YTD Avg AVERAGE DAILY CENSUS FY 2018 FY 2017 Budget FY 2018 YTD Avg

63 $2,500 Kaweah Delta Health Care District NET PATIENT REVENUE PER ADJ PATIENT DAY $2,400 $2,300 $2,200 $2,100 $2,000 $1,900 $1,800 $1,700 FY 2018 FY 2017 Budget FY 2018 YTD Avg $2,600 COST PER ADJUSTED PATIENT DAY $2,500 $2,400 $2,300 $2,200 $2,100 $2,000 $1,900 FY 2018 FY 2017 Budget FY 2018 YTD Avg 5.1 FTEs PER ADJUSTED OCCUPIED BED FY 2018 FY 2017 Budget FY 2018 YTD Avg

64 Kaweah Delta Health Care District CASE-MIX INDEX WITHOUT NORMAL NEWBORNS FY 2018 FY 2017 FY 2018 YTD Avg NET DAYS IN ACCOUNTS RECEIVABLE FY 2018 FY 2017 Benchmark FY 2018 YTD Avg DAYS CASH ON HAND Kaweah Delta Health Care District FY 2018 FY 2017 Benchmark FY 2018 YTD Avg

65 60.0% 55.0% 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 2,600,000 2,550,000 2,500,000 2,450,000 2,400,000 2,350,000 2,300,000 2,250,000 2,200,000 2,150,000 2,100,000 2,050,000 2,000,000 1,950,000 1,900,000 1,850,000 1,800,000 1,750,000 1,700,000 Kaweah Delta Health Care District GROSS ACCOUNTS RECEIVABLE AGING Current Jun 30-Sep 31-Dec 31-Mar AVERAGE DAILY COLLECTIONS FY 2018 FY 2017 FY 2018 YTD Avg CASH TO NET REVENUE REALIZATION % % % % % % 95.00% 90.00% 85.00% 80.00% 75.00% FY 2018 FY 2017 FY 2018 YTD Avg

66 19.00% Kaweah Delta Health Care District SUPPLIES COST AS A PERCENTAGE OF OPERATING REVENUE 18.00% 17.00% 16.00% 15.00% 14.00% 13.00% FY 2018 FY 2017 Budget FY 2018 YTD Avg SALARIES & CONTRACT LABOR AS A % OF TOTAL OPERATING REVENUE 45.00% 44.00% 43.00% 42.00% 41.00% 40.00% 39.00% 38.00% 37.00% 36.00% 35.00% FY 2018 FY 2017 Budget FY 2018 YTD Avg

67 KAWEAH DELTA HEALTH CARE DISTRICT BALANCE SHEET MAY 31, 2018 ASSETS AND DEFERRED OUTFLOWS CURRENT ASSETS Current Period June 30, 2017 (Audited) Cash and cash equivalents $ 2,411,256 $ 3,992,275 Accounts receivable: Patient accounts, less allowance for doubtful accounts 114,205,341 92,049,996 Other receivables 16,613,595 20,986, ,818, ,036,101 Medicare and Medi-Cal settlements 30,854,241 26,326,424 Inventories 7,598,134 8,168,590 Prepaid expenses 10,949,972 8,375,461 Current portion of assets whose use is limited 19,376,259 12,147, ,008, ,046,537 ASSETS WHOSE USE IS LIMITED, less current portion Board designated cash and assets 259,758, ,913,339 Revenue bond assets held in trust 60,535,801 81,830,759 Assets in self-insurance trust fund 5,112,028 5,642, ,405, ,386,673 CAPITAL ASSETS Land 15,868,676 15,758,181 Buildings and improvements 342,980, ,412,653 Equipment 237,610, ,438,466 Construction in progress 27,181,934 47,257, ,642, ,866,737 Less accumulated depreciation 307,184, ,440, ,457, ,425,974 Property under capital leases, less accumulated amortization 5,882,418 7,485, ,340, ,911,158 OTHER ASSETS Property not used in operations 3,801,706 3,420,518 Health-related investments 5,231,729 3,342,533 Other 8,854,259 7,002,445 17,887,694 13,765,496 DEFERRED OUTFLOWS 13,465,123 12,719,424 $ 881,107,548 $ 855,829,288

68 KAWEAH DELTA HEALTH CARE DISTRICT BALANCE SHEET MAY 31, 2018 LIABILITIES AND NET ASSETS Current Period June 30, 2017 (Audited) CURRENT LIABILITIES Accounts payable and accrued expenses $ 35,232,892 $ 31,349,099 Accrued payroll and related liabilities 42,366,963 40,928,648 Long-term debt, current portion 8,276,021 8,180,021 85,875,876 80,457,768 LONG-TERM DEBT, less current portion Bonds payable 271,484, ,960,479 Capital leases 2,421,202 16,870, ,905, ,831,088 NET PENSION LIABILITY 52,883,287 51,749,371 OTHER LONG-TERM LIABILITIES 26,939,161 25,235,748 NET ASSETS Unrestricted 299,175, ,120,184 Invested in capital assets, net of related debt 104,715,124 99,956,382 Restricted 37,612,342 30,478, ,503, ,555,313 $ 881,107,548 $ 855,829,288

69 KAWEAH DELTA HEALTH CARE DISTRICT SUMMARY OF FUNDS May 31, 2018 Maturity Investment G/L Board designated funds Date Yield Type Account Amount Total LAIF 1.76 Various 31,209,084 Cal Trust 1.97 Cal Trust 21,051,040 CAMP 1.95 CAMP 20,176,650 Wells Cap 0.02 Money market 156,950 PFM 0.02 Money market 584,334 Wells Cap 1-Sep Municipal Oakland Ca 650,000 PFM 10-Jan CD Svenska NY CD 1,800,000 PFM 25-Jan ABS FNMA 95,400 PFM 7-Feb CD Bank of CD 1,200,000 Wells Cap 15-Feb Municipal New Jersey Economic 725,000 Torrey Pines Bank 5-Mar CD Torrey Pines Bank 3,009,010 PFM 15-Mar Municipal Connecticut ST 500,000 PFM 5-Apr CD Bank of Nova 2,000,000 Wells Cap 29-Apr MTN-C Reliance Stand Mtn 450,000 Wells Cap 1-May Municipal San Francisco 1,200,000 PFM 3-May CD Sumito MTSU 1,625,000 Wells Cap 6-May MTN-C Union Bank 500,000 PFM 15-May ABS Toyota Auto Recvs 56,344 PFM 17-May MTN-C IBM 875,000 Wells Cap 18-Jun MTN-C New York Life Mtn 500,000 Wells Cap 1-Jul Municipal Univ California Ca 1,000,000 Wells Cap 18-Jul MTN-C Toyota Motor 500,000 Wells Cap 25-Jul MTN-C Manuf Traders Trust 650,000 PFM 2-Aug CD Skandin Ens CD 2,000,000 PFM 15-Aug MTN-C American Honda Mtn 1,305,000 Wells Cap 12-Sep Supra-National Agency Intl Bk 1,900,000 Wells Cap 15-Sep MTN-C Paccar Fin Corp 600,000 PFM 25-Sep ABS FNMA 316,078 PFM 25-Sep CD Bank of Tokyo CD 900,000 Wells Cap 30-Sep Supra-National Agency Intl Bk 1,500,000 PFM 1-Oct MTN-C Burlington North 425,000 PFM 7-Oct Supra-National Agency Intl Bk 1,750,000 Wells Cap 7-Oct Supra-National Agency Intl Bk 1,975,000 PFM 15-Oct ABS Nissan Auto 59,667 Wells Cap 18-Oct MTN-C PNC Bank 575,000 Wells Cap 25-Oct U.S. Govt Agency FHLMC 1,300,000 Wells Cap 28-Oct MTN-C US Bank Na Mtn 575,000 PFM 15-Nov ABS Ford Credit Auto 51,865 Wells Cap 11-Dec MTN-C General Electric Cap 1,200,000 PFM 8-Jan MTN-C General Electric Cap 500,000 PFM 30-Jan MTN-C Wells Fargo Company 850,000 PFM 7-Feb CD Credit Suisse 750,000 PFM 15-Feb ABS Ford Credit Auto 145,843 PFM 20-Feb CD Nordea Bank 1,800,000 PFM 12-Mar MTN-C Toyota Motor 550,000 PFM 15-Mar ABS Ally Auto 194,772 Wells Cap 15-Mar U.S. Govt Agency US Treasury Bill 1,010,000 PFM 16-Mar ABS Nissan Auto 218,025 PFM 31-Mar U.S. Govt Agency US Treasury Bill 998,000 Wells Cap 31-Mar U.S. Govt Agency US Treasury Bill 700,000 PFM 10-Apr CD Canadian C D 1,400,000 Wells Cap 15-Apr ABS Mercedes Benz Auto 1,200,000 Wells Cap 1-May MTN-C E I DU PONT DE 500,000 Wells Cap 8-May U.S. Govt Agency FFCB 1,050,000 Wells Cap 19-May MTN-C PNC Bank 250,000 Wells Cap 31-May U.S. Govt Agency US Treasury Bill 1,650,000 PFM 5-Jun MTN-C Home Depot Inc 425,000 PFM 15-Jun ABS John Deere 156,374 Wells Cap 15-Jun U.S. Govt Agency US Treasury Bill 1,000,000 PFM 22-Jun MTN-C John Deere 200,000 PFM 23-Jun MTN-C JP Morgan 1,000,000 Wells Cap 29-Jun MTN-C BB T Corp 1,280,000 PFM 20-Jul MTN-C American Honda Mtn 420,000 PFM 22-Jul MTN-C Wells Fargo Company 1,150,000 PFM 3-Aug CD Westpac Bking CD 1,570,000 Wells Cap 18-Aug MTN-C State Street Corp 830,000 PFM 31-Aug U.S. Govt Agency US Treasury Bill 1,080,000 Wells Cap 31-Aug U.S. Govt Agency US Treasury Bill 1,055,000 PFM 4-Sep MTN-C Caterpillar Finl Mtn 670,000 PFM 4-Sep Supra-National Agency Intl BK 1,250,000 PFM 12-Sep Supra-National Agency Intl Bk 1,750,000 PFM 15-Sep ABS Hyundai Auto 156,413 Wells Cap 15-Sep MTN-C Automatic Data 800,000 Wells Cap 15-Sep MTN-C Goldman Sachs 350,000 Wells Cap 30-Sep U.S. Govt Agency US Treasury Bill 400,000 Wells Cap 30-Sep U.S. Govt Agency US Treasury Bill 1,500,000 Wells Cap 15-Oct ABS Toyota Auto 650,000 Wells Cap 15-Oct MTN-C Unitedhealth Group 595,000 Wells Cap 26-Oct U.S. Govt Agency FFCB 1,400,000 PFM 31-Oct U.S. Govt Agency US Treasury Bill 2,875,000 Wells Cap 31-Oct U.S. Govt Agency US Treasury Bill 400,000 PFM 9-Nov MTN-C Walmart Stores Inc. 1,925,000 PFM 13-Nov MTN-C Apple, Inc 900,000 PFM 15-Nov U.S. Govt Agency US Treasury Bill 2,655,000 PFM 16-Nov CD Swedbank 1,800,000 Wells Cap 25-Nov ABS BMW Vehicle Owner 898,982 Wells Cap 30-Nov U.S. Govt Agency US Treasury Bill 150,000 Wells Cap 14-Dec MTN-C Visa Inc 700,000 PFM 15-Dec Supra-National Agency Inter Amer Dev Bk 1,800,000 Wells Cap 18-Dec ABS Honda Auto 720,000 PFM 31-Dec U.S. Govt Agency US Treasury Bill 1,525,000 Wells Cap 31-Dec U.S. Govt Agency US Treasury Bill 600,000 PFM 8-Jan MTN-C John Deere 750,000 PFM 20-Jan MTN-C IBM 900,000 Wells Cap 25-Jan Supra-National Agency Intl Bk 750,000 PFM 16-Feb ABS Toyota Auto Recvs 225,000 Wells Cap 18-Feb U.S. Govt Agency FHLB 980,000 Wells Cap 23-Feb MTN-C Apple, Inc 615,000 Wells Cap 28-Feb U.S. Govt Agency US Treasury Bill 700,000 PFM 12-Mar MTN-C Texas Instruments 180,000 Wells Cap 12-Mar MTN-C Texas Instruments 630,000 Wells Cap 15-Mar ABS Smart Trust 1,150,000 Wells Cap 31-Mar U.S. Govt Agency US Treasury Bill 935,000 PFM 1-Apr Municipal California ST 530,000 Wells Cap 1-Apr Municipal California ST High 1,250,000 Wells Cap 1-Apr Municipal Sacramento Ca Public 1,200,000 Wells Cap 13-Apr MTN-C Toyota Motor 600,000 PFM 15-Apr ABS Hyundai Auto 465,000 PFM 15-Apr MTN-C Bank of NY 900,000 Wells Cap 19-Apr MTN-C Bank of America 435,000 PFM 21-Apr MTN-C Morgan Stanley 450,000 PFM 21-Apr MTN-C Morgan Stanley 450,000 Wells Cap 21-Apr MTN-C Morgan Stanley 750,000 PFM 25-Apr MTN-C Goldman Sachs 900,000 Wells Cap 29-Apr MTN-C PNC Bank 400,000 Wells Cap 30-Apr U.S. Govt Agency US Treasury Bill 875,000 PFM 5-May MTN-C American Express 450,000 PFM 6-May U.S. Govt Agency FNMA 3,650,000 Wells Cap 6-May U.S. Govt Agency FNMA 700,000 PFM 10-May MTN-C BB T Corp 450,000 Wells Cap 11-May MTN-C General Dynamics 425,000 Wells Cap 17-May ABS USAA Auto Owner 370,000 PFM 19-May MTN-C State Street Corp 245,000 PFM 24-May MTN-C US Bancorp 900,000

70 KAWEAH DELTA HEALTH CARE DISTRICT SUMMARY OF FUNDS May 31, 2018 PFM 31-May U.S. Govt Agency US Treasury Bill 850,000 Wells Cap 7-Jun MTN-C JP Morgan 910,000 Wells Cap 14-Jun MTN-C Fifth Third Bank 800,000 PFM 15-Jun ABS Ford Credit Auto 355,000 Wells Cap 30-Jun U.S. Govt Agency US Treasury Bill 400,000 Wells Cap 1-Jul Municipal San Francisco 935,000 PFM 14-Jul U.S. Govt Agency FHLB 1,775,000 PFM 15-Aug ABS Honda Auto 900,000 PFM 16-Aug ABS Hyundai Auto 430,000 Wells Cap 16-Aug ABS Nissan Auto 1,050,000 Wells Cap 17-Aug U.S. Govt Agency FNMA 1,400,000 Wells Cap 17-Aug U.S. Govt Agency FNMA 1,500,000 PFM 31-Aug U.S. Govt Agency US Treasury Bill 2,250,000 PFM 31-Aug U.S. Govt Agency US Treasury Bill 5,750,000 Wells Cap 1-Sep MTN-C Ryder System Inc 420,000 PFM 15-Sep ABS FHLMC 2,987 PFM 15-Sep MTN-C Oracle Corp 900,000 PFM 20-Sep MTN-C Cisco Systems Inc 800,000 PFM 1-Oct MTN-C Bank of America 640,000 PFM 6-Oct MTN-C Pepsico Inc 1,320,000 PFM 15-Oct ABS John Deere 340,000 Wells Cap 30-Oct MTN-C Boeing Co 1,000,000 PFM 31-Oct U.S. Govt Agency US Treasury Bill 290,000 PFM 31-Oct U.S. Govt Agency US Treasury Bill 2,000,000 PFM 15-Nov ABS Toyota Auto Recvs 250,000 Wells Cap 19-Nov ABS Citibank Credit 1,100,000 PFM 30-Nov U.S. Govt Agency US Treasury Bill 2,000,000 Wells Cap 30-Nov U.S. Govt Agency US Treasury Bill 1,160,000 PFM 15-Dec ABS Ally Auto 360,000 PFM 15-Dec ABS American Express 330,000 PFM 31-Dec U.S. Govt Agency US Treasury Bill 3,600,000 Wells Cap 31-Dec U.S. Govt Agency US Treasury Bill 1,225,000 PFM 15-Jan MTN-C Comcast Corp 450,000 PFM 18-Jan ABS Toyota Auto 625,000 Wells Cap 7-Feb MTN-C Bank of NY 1,000,000 PFM 12-Feb MTN-C Microsoft Corp 450,000 Wells Cap 28-Feb U.S. Govt Agency US Treasury Bill 390,000 Wells Cap 3-Mar MTN-C Johnson Johnson 500,000 PFM 4-Mar MTN-C Walt Disney Co 375,000 PFM 8-Mar MTN-C PNC Funding Corp 494,000 PFM 15-Mar ABS Ally Auto 735,000 PFM 15-Mar ABS Ford Credit Auto 945,000 PFM 1-Apr MTN-C BB T Corp 450,000 Wells Cap 5-Apr U.S. Govt Agency FNMA 920,000 Wells Cap 18-Apr ABS John Deere 500,000 PFM 25-Apr MTN-C Citigroup 1,000,000 Wells Cap 25-Apr MTN-C National Rural 950,000 Wells Cap 26-Apr MTN-C Goldman Sachs 440,000 Wells Cap 30-Apr U.S. Govt Agency US Treasury Bill 800,000 PFM 16-May MTN-C United Parcel 450,000 PFM 17-May MTN-C Bank of America 300,000 Wells Cap 18-May MTN-C Costco Wholesale 1,000,000 Wells Cap 25-May MTN-C Coca Cola Co 500,000 Wells Cap 30-Jun U.S. Govt Agency US Treasury Bill 660,000 PFM 31-Aug U.S. Govt Agency US Treasury Bill 2,000,000 Wells Cap 31-Aug U.S. Govt Agency US Treasury Bill 590,000 PFM 8-Sep MTN-C Toyota Motor 450,000 Wells Cap 15-Sep ABS American Express 1,656,000 Wells Cap 15-Sep ABS Capital One 867,000 PFM 30-Sep U.S. Govt Agency US Treasury Bill 750,000 Wells Cap 5-Oct U.S. Govt Agency FNMA 950,000 PFM 17-Oct ABS American Express 420,000 Wells Cap 27-Oct MTN-C Citigroup 750,000 Wells Cap 31-Oct U.S. Govt Agency US Treasury Bill 3,150,000 Wells Cap 30-Nov U.S. Govt Agency US Treasury Bill 2,770,000 Wells Cap 31-Jan U.S. Govt Agency US Treasury Bill 350,000 Wells Cap 28-Feb U.S. Govt Agency US Treasury Bill 2,100,000 PFM 31-Mar U.S. Govt Agency US Treasury Bill 900,000 Wells Cap 30-Apr U.S. Govt Agency US Treasury Bill 700,000 Wells Cap 30-Apr U.S. Govt Agency US Treasury Bill 950,000 $ 251,889,818

71 KAWEAH DELTA HEALTH CARE DISTRICT SUMMARY OF FUNDS May 31, 2018 Self-insurance trust Maturity Investment G/L Date Yield Type Account Amount Total Wells Cap Money market ,242 Wells Cap Fixed income - L/T ,195, revenue bonds US Bank Project fund ,447 US Bank Principal/Interest payment fund ,713, A revenue bonds US Bank Principal/Interest payment fund , B revenue bonds US Bank Principal/Interest payment fund ,073,691 US Bank Project Fund ,223, A/B revenue bonds US Bank Principal/Interest payment fund , C revenue bonds US Bank Principal/Interest payment fund ,006, general obligation bonds LAIF Interest Payment fund ,230,213 5,943,640 3,985, ,932 62,297, ,190 1,006,125 3,230,213 Operations Wells Fargo Bank 0.20 Checking (1,820,215) Wells Fargo Bank 0.20 Checking ,522 Payroll (1,093,693) Wells Fargo Bank 0.20 Checking (32,646) Wells Fargo Bank 0.20 Checking Benesyst (1,714) Wells Fargo Bank Checking Resident Fund Bancorp Checking ,400 36,772 (1,056,921) Total investments $ 328,803,285 Kaweah Delta Medical Foundation Wells Fargo Bank Checking $ 2,285,834 Sequoia Regional Cancer Center Wells Fargo Bank Checking $ 608,999 Wells Fargo Bank Checking Kaweah Delta Hospital Foundation $ 608,999 VCB Checking Investments $ 533,949 Various S/T Investments ,655,619 Various L/T Investments ,884,332 Various Unrealized G/L ,818,201 $ 17,892,101 Summary of board designated funds: Plant fund: Uncommitted plant funds $ 184,975, Committed for capital 36,739, ,714,831 GO Bond reserve - L/T 1,947, k Matching 3,772, Cost report settlement - current 2,135, Cost report settlement - L/T 1,312, ,448,111 Development fund/memorial fund 104, Workers compensation - current 4,962, Workers compensation - L/T 15,941, ,903,000 $ 251,889,818

72 KAWEAH DELTA HEALTH CARE DISTRICT SUMMARY OF FUNDS May 31, 2018 Investment summary by institution: Total Trust Surplus Investments % Accounts Funds % Bancorp $ 70, % 70, % Cal Trust 21,051, % 21,051, % CAMP 20,176, % 20,176, % Local Agency Investment Fund (LAIF) 31,209, % 31,209, % Local Agency Investment Fund (LAIF) - GOB Tax Rev 3,230, % 3,230, % Wells Cap 88,747, % 5,943,640 82,803, % PFM 93,640, % 93,640, % Torrey Pines Bank 3,009, % 3,009, % Wells Fargo Bank (1,127,321) -0.3% (1,127,321) -0.4% US Bank 68,796, % 68,796, % Total investments $ 328,803, % $ 77,970,388 $ 250,832, % Investment summary of surplus funds by type: Investment Limitations Negotiable and other certificates of deposit $ 19,854,010 $ 75,250,000 (30%) Checking accounts (1,056,921) Local Agency Investment Fund (LAIF) 31,209,084 65,000,000 Cal Trust 21,051,040 CAMP 20,176,650 Medium-term notes (corporate) (MTN-C) 48,829,000 75,250,000 (30%) U.S. government agency 71,368,000 Municipal securities 7,990,000 Money market accounts 741,284 50,167,000 (20%) Asset Backed Securties 17,995,750 50,167,000 (20%) Supra-National Agency 12,675,000 75,250,000 (30%) $ 250,832,897 Return on investment: Current month 1.70% Year-to-date 1.51% Prospective 1.94% LAIF (year-to-date) 1.32% Budget 1.45% Material current-month nonroutine transactions: Sell/Called/Matured: US Treasury, $350,000, 1.625% Harley Davidson, $853,894.13, 1.34% Bank of America, $300,000, 2.625% Buy: US Treasury, $700,000, 2.75% General Dynamics, $425,000, 3.00% PNC Bank, $250,000, 2.00% US Treasury, $900,000, 1.50% Bank of America, $300,000, 3.499% Fair market value disclosure for the quarter ended March 31, 2018 (District only): Quarter-to-date Year-to-date Difference between fair value of investments and amortized cost (balance sheet effect) N/A $ (3,750,568) Change in unrealized gain (loss) on investments (income statement effect) $ (1,899,360) $ (3,108,472)

73 KAWEAH DELTA HEALTH CARE DISTRICT SUMMARY OF FUNDS May 31, 2018 Investment summary of CDs: Bank of CD $ 1,200,000 Bank of Nova 2,000,000 Bank of Tokyo CD 900,000 Canadian C D 1,400,000 Credit Suisse 750,000 Nordea Bank 1,800,000 Skandin Ens CD 2,000,000 Sumito Mtsu 1,625,000 Svenska NY CD 1,800,000 Swedbank 1,800,000 Torrey Pines Bank 3,009,010 Westpac Bking CD $ 1,570,000 19,854,010 Investment summary of asset backed securities: Ally Auto $ 1,289,772 American Express 2,406,000 BMW Vehicle Owner 898,982 Capital One 867,000 Citibank Credit 1,100,000 FHLMC 2,987 FNMA 411,478 Ford Credit Auto 1,497,708 Honda Auto 1,620,000 Hyundai Auto 1,051,413 John Deere 996,374 Mercedes Benz Auto 1,200,000 Nissan Auto 1,327,692 Smart Trust 1,150,000 Toyota Auto 1,275,000 Toyota Auto Recvs 531,344 USAA Auto Owner $ 370,000 17,995,750 Investment summary of medium-term notes (corporate): American Express $ 450,000 American Honda Mtn 1,725,000 Apple, Inc 1,515,000 Automatic Data 800,000 Bank of America 1,375,000 Bank of NY 1,900,000 BB T Corp 2,180,000 Boeing Co 1,000,000 Burlington North 425,000 Caterpillar Finl Mtn 670,000 Cisco Systems Inc 800,000 Citigroup 1,750,000 Coca Cola Co 500,000 Comcast Corp 450,000 Costco Wholesale 1,000,000 E I DU PONT DE 500,000 Fifth Third Bank 800,000 General Dynamics 425,000 General Electric Cap 1,700,000 Goldman Sachs 1,690,000 Home Depot Inc 425,000 IBM 1,775,000 John Deere 950,000 Johnson Johnson 500,000 JP Morgan 1,910,000 Manuf Traders Trust 650,000 Microsoft Corp 450,000 Morgan Stanley 1,650,000 National Rural 950,000 New York Life Mtn 500,000 Oracle Corp 900,000 Paccar Fin Corp 600,000 Pepsico Inc 1,320,000 PNC Bank 1,225,000 PNC Funding Corp 494,000 Reliance Stand Mtn 450,000 Ryder System Inc 420,000 State Street Corp 1,075,000 Texas Instruments 810,000 Toyota Motor 2,100,000 Union Bank 500,000 Unitedhealth Group 595,000 United Parcel 450,000 US Bank Na Mtn 575,000 US Bancorp 900,000 Visa Inc 700,000 Walmart Stores Inc. 1,925,000 Walt Disney Co 375,000 Wells Fargo Company $ 2,000,000 48,829,000 Investment summary of U.S. government agency: Federal National Mortgage Association (FNMA) $ 9,120,000 Federal Home Loan Bank (FHLB) 2,755,000 Federal Home Loan Mortgage Corporation (FHLMC) 1,300,000 Federal Farmers Credit Bank (FFCB) 2,450,000 US Treasury Bill $ 55,743,000 71,368,000 Investment summary of municipal securities: California ST High $ 1,250,000 California ST 530,000 Connecticut ST 500,000 New Jersey Economic 725,000 Oakland Ca 650,000 Sacramento Ca Public 1,200,000 San Francisco 2,135,000 Univ California Ca $ 1,000,000 7,990,000 Investment summary of Supra-National Agency: Intl Bk $ 10,875,000 Inter Amer Dev Bk $ 1,800,000 12,675,000

74 Kaweah Delta Health Care District Annual Report to the Board of Directors Endoscopy Lab Benton Duckett, MBA, RN, Director of Cardiac and Surgical Services June 25, 2018 Summary Issue/Service Considered Continue to provide personal, professional and compassionate care for our patients, families, physicians, staffs, customers and team. Maintain highest quality care, compliance and profitability while sustaining an ideal work environment. Financial/Statistical Data 2017 demonstrated strong performance: An increase of 340 cases Net Revenue increase of 3M Contribution Margin increase of 1.4M Quality/Performance 1. Stay up-to-date with cleaning and sterilizing processes required by The Joint Commission standards of Care. 2. We purchased (3) state of the art reprocessing scope cleaning machines. This technology supports a faster turnover of the scopes, and allows opportunity to increase our caseload each day. 3. We purchased (7) scopes which enhanced our ability to perform colonoscopy, endoscopy, and bronchoscopy procedures. Upgrades We are currently planning a complete remodel of the Endoscopy Center to be completed September This will: Provide an ideal work environment for staff and physicians. Comply with regulatory requirements. Enhance recruitment of Gastroenterologists/Surgeons/Pulmonologists. Become the provider of choice for our physicians and community. Maintain positive financial contribution/viability. Solidifying our commitment to highest quality patient-centered care and excellence.

75 Recommendations/Next Steps 1. Collaborate with anesthesia on supporting monitored anesthesia care that is immediately available when needed for certain procedures. 2. Transitioned from paper charting to the new KD*Hub electronic record. 3. Recruit two more Gastroenterologists for the inpatient setting. Conclusions This coming year the Endoscopy Lab will focus on: 1. Remaining committed to providing high quality care and, uncompromising patient centered service excellence. 2. Continue to evaluate and implement process improvements designed to enhance patient and physician satisfaction through increased quality, efficiency, safety, and compassion. 3. We will continuously monitor our progress, achievement and alignment with Kaweah Delta and strategic nursing goals.

76 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Endoscopy Services Steve Hensley ( ) December 9, 2013 Service Line Report Data: Fiscal Year 2013 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,613 $13,921,941 $6,739,414 $7,182,527 $4,446,110 $2,736,417 Endoscopy-Outpatient 3,670 5,192,752 1,350,683 3,842, ,320 3,177,749 Endoscopy-O/P-Pediatric 70 66,947 27,666 39,281 14,575 24,706 Grand Total 5,353 $19,181,640 $8,117,763 $11,063,877 $5,125,005 $5,938,872 Service Line Report Data: Fiscal Year 2012 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,813 $14,657,678 $7,550,193 $7,107,485 $4,630,825 $2,476,660 Endoscopy-Outpatient 3,862 5,022,694 1,347,742 3,674, ,719 3,091,233 Endoscopy-O/P-Pediatric 58 78,372 54,717 23,655 14,246 9,409 Grand Total 5,733 $19,758,744 $8,952,652 $10,806,092 $5,228,790 $5,577,302 Increase (Decrease) (380) ($577,104) ($834,889) $257,785 ($103,785) $361,570

77 Net Revenue Per Case This Year Last Year $3,000 $3,200 $3,400 $3,600 $3,800 $4,000 Direct Cost Per Case This Year Last Year $1,300 $1,400 $1,500 $1,600 $1,700 Contribution Margin Per Case This Year Last Year $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200

78 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Endoscopy Services Steve Hensley ( ) February 23, 2015 Service Line Report Data: Fiscal Year 2014 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,592 $14,864,616 $7,049,243 $7,815,373 $4,527,632 $3,287,741 Endoscopy-Outpatient 3,780 5,294,111 1,610,522 3,683, ,897 2,931,692 Endoscopy-O/P-Pediatric 30 30,003 12,693 17,310 6,033 11,277 Grand Total 5,402 $20,188,730 $8,672,458 $11,516,272 $5,285,562 $6,230,710 Service Line Report Data: Fiscal Year 2013 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,613 $13,921,941 $6,739,414 $7,182,527 $4,446,110 $2,736,417 Endoscopy-Outpatient 3,670 5,192,752 1,350,683 3,842, ,320 3,177,749 Endoscopy-O/P-Pediatric 70 66,947 27,666 39,281 14,575 24,706 Grand Total 5,353 $19,181,640 $8,117,763 $11,063,877 $5,125,005 $5,938,872 Increase (Decrease) 49 $1,007,090 $554,695 $452,395 $160,557 $291,838

79 Net Revenue Per Case This Year Last Year $3,000 $3,200 $3,400 $3,600 $3,800 $4,000 Direct Cost Per Case This Year Last Year $1,300 $1,400 $1,500 $1,600 $1,700 Contribution Margin Per Case This Year Last Year $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200

80 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Endoscopy Services Steve Hensley ( ) January 2016 Service Line Report Data: Fiscal Year 2015 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,461 $14,063,012 $8,785,646 $5,277,366 $3,190,322 $2,087,044 Endoscopy-Outpatient 2,680 3,888,001 1,274,008 2,613, ,762 2,006,231 Endoscopy-O/P-Pediatric 7 6,460 2,497 3,963 1,102 2,861 Grand Total 4,148 $17,957,473 $10,062,151 $7,895,322 $3,799,186 $4,096,136 Service Line Report Data: Fiscal Year 2014 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,592 $14,864,616 $7,049,243 $7,815,373 $4,527,632 $3,287,741 Endoscopy-Outpatient 3,780 5,294,111 1,610,522 3,683, ,897 2,931,692 Endoscopy-O/P-Pediatric 30 30,003 12,693 17,310 6,033 11,277 Grand Total 5,402 $20,188,730 $8,672,458 $11,516,272 $5,285,562 $6,230,710 Increase (Decrease) (1,254) ($2,231,257) $1,389,693 ($3,620,950) ($1,486,376) ($2,134,574)

81 Net Revenue Per Case This Year Last Year $3,000 $3,500 $4,000 $4,500 Direct Cost Per Case This Year Last Year $1,000 $1,500 $2,000 $2,500 Contribution Margin Per Case This Year Last Year $1,000 $1,500 $2,000 $2,500

82 Indirect Cost Per Case This Year Last Year $850 $900 $950 $1,000 Net Income Per Case This Year Last Year $900 $1,000 $1,100 $1,200

83 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Endoscopy Services Steve Hensley ( ) January 2017 Service Line Report Data: Fiscal Year 2016 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,592 $15,517,924 $10,036,520 $5,481,404 $3,345,414 $2,135,990 Endoscopy-Outpatient 3,296 5,081,512 1,558,049 3,523, ,398 2,843,065 Endoscopy-O/P-Pediatric 4 4,388 1,096 3, ,789 Grand Total 4,892 $20,603,824 $11,595,665 $9,008,159 $4,026,315 $4,981,844 Service Line Report Data: Fiscal Year 2015 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,461 $14,063,012 $8,785,646 $5,277,366 $3,190,322 $2,087,044 Endoscopy-Outpatient 2,680 3,888,001 1,274,008 2,613, ,762 2,006,231 Endoscopy-O/P-Pediatric 7 6,460 2,497 3,963 1,102 2,861 Grand Total 4,148 $17,957,473 $10,062,151 $7,895,322 $3,799,186 $4,096,136 Increase (Decrease) 744 $2,646,351 $1,533,514 $1,112,837 $227,129 $885,708

84 Net Revenue Per Case This Year Last Year $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 Direct Cost Per Case This Year Last Year $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 Contribution Margin Per Case This Year Last Year $1,500 $1,600 $1,700 $1,800 $1,900 $2,000

85 Indirect Cost Per Case This Year Last Year $700 $800 $900 $1,000 Net Income Per Case This Year Last Year $800 $900 $1,000 $1,100

86 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Endoscopy Services Benton Duckett February 2018 Service Line Report Data: Fiscal Year 2017 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,824 $18,345,768 $11,716,466 $6,629,302 $3,614,988 $3,014,314 Endoscopy-Outpatient 3,406 5,310,436 1,538,803 3,771, ,268 3,147,365 Endoscopy-O/P-Pediatric 2 1, , Grand Total 5,232 $23,657,568 $13,255,588 $10,401,980 $4,239,390 $6,162,590 Service Line Report Data: Fiscal Year 2016 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Gastroenterology-Inpatient 1,592 $15,517,924 $10,036,520 $5,481,404 $3,345,414 $2,135,990 Endoscopy-Outpatient 3,296 5,081,512 1,558,049 3,523, ,398 2,843,065 Endoscopy-O/P-Pediatric 4 4,388 1,096 3, ,789 Grand Total 4,892 $20,603,824 $11,595,665 $9,008,159 $4,026,315 $4,981,844 Increase (Decrease) 340 $3,053,744 $1,659,923 $1,393,821 $213,075 $1,180,746 Net Revenue Per Case This Year Last Year $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600

87 Direct Cost Per Case This Year Last Year $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 Contribution Margin Per Case This Year Last Year $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 Last Year This Year Net Revenue Per Case $4,212 $4,522 Direct Cost Per Case $2,370 $2,534 Contribution Margin Per Case $1,841 $1,988

88 Kaweah Delta Health Care District Annual Report to the Board of Directors Non-Invasive Cardiology (Adult and Pediatric Echocardiography, Transesophageal Echocardiography, Peripheral Vascular-Venous, Arterial, Carotids, Cardiac Stress Tests, Tilt Tables, and Pacemaker/Holter monitoring) Steve Hensley RN, RRT, Director of Respiratory Cheryl Clark, Manager Non-Invasive Cardiovascular Diagnostics June 25, 2018 Summary Issue/Service Considered The Non-Invasive Cardiology Department has experienced an 8.9% increase in volume during this reporting period. While continuing on an ascendant trajectory we have far greater expectations to steepen our ascent which includes the following: Successfully achieving Intersocietal Accreditation Committee (IAC) Certification of our Non-Invasive Cardiology Lab. Sonographer support for the Kaweah Delta Sequoia Cardiology Clinic on our west campus. Solidify Nursing Support for: Stress Testing Bubble Studies Image enhancement (Definity) Studies Chemical Stress Testing Tilt Table Exams Advance collaboration with Valley Children s Hospital to enhance our care of our neonatal and pediatric populations here at Kaweah Delta. Quality/Performance Improvement Data Ongoing monthly performance improvement monitors: Retrospective review of overall turnaround time (TAT) for echocardiograms: Benchmark from echocardiographs performed to final report by cardiologist <12 hours. Current TAT for 2017 is 82% compared to our goal of 85%. We will remain steadfast in our commitment to work collaboratively with our Medical Director and Cardiologists to not only meet but exceed our desired goal of 85%.

89 2017 (Study completed/final report less than 12 hours (Goal 85%) % Mean Total Mean # done <12hrs <12hrs Hrs hrs JAN % FEB % MAR % Q % APR % MAY % JUN % Q % JUL % AUG % SEP % Q % OCT % NOV % DEC % Q % Outcomes % Policy, Strategic or Tactical Issues 1. Complete preparation/application for successful IAC survey: All staff must achieve certification in Echocardiography prior to application (IAC required). Acquisition of advanced technology (IAC required). Unanimous engagement/support from all Cardiologists in achieving IAC quality measures (IAC required). 2. Monthly offering of case studies with continuing education units (CEU s) for technical and professional staffs. Recommendations/Next Steps 1. Assist with successful opening of Kaweah Delta Sequoia Cardiology Clinic 2. Successful addition of Definity contrast for enhanced echocardiography imaging Includes RN support 3. Successful acquisition of Intersocietal Accreditation Committee (IAC) Certification. Approvals/Conclusions 1. Continue to evaluate and implement process improvements designed to enhance patient and physician satisfaction through increased quality, efficiency and productivity. 2. We remain committed to the delivery of highest quality care with uncompromising service excellence.

90 Kaweah Delta Health Care District Annual Report to the Board of Directors Financial & Statistical Information Noninvasive Cardiology Services Steve Hensley ( ) March 27, 2018 Service Line Report Data: Fiscal Year 2017 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Noninvasive Cardiology 3,865 $1,569,457 $543,986 $1,025,471 $217,376 $808,095 Grand Total 3,865 $1,569,457 $543,986 $1,025,471 $217,376 $808,095 Service Line Report Data: Fiscal Year 2016 Patient Net Direct Contribution Indirect Net Service Cases Revenue Costs Margin Costs Income Noninvasive Cardiology 3,474 $1,191,609 $472,556 $719,053 $197,965 $521,088 Grand Total 3,474 $1,191,609 $472,556 $719,053 $197,965 $521,088 Increase (Decrease) 391 $377,848 $71,430 $306,418 $19,411 $287,007 Net Revenue Per Case This Year Last Year $290 $310 $330 $350 $370 $390 $410

91 Direct Cost Per Case This Year Last Year $131 $133 $135 $137 $139 $141 $143 $145 Contribution Margin Per Case This Year Last Year $120 $140 $160 $180 $200 $220 $240 $260 Last Year This Year Net Revenue Per Case $343 $406 Direct Cost Per Case $136 $141 Contribution Margin Per Case $207 $265

92 Policy Submission Summary Manual Name: Administrative Date: June 2018 Support Staff Name: Cindy Moccio Policy/Procedure Title # Status New, Revised, Reviewed, or Deleted * Name and phone extension of person who wrote or revised policy - * for New and Revised policies only Patient Safety Plan AP175 Revised Evelyn McEntire x5241 Quality Improvement Plan AP41 Revised Sandy Volchko x2169 Travel, Per Diem, and Other Employee Reimbursement AP19 Revised Tom Rayner / ET x2221 Risk Management Plan AP45 Reviewed Evelyn McEntire x5241

93 Subcategories of Department Manuals not selected. Policy Number: AP175 Date Created: No Date Set Document Owner: Cindy Moccio (Board Clerk/Exec Date Approved: Not Approved Yet Assist-CEO) Approvers: Board of Directors (Administration), Cindy Moccio (Board Clerk/Exec Assist-CEO) Patient Safety Plan Printed copies are for reference only. Please refer to the electronic copy for the latest version. I. Purpose II. III. Encourage organizational learning about medical/health care risk events and near misses Encourage recognition and reporting of medical/health events and risks to patient safety using just culture concepts Collect and analyze data, evaluate care processes for opportunities to reduce risk and initiate actions Report internally what has been found and the actions taken with a focus on processes and systems to reduce risk Support sharing of knowledge to effect behavioral changes in itself and within Kaweah Delta Healthcare District (KDHCD)DHCD Scope All Kaweah Delta Healthcare District (KDHCD) facilities, departments, patient care delivery units and/or service areas fall within the scope of the quality improvement and patient safety plan requirements. Structure and Accountability A. Board of Directors The Board of Directors retains overall responsibility for the quality of patient care and patient safety. The Board approves annually the Patient Safety Plan and assures that appropriate allocation of resources is available to carry out that plan. The Board receives reports from the Patient Safety Committee through the Professional Staff Quality Committee. The Board shall act as appropriate on the recommendations of these bodies and assure that efforts undertaken are effective and appropriately prioritized. B. Quality Council The Quality Council is responsible for establishing and maintaining the organization s Patient Safety Plan and is chaired by a Board member. The Quality Council shall consist of the Chief Executive Officer, representatives of the Medical Staff and other key hospital leaders. It shall hold primary responsibility for the functioning of the Quality Assessment and Performance Improvement program. Because District performance improvement activities may involve both the Medical Staff and other representatives of the District, membership is multidisciplinary. The Quality Council requires the Medical Staff and the organization s staff to implement and report on the activities for identifying and evaluating opportunities to improve patient care and services throughout the organization. The effectiveness of the quality improvement and patient safety activities will be evaluated and reported to the Quality Council. C. Patient Safety Committee The Patient Safety Team is a standing interdisciplinary group that manages the organization s Patient Safety Program through a systematic, coordinated, continuous approach. The Team will meet monthly to assure the maintenance and improvement of Patient Safety in establishment of plans, processes and mechanisms involved in the provision of the patient care.

94 Patient Safety Plan 2 IV. The scope of the Patient Safety Team includes medical/healthcare risk events involving the patient population of all ages, visitors, hospital/medical staff, students and volunteers. Aggregate data* from internal (IS data collection, incident reports, questionnaires,) and external resources (Sentinel Event Alerts, evidence based medicine, etc.) will be used for review and analysis in prioritization of improvement efforts, implementation of action steps and follow-up monitoring for effectiveness. The Patient Safety Committee has oversight of KDHCD activities related to the National Quality Forum s (NQF) Safe Practices (SP) #1 Culture of Safety Leadership Structures & System Documentation; #2 Culture Measurement, Feedback & Intervention Documentation; # 3 Teamwork Training & Skill Building Documentation; #4 Risks & Hazards; #9 Nursing Workforce; #17 Medication Reconciliation; #19 Hand Hygiene; and #23 Prevention of Ventilator Associated Complications. 1. The Patient Safety Officer is the Medical Director of Performance Improvement 2. The Patient Safety Committee is chaired by the Patient Safety Officer or designee. 3. The responsibilities of the Patient Safety Officer include institutional compliance with patient safety standards and initiatives, reinforcement of the expectations of the Patient Safety Plan, and acceptance of accountability for measurably improving safety and reducing errors. These duties may include listening to employee and patient concerns, interviews with staff to determine what is being done to safeguard against occurrences, and immediate response to reports concerning workplace conditions. 4. Team membership includes services involved in providing patient care, such as: Pharmacy, Laboratory, Surgical Services, Risk Management, Infection Prevention, Medical Imaging, and Nursing. The medical staff representative on the team will be the Vice Chief of Staff. D. Medication Safety Quality Focus Team The Medication Safety Quality Focus Team (MSQFT) is an interdisciplinary group that manages the organizations Medication Safety Program including the District Medication Error Reduction Plan (MERP). The purpose of the MSQFT is to direct system actions regarding reductions in errors attributable to medications promoting effective and safe use of medication throughout the organization. Decisions are made utilizing data review, approval of activities, resource allocation, and monitoring activities. Activities include processes that are high risk, high volume, or problem prone, some of which may be formally approved by the MSQFT as a District MERP goal (see Policy AP154 Medication Error Reduction Plan). The MSQFT provides a monthly report to the Pharmacy and Therapeutics Committee and quarterly reports to the Professional Staff Quality Committee and directly to Quality Council. The MSQFT Chair is a member of the Patient Safety Committee. A quarterly report is presented at Patient Safety Committee in addition to active participation in patient safety activities related to medication use. Organization and Function A. The mechanism to insure all components of the organization are integrated into the program is through a collaborative effort of multiple disciplines. This is accomplished by: 1. Reporting of potential or actual occurrences through the Occurrence Reporting Process Policy (AP10) by any employee or member of the medical staff. Examples of potential or actual occurrences include pressure ulcers, falls, adverse drug events, and misconnecting of: intravenous lines, enteral feeding tubes and epidural lines. 2. Communication between the Patient Safety Officer and the Chief Operating Officer to assure a comprehensive knowledge of not only clinical, but also environmental factors involved in providing an overall safe environment. 3. Reporting of patient safety and operational safety measurements/activity to the performance improvement oversight group, Professional Services Quality Committee Prostaff. Prostaff is a multidisciplinary medical staff committee composed of various key organizational leaders including: Medical Executive Committee members, Chief Executive Officer, Chief Operating Officer, Chief Medical

95 Patient Safety Plan 3 Officer/Chief Quality Officer, Chief Nursing Officer, Member of the Board of Directors, and Directors of Nursing, Performance Improvement, Risk Management, and Pharmacy. B. The mechanism for identification and reporting a Sentinel Event/other medical error will be as indicated in Organizational Policies AP87. Any root cause analysis of hospital processes conducted on either Sentinel Events or near misses will be submitted for review/recommendations to the Patient Safety Committee, Professional Staff Quality Committee and Quality Council. C. As this organization supports the concept that events most often occur due to a breakdown in systems and processes, staff involved in an event with an adverse outcome will be supported by: 1. A non-punitive approach without fear of reprisal (just culture concepts). 2. Voluntary participation into the root cause analysis for educational purposes and prevention of further occurrences. 3. Resources such as Pastoral Care, Social Services, or EAP should the need exist to counsel the staff 4. Biannual ssafety culture staff survey (i.e. the Safety Attitudes Questionnaire) administered at least every 2 years to targeted staff and providers. about their willingness to report medical errors, (i.e. the Safety Attitudes Questionnaire) D. As a member of an integrated healthcare system and in cooperation with system initiatives, the focus of Patient Safety activities include processes that are high risk, high volume or problem prone, and may include: 1. Adverse Drug Events 2. Nosocomial Infections 3. Decubitus Ulcers 4. Blood Reactions 5. Slips and Falls 6. Restraint Use 7. Serious Event Reports 8. DVT/PE E. A proactive component of the program includes the selection at least every 18 months of a high risk or error prone process for proactive risk assessment such as a Failure Modes Effects Analysis (FMEA), ongoing measurement and periodic analysis. The selected process and approach to be taken will be approved by the Patient Safety Committee and Quality Council. The selection may be based on information published by The Joint Commission (TJC) Sentinel Event Alerts, and/or other sources of information including risk management, performance improvement, quality assurance, infection prevention, research, patient/family suggestions/expectations or process outcomes. F. Methods to assure ongoing inservices, education and training programs for maintenance and improvement of staff competence and support to an interdisciplinary approach to patient care is accomplished by: 1. Providing information and reporting mechanisms to new staff in the orientation training. 2. Providing ongoing education in organizational communications such as newsletters and educational bundles. 3. Obtaining a confidential assessment of staff s willingness to report medical errors at least once every two yearsbiannually. G. Internal reporting To provide a comprehensive view of both the clinical and operational safety activity of the organization: 1. The minutes/reports of the Patient Safety TeamCommittee, as well as minutes/reports from the Environment of Care Committee will be submitted through

96 Patient Safety Plan 4 the Director of Performance Improvement and Patient Safety to the Professional Staff Quality Committee. 2. These monthly reports will include ongoing activities including data collection, analysis, and actions taken and monitoring for the effectiveness of actions. 3. Following review by Professional Staff Quality Committee, the reports will be forwarded to Quality Council. H. The Patient Safety Officer or designee will submit an Annual Report to the KDHCD Board of Directors and will include: 1. Definition of the scope of occurrences including sentinel events, near misses and serious occurrences 2. Detail of activities that demonstrate the patient safety program has a proactive component by identifying the high-risk process selected 3. Results of the high-risk or error-prone processes selected for proactive risk assessment. 4. The results of the program that assesses and improves staff willingness to report medical/health care risk events 5. A description of the examples of ongoing in-service, and other education and training programs that are maintaining and improving staff competence and supporting an interdisciplinary approach to patient care. V. Evaluation and Approval VI. The Patient Safety Plan will be evaluated at least every three years or as significant changes occur, and revised as necessary at the direction of the Patient Safety Committee, Professional Staff Quality Committee, and/or Quality Council. Annual evaluation of the plan s effectiveness will be documented in a report to the Quality Council and the KDHCD Board of Directors. Confidentiality All quality assurance and performance improvement activities and data are protected under the Health Care Quality Improvement Act of 1986, as stated in the Bylaws, Rules and Regulations of the Medical Staff, and protected from discovery pursuant to California Evidence Code Attachments - Attachment 1: Quality Improvement/Patient Safety Committee Structure "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new

97 Patient Safety Plan 5 techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

98 Administrative Policy Number: AP41 Date Created: No Date Set Document Owner: Cindy Moccio (Board Clerk/Exec Date Approved: Not Approved Yet Assist-CEO) Approvers: Board of Directors (Administration) Quality Improvement Plan Printed copies are for reference only. Please refer to the electronic copy for the latest version. I. Purpose The purpose of Kaweah Delta Health Care District s (KDHCD) Quality Improvement Plan is to have an effective, data-driven Quality Assessment Performance Improvement program that delivers high-quality, excellent clinical services and enhances patient safety. II. Scope All KDHCD facilities, departments, patient care delivery units and/or service areas fall within the scope of the quality improvement plan requirements. III. Structure and Accountability Board of Directors The Board of Directors retain overall responsibility for the quality of patient care. The Board approves the annual Quality Improvement Plan and assures that appropriate allocation of resources is available to carry out that plan. The Board receives reports from the Medical Staff and Quality Council. The Board shall act as appropriate on the recommendations of these bodies and assure that efforts undertaken are effective and appropriately prioritized. Quality Council The Quality Council is responsible for establishing and maintaining the organization s Quality Improvement Plan and is chaired by a Board member. The Quality Council shall consist of the Chief Executive Officer, representatives of the Medical Staff and other key hospital leaders. It shall hold primary responsibility for the functioning of the Quality Assessment and Performance Improvement program. Because District performancequality improvement activities may involve both the Medical Staff and other representatives of the District, membership is multidisciplinary. The Quality Council requires the Medical Staff and the organization s staff to implement and report on the activities for identifying and evaluating opportunities to improve patient care and services throughout the organization. The effectiveness of the quality improvement and patient safety activities will be evaluated and reported to the Quality Council. Medical Staff The Medical Staff, in accordance with currently approved medical staff bylaws, shall be accountable for the quality of patient care. The Board delegates authority and responsibility for the monitoring, evaluation and improvement of medical care to the Professional Staff Quality Committee Prostaff, chaired by the Vice Chief of Staff. The Chief of Staff delegates accountability for monitoring individual performance to the Clinical Department Chiefs. Prostaff shall receive reports from and assure the

99 Quality Improvement Plan 2 appropriate functioning of the Medical Staff committees. Prostaff provides oversight for medical staff quality functions including peer review. Professional Staff Quality Committee- Prostaff : The Prostaff Committee has responsibility for oversight of organizational performance improvement. Membership includes key organizational leaders including: Medical Executive Committee members, Medical Director of Quality and Patient Safety, Chief Executive Officer, Chief Operating Office, Chief Medical Officer/Chief Quality Officer, Chief Nursing Officer, member of the Board of Directors, and Directors of Nursing, Quality and Patient Safety, Risk Management and Pharmacy. This committee reports to the Quality Council. The Prostaff Committee shall have primary responsibility for the following functions: 1. Health Outcomes: The Prostaff Committee shall assure that there is measureable improvement in indicators with a demonstrated link to improved health outcomes. Such indicators include but are not limited to measures reported to the Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC), and other quality indicators, as appropriate. 2. Quality Indicators: a. The Prostaff Committee shall oversee measurement, and shall analyze and track quality indicators and other aspects of performance. These indicators shall measure the effectiveness and safety of services and quality of care. b. The Prostaff Committee shall approve the specific indicators used for these purposes along with the frequency and detail of data collection. c. The Board shall ratify the indicators and the frequency and detail of data collection used by the program. 3. Prioritization: The Prostaff Committee shall prioritize performance quality improvement activities to assure that they are focused on highrisk, high- volume, or problem- prone areas. It shall focus on issues of known frequency, prevalence or severity and shall give precedence to issues that affect health outcomes, quality of care and patient safety. 4. Improvement: The Prostaff Committee shall use the analysis of the data to identify opportunities for improvement and changes that will lead to improvement. The Prostaff Committee will also oversee implementation of actions aimed at improving performance. 5. Follow- Up: The Prostaff Committee shall assure that steps are taken to improve performance and enhance safety are appropriately implemented, measured and tracked to determine that the steps have achieved and sustained the intended effect. 6. Performance Improvement Projects: The Prostaff Committee shall oversee performancequality improvement projects, the number and scope of which shall be proportional to the scope and complexity of the hospital s services and operations. The Prostaff Committee must also ensure there is documentation of what quality improvement projects are being conducted, the reasons for conducting those projects, and the measureable progress achieved on the projects. Medical Executive Committee

100 Quality Improvement Plan 3 The Medical Executive Committee (MEC) receives, analyzes and acts on performance improvement and patient safety findings from committees and is accountable to the Board of Directors for the overall quality of care. Nursing Practice Improvement Council The Nursing Practice Improvement Council is designed to ensure quality assessment and continuous qualityperformance improvement and to oversee the quality of patient care (with focus on systems improvements related to nursing practices and care outcomes). The Nursing Practice Improvement Council is chaired by the Director of Nursing Practice and facilitated by a member of the Quality and Patient Safety Performance Improvement department. This Council has staff nurse representation from a broad scope of inpatient and out-patient nursing units, and procedural nursing units. The Council will report to Patient Care Leadership, Professional Practice Council (PPC) and the Professional Staff Quality Committee. Methodology: The FOCUS-Plan, Do, Check, Act (PDCA) methodology is utilized to plan, design, measure, assess and improve functions and processes related to patient care and safety throughout the organization. F Find a process to improve O Organize effort to work on improvement C Clarify knowledge of current process U---Understand process variation S Select improvement Plan: Objective and statistically valid performance measures are identified for monitoring and assessing processes and outcomes of care including those affecting a large percentage of patients, and/or place patients at serious risk if not performed well, or performed when not indicated, or not performed when indicated; and/or have been or likely to be problem prone. Performance measures are based on current knowledge and clinical experience and are structured to represent crossdepartmental, interdisciplinary processes, as appropriate. Do: Data is collected to determine: Whether design specifications for new processes were met The level of performance and stability of existing processes Priorities for possible improvement of existing processes Check: Assess care when benchmarks or thresholds are reached in order to identify opportunities to improve performance or resolve problem areas

101 Quality Improvement Plan 4 Act: Take actions to correct identified problem areas or improve performance Evaluate the effectiveness of the actions taken and document the improvement in care Communicate the results of the monitoring, assessment and evaluation process to relevant individuals, departments or services IV. Confidentiality All quality assurance and performance improvement activities and data are protected under the Health Care Quality Improvement Act of 1986, as stated in the Bylaws, Rules and Regulations of the Medical Staff, and protected from discovery pursuant to California Evidence Code V. Annual Evaluation Organization and Medical Staff leaders shall review the effectiveness of the Quality Improvement Plan at least annually to insure that the collective effort is comprehensive and improving patient care and patient safety. An annual evaluation is completed to identify components of the plan that require development, revision or deletion. Organization and Medical Staff leaders also evaluate annually their contributions to the Quality Improvement Program and to the efforts in improving patient safety. VI. Attachments-- Components of the Quality Improvement and Patient Safety Plan: Attachment 1: Attachment 2: Attachment 3: Quality Improvement Committee Structure KDHCD- Prostaff Reporting Documents 2016 Value Based Purchasing (VBP) Objectives "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

102 Administrative Policy Number: AP19 Date Created: No Date Set Document Owner: Cindy Moccio (Board Clerk/Exec Date Approved: Not Approved Yet Assist-CEO) Approvers: Board of Directors (Administration) Travel, Per Diem and Other Employee Reimbursement Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: Kaweah Delta Health Care District will reimburse employees for certain travel and acceptable business expenses which are reasonably incurred in the course of District business. For travel costs relating to the cost of meals and incidentals while on travel to conduct District business, the employee will receive a per diem rate to cover such costs. All expenses submitted for reimbursement will require original receipts when not covered by the per diem rate. All receipts must include a detail of all items purchased. A summary credit card receipt will not be sufficient for reimbursement. Unless otherwise approved by an Executive Team Member ET", expenses submitted without original detailed receipts will not be reimbursed by the District. Travel or attendance at conferences outside the Contiguous US are generally prohibited. (Contiguous United States consists of the lower 48 states. This excludes Alaska and Hawaii.) Any exception requires the prior approval of the appropriate Director and Executive Team member. Before planning on attending an out-of-state conference outside of California or Nevada, employees should research if a comparable conference is offered in these two states. If the desired conference is not available, then the out-of-state travel should be approved by an Executive Team member. REFERENCES: AP46 Commercial Card Expense Reporting Program (CCER) AP84 Mileage Reimbursements AP105 Professional and Service Club District Reimbursed Memberships AP156 Standard Procurement Practices AUTHORIZATION: Authorization for expenses will be obtained as follows: Pre-Approval: For conference travel, the employee must obtain written approval from their immediate supervisor (immediate supervisor refers to department Director or a member of the Executive Team) prior to the travel taking place ( approval is acceptable). Travel expenses not receiving prior approval will not be reimbursed by the District unless later approved by an ET member. After travel: Employee expenses must be approved by the employee s authorized signer (generally a director or ET member). The approver must

103 Travel, Per Diem and Other Employee Reimbursement be an authorized signer with a completed Purchase Authorization Sheet on file with Materials Management (See District Policy AP156) having purchase limits and authority to approve travel expenses. Department Manager/Supervisor expenses must be approved by their Director, Vice President or Sr. Vice President. Vice Presidents may sign for expenses to the limit of the authority provided them through the budgeting process. Vice President / Sr. Vice President s travel expenses must be approved by the Chief Executive Officer. Goods and services purchased for the benefit of employees and staff appreciation accounted for under any HR program (such as Job Well Done) must have VP and HR approval before the purchase is made to confirm that the department has sufficient budgeted funds available to secure the purchase. METHODS OF PAYMENT: Method of payments of approved travel expense is as follows: PROCEDURE: Payment by a District issued credit card Approved business expenses paid for by using a District issued credit card must follow policies as set forth in AP46 (Commercial Card Expense Reporting (CCER)) Prepayment by Accounts Payable Travel expenses which are being paid for directly by the District to a third party vendor must be submitted on the attached Travel Reimbursement Form or nonstock before payment will be processed. Payment by the Employee (out of pocket expenses) Approved business expenses may be paid by the employee and reimbursed based on employee reimbursement procedures as outlined herein. Travel, Per Diem, and other Employee Reimbursement not related to travel: I. No matter what mode of travel is being used, travel costs paid for by the District for travel subsequently cancelled must immediately be refunded to the District unless such cancellation is for the business benefit or convenience of the District and has been approved by a member of the ET. The approver authorizing the travel is responsible to ensure that the refund is received by the District timely and the appropriate cost center properly credited for the refund. Non-reimbursable travel and non-travel expenses include, but may not be limited to: A. charge card fees B. meals in excess of the per diem rate, unless approved by the Executive Team C. airline hospitality fees D. frequent user program fees E. personal services and sundries F. personal gas or oil if a mileage allowance is received G. baby-sitting/child care fees

104 Travel, Per Diem and Other Employee Reimbursement H. traffic or parking violation citations I. laundry and valet services J. pet care K. replacement of lost luggage L. personal gifts M. alcoholic beverages except as permitted under section IV and approved by a member of the ET or Board of Directors. II. III. IV. Air Travel and Lodging A. The lowest appropriate airfare will be obtained at all times unless alternative is specifically approved by the Employee's supervisor (supervisor refers to department Director or a member of the Executive Team) as applicable. Employees will only be reimbursed for the cost of coach fares and standard luggage fees. B. Hotels offering special or corporate rates should be used whenever possible. When attending a conference, employees may stay at the hotel where the event is held to take advantage of the conference host discount. C. Employees may participate, to their own personal benefit, in frequent user bonus programs. KDHCD will not reimburse any employee for costs associated with participation in frequent user bonus programs. Ground Transportation - Employees requiring ground transportation shall determine and utilize the most cost-effective means available. A. Personal Vehicle - When it is necessary for an employee to utilize their personal vehicle to conduct District business, expenses will be reimbursed in accordance with AP84 (Mileage Reimbursement). B. Taxi, Hotel or Airport Shuttle, Convenience Vans, etc. - Employees requiring transportation to or from a commercial carrier port such as an airport shall employ the most cost-effective alternative in arriving at their destination. Reimbursement will be made available to employees based upon actual costs incurred, supported by a detailed receipt. The use of alternate transportation shall only be used if more cost effective than the use of the employee s personal vehicle. Any exceptions must be approved by the employee s supervisor. C. Rental Cars - When adequate transportation at lower cost is not available (i.e., personal car, hotel or airport shuttle, taxi, etc.), cars (up to mid-sized) may be rented from a local vendor. Employees will not be reimbursed for charges associated with the rental company fee for waiver for collision/loss damage or liability. D. Private Limousine - Limousine costs will be reimbursed only when other reasonable transportation (i.e., shuttle, rental car, taxi cab, etc.) is not available. Meals and incidentals Other than specific identified exceptions, meals and incidentals will not be reimbursed based on the cost of the meal or item of purchase. Instead, employees shall receive a standard travel per diem rate to cover all meals and incidentals while traveling (See Per Diem Section below). Exception to the per diem rate for which meals can be reimbursed based on original receipt include:

105 Travel, Per Diem and Other Employee Reimbursement A. Reimbursing an ET member, Director, or Board member for the cost of a group meal incurred while meeting with a business group consisting of employee(s), physician(s), vendor(s), employee or physician recruitment or any group meeting on District business. B. Reimbursing an employee for the cost of a meal incurred while entertaining a visitor or other non-district employee on District business with the approval of the ET or Board member. C. Reimbursing an employee for the cost of a meal incurred while entertaining a prospective physician candidate with the approval of the Vice President of Human Resources or Medical Staff Office. D. In the circumstances described above in items A, B, and C, alcoholic beverages may be consumed in connection with the meal and shall be considered a reimbursable business expense. Such purchases shall be reasonable and reflective of appropriate judgement/prudence. V. Per Diem - Employees will receive a standard travel per diem rate to cover all expenses incurred by the employee on behalf of the District during travel (aside from air fares, standard luggage fees, hotel registrations, mileage, transportation, and registration fees which are paid for by the District or directly reimbursed to the employee). A travel day includes the day immediately before and after the business event or if traveling on the same day as the business event, the travel day includes the official work day that is more than 12 hours but less than 24 hours as allowable by the U.S. General Service Administration located at A. To receive a per diem payment prior to travel, the employee must submit to Finance at least one week prior to travel an approved Travel Reimbursement Form (see attached form) requesting a per diem payment along with the required documentation described below in Section VII. If travel is canceled, and not approved by an ET member, the employee must immediately refund the District the per diem payment received for days not traveled. B. To receive the per diem payment after travel has been completed the employee must submit to Finance within 60 days after travel has been completed an approved Travel Reimbursement Form (see attached form) requesting per diem pay along with the required documentation described below in Section VII. VI. VII. Entertainment All requests for reimbursement of entertainment expenses must be approved by an Executive Team member. Required Documentation for all travel: A. Instead of completing a nonstock form, the employee must complete the Travel Reimbursement Form (see attached form) and must include (i) appropriate approval for travel as discussed above under Authorization, (ii) the allowable per diem rate for location of travel as provided by the U.S. General Service Administration located at and included on KD Central and (iii) evidence of the number of days traveling and location. The Travel Reimbursement Form is to be completed for each request for payment. B. No receipts need to be submitted for expenses incurred that will be covered by the per diem rate. For expenses not covered by the per diem rate, original receipts MUST be

106 Travel, Per Diem and Other Employee Reimbursement submitted to the approver and attached to the Travel Reimbursement Form in order to be submitted to Finance for reimbursement. 1. For vendor purchases, a receipt including the vendor name, transaction amount, date, and detail of the item(s) purchased. 2. For Internet purchases, a screen print or order confirmation 3. All receipts and/or invoices less than 8 ½ by 5 ½ inches must be taped to a plain white sheet of paper. Multiple receipts may be included on the same sheet of paper, but they may not overlap. C. In the rare and unique occurrence that a receipt cannot be located, an Executive Team member must sign the Travel Reimbursement Form approving the missing receipt. The executive team member can deny the reimbursement request. D. If the business purpose of the transaction is not evident upon review of the receipt, further documentation of the business purpose is required. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document." Formatted: Indent: Left: 0.5", Tab stops: 3.63", Left

107 Travel, Per Diem and Other Employee Reimbursement Kaweah Delta Health Care District 400 W. Mineral King Visalia, CA (559) Travel Approval and Reimbursement Form *This form must be completed to submit request for conference and travel approval and for payment of per diem or reimbursement of travel expenses* Submit completed form with supporting documentation and/or receipts to your Department Manager / Supervisor or Vice President / Sr. Vice President / CEO as applicable. Name: Department # Date: Title of Seminar / Conference: Location (City, State) of Seminar / Conference: Dates of Conference From: To: TRIP DETAIL Estimated Expense Actual Expense Method of Payment Supporting Documentation for payment request? If no explain why. Registration Fees (608700) Mileage rate when using own car: Total miles x $ per mile KD Wells Fargo Personal Card Cash Rate is determined by IRS.gov rate Public Transportation: Air, Bus, Train, Cab, etc. Lodging(See AP19- Air Travel and Lodging Paragraph: Total days x $ per day* KD Wells Fargo Personal Card Cash KD Wells Fargo Personal Card Cash Per Diem(See AP19 - Per Diem Section III)Working days x $ per day*travel days x $ per day x 75%* Meals(See AP19- Meals Section III) Misc. Expenses (please specify) Parking / Car Rental, etc. KD Wells Fargo Personal Card Cash KD Wells Fargo Personal Card Cash TRAVEL COSTS TO BE CHARGED TO (608800) * Amounts exceeding the per-day allowances must be approved by an Executive Team member prior to travel. Approval (Must include an Authorized Signor for the department being charged) Conference Approval Expense/Reimbursement Approval Employee Signature Authorizing Supervisor (Director level or above) Employee Signature Authorizing Supervisor Director level or above

108 Policy Submission Summary Manual Name: Risk Management Date: June 2018 Support Staff Name: Evelyn McEntire Policy/Procedure Title # Reporting and Investigation of Sentinel or Adverse Events {Duplicate effort of Administrative Policy 87 Sentinel Event and Adverse Event Response and Reporting} Status New, Revised, Reviewed, or Deleted * Name and phone extension of person who wrote or revised policy - * for New and Revised policies only RM06 Delete Evelyn McEntire x5241

109 Policy Submission Summary Manual Name: Human Resources Date: June 13, 2018 Support Staff Name: Blanca Bedolla Policy/Procedure Title # Status (New, Revised, Reviewed, Deleted) Name and Phone # of person who wrote the new policy or revised an existing policy Employee Benefits Overview HR.128 Revised Dianne Cox, VP HR Notification Requirements and Appeal Process for Involuntary Termination and Demotion HR.218 Revised Dianne Cox, VP HR Reporting Fraud and Abuse HR.192 DELETE Dianne Cox, VP HR Educational Leave of HR.150 DELETE Dianne Cox, VP HR Absence Confidential Information HR.194 DELETE Dianne Cox, VP HR

110 Human Resources Policy Number: HR.128 Date Created: 06/01/2007 Document Owner: Dianne Cox (VP Human Date Approved: 12/08/2014 Resources) Approvers: Board of Directors (Administration), Debbie Wood (VP Human Resources) Health and Welfare Benefits EligibilityEmployee Benefits Overview Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: The District provides a variety of benefit plans to all its employees. All benefits have established eligibility requirements which employees must meet in order to participate in the program. PROCEDURE: I. Scope of Benefits Provided Detailed information regarding Group Medical, Dental, Vision, Life, Accidental Death and Dismemberment, and Long Term Disability coverage is provided in detail in the Summary Plan Description and the Plan Document. II. Eligibility Requirements and Effective Date for Benefits A. Full-time Status- Benefits Eligible Employees occupying positions designated as fulltime are normally and regularly scheduled to work 36 to 40 hours per week. Weekly Bi-Weekly Hours Classification Hours Full Time Benefits Eligible B. Part-time Status- Benefits Eligible Employees occupying positions designated as part-time are normally and regularly scheduled to work hours per week. Benefits may be available based on hours worked. Weekly Hours Bi-Weekly Hours Classification Part Time Benefits Eligible

111 Health and Welfare Benefits Eligibility 2 Effective date for an eligible employee s coverage is, subject to timely enrollment, upon completion of a waiting period on the first of the month following thirty (30) days of active employment. III. Group Medical, Dental & Vision Benefits Coverage is available to full-time and part-time benefit eligible employees and their eligible dependents the first day of the month following thirty days of continuous employment provided enrollment forms have been completed and submitted to the Human Resources Department as required. Employees changing from a benefits-ineligible to a benefits-eligible employment status may apply for group insurance coverage for themselves and their eligible dependents within thirty (30) days of that eligibility. Coverage will be effective the first of the month following receipt of the completed enrollment form. If a full time employee does not elect medical coverage their coverage will default to the EPO plan. All full-time employees are required to have medical insurance for themselves either by electing one of the District plans or showing proof of coverage from an outside source. All full-time employees who have other coverage will receive Cash Back when waiver is signed and proof of other coverage is given to Human Resources Department. IV. Life/Accidental Death and Dismemberment Insurance Basic coverage (one time annual salary not to exceed $150,000) is effective on the first of the month following thirty days of active employment for full-time employees. Additional voluntary coverage is available at a nominal cost to employees for themselves and qualified dependents. V. Long Term Disability Voluntary coverage is available to all eligible full-time and part-time employees provided the employee is seventy (70) years of age or less. VI. Workers' Compensation All employees are covered as required by law.

112 Health and Welfare Benefits Eligibility 3 VII. Benefits Before Employee Taxes (Sec.125) All benefit eligible employees will have the opportunity to participate in the Benefits Before Employee Taxes (Sec.125) program in order to reduce their tax liability for dollars earned and spent for eligible healthcare and/or child care expenses as defined by the Internal Revenue Service, Section 125 of the code. Complete and detailed information including eligibility, effective date, enrollment requirements, etc., is contained within the Summary Plan Description/Flexible Spending Account available through the Human Resources Department. PURPOSE: Formatted: Font: Arial To provide department heads with general guidelines regarding the various employee benefit programs available to eligible employees. POLICY: Eligible Kaweah Delta Health Care District Employees are provided a wide range of employee benefits. A number of the programs, such as Social Security, Workers Compensation, and Unemployment Insurance, cover all employees in the manner prescribed by Federal or State law. Hospital-sponsored benefits eligibility is dependent upon a variety of factors, including employee classification. Human Resources maintains a listing of current benefits available. The controlling terms and conditions of all benefits are contained within the plan documents which define each benefits plan. In the event of discrepancies between other printed material and formal plan provisions describing Kaweah Delta Health Care District employee benefits programs, the official plan documents and instruments provisions govern. Employees will be responsible for paying their insurance premiums and those for their enrolled dependents based on status and the date of eligibility. Enrollment in most plans must be completed within 30 days of the date of eligibility for the plan. Benefit eligible employees may also apply for offered benefits during Open Enrollment, normally offered in fall of each year for a n January 1 st effective date. If a full time employee does not elect or waive medical coverage, their coverage will default to the EPO Medical Plan. Please review Summary Plan Documents for each plan for complete information. PROCEDURE: Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial General: 1. Insurance premiums for medical, dental, vision, supplemental life, dependent life, etc., are deducted each pay period (24 per calendar year) from paychecks. 2. Eligible employees may opt to cover eligible dependents with timely enrollment and financial responsibility for any dependent coverage.coverage. If a spouse or registered domestic partner has coverage through his or her own outside employer (not KDHCD); the KDHCD plan will pay only as a secondary insurance. Formatted: Font: Arial

113 Health and Welfare Benefits Eligibility 4 3. If an event occurs which will change the amount of premium the employee pays, the employee will either be required to pay back premiums or will receive reimbursement for premiums already deducted, depending on the nature of the event. 4. All premium contributions for medical, dental and vision are deducted on pre-tax basis. The conditions of Internal Revenue Service Code, Section 125, specifically prohibit employees from changing their insurance benefit coverage until an Open Enrollment period is offered or unless there is a major life change or qualifying event. Certain qualifying events may permit an employee to apply for late enrollment or changes in the employee s enrolled dependents. Formatted: Font: Arial Normal Waiting Period: 1. Coverage for health benefits normally begins the first of the month following 30 days of regular employment or first of the month following a status change to a benefit-eligible position. Formatted: Font: Arial Status Change: 1. The department head will submit a Status Change Form to Human Resources when an employee changes employment status. The effective date of the status change is the first day of the pay period in which the status change occurs. 2. Human Resources will notify the employee of changes in eligibility and/or applicable premium levels for eligible benefits. If a full time employee does not elect or waive medical coverage, their coverage will default to the EPO Plan. Formatted: Font: Arial Formatted: Font: Arial 3. The premiums to be deducted are dependent on the date of the status change and may apply to the portion of the premium covering the employee as well as the dependent coverage. 4. If a Per Diem employee with coverage converts to Benefitted status, premiums deducted will be appropriately adjusted. 5. A newly n eligible employee, i.e., one who converts from Part Time No Benefits or Per Diemconverts from Full Time or Part Time, A1 or A2, (because of a qualifying event) or Per Diem to Benefitted or benefits eligible status, who has already satisfied the waiting period will not have to satisfy an additional waiting period. An employee who was eligible for coverage, but declined it, who has now converted to a Benefitted status will not be subject to the normal waiting period. Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial 6. An employee who was previously eligible and enrolled in the insurance plans and subsequently changed to a non-benefit eligible status, who has now converted to a benefits eligible status will not be subject to the waiting period. 7. An eligible employee who was eligible for, and declined benefits because of other coverage and then loses the other coverage is eligible to enroll in benefits with no waiting period under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The employee must enroll within 30 days of the loss of other coverage and provide a Certificate of Creditable Coverage from the other plan. 8. An employee who loses medical, vision, dental coverage or a medical spending account due to conversion to an ineligible status or termination of employment will be offered continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), except in the case of discharge for gross misconduct. Eligibility, payment of premiums, and length of available coverage are determined by COBRA regulations.

114 Health and Welfare Benefits Eligibility 5 9. In the case of a Leave of Absence, if an employee is on paid status (utilizing PTO/EIB), the employee may continue his/her normal premiums through payroll deduction. If on unpaid status, he/she is required to pay Kaweah Delta his/her portion of the premiums biweekly/monthly while on a leave of absence for a total of four months combined within a rolling 12 months. After four months, employees will be offered COBRA Continuation Coverage for applicable benefits. Group medical, dental and vision insurance coverage will cease on the last day of the month in which an employee reaches four months of leave or employment ends except that continuation is allowed under COBRA regulations if applicable to the plan. In the case where Pregnancy Disability Leave (FMLA) combined with CFRA bonding leave applies, if an employee is on paid status (utilizing PTO/EIB), the employee may continue her normal premiums through payroll deduction. If on unpaid status, she is required to pay Kaweah Deltathe Hospital her portion of the premiums monthly while on a leave of absence for a total of up to seven months; COBRA rules then apply. Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial Procedures for COBRA: a. At the time of the qualifying event, Human Resources or the COBRA Administrator will forward the Employee Notice and Election Form to the employee via US mail. COBRA qualifiers: Death of a covered employee, divorce or legal separation, a covered employee becoming eligible for Medicare, or a covered dependent child who is no longer eligible for coverage under the group plan. b. The employee, the separated or divorced spouse, or covered dependent will have no more than 60 days from the date of receipt of the COBRA letter to apply for continuance of medical, dental, or vision coverage. Notification is accomplished by completing the Employee Notice and Election form. If the employee, separated or divorced spouse, or covered dependent wishes to continue with medical, dental, or vision coverage, the initial premium payment to the COBRA Administrator must be received within 45 days of the date the employee signs the Employee Notice and Election Form and must be paid in full, back to the date of COBRA coverage. Formatted: Font: Arial Formatted: Font: Arial Formatted: Font: Arial c. Upon receipt of the initial payment, the COBRA Administrator will begin the COBRA coverage and will expect future premiums due. The employee or eligible dependent must continue payments each month in order to continue coverage. COBRA coverage will be terminated if payments are not made within the guidelines set forth. Reinstated Employee: Employees who are reinstated within twelve months will retain their original seniority date for PTO accrual rate, reinstatement of PLC, and service awards eligibility, but are subject to a new probationary period and evaluation schedule. Reinstated employees may have to complete all new-hire paperwork and attend General and other Orientation programs. Formatted: Font: Arial

115 Health and Welfare Benefits Eligibility 6 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document." Formatted: Indent: Left: 0"

116 Human Resources, Human Resources Policy Number: HR.218 Date Created: 06/01/2007 Document Owner: Dianne Cox (VP Human Date Approved: Not Approved Yet Resources) Approvers: Board of Directors (Administration), Dianne Cox (VP Human Resources Jane Bedrosian (Director of Human Resources), Julie Sena (Director of Human Resources) Notification Requirements, Pre-Determination Process and Appeal Process for Involuntary Termination, Suspension without Pay for More Than Five Days and Demotion Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: Employees of the District by statute, serve at the pleasure of the Board of Directors (see Health and Safety ccode Section 32121(h)). When an employee who has passed his/her six (6) month introductory period is informed of his/her involuntary termination, suspension of five days or more or demotion, the employee will be provided the opportunity for a pre-determination review of athe Nnotice of proposed Iintent, discipline and written notice of the pre-determination review process, and the District s post-determination review and appeal process. The purpose of a pre-determination review is to provide employees the opportunity to appealbe heard and to defend themselves before a decision is made to terminate, demote, or suspend for more than five (5) days. Nothing in this policy should be interpreted as modifying or diminishing in any way, the District s right to terminate or discipline an employee at will that is for any reason which the District considers to be sufficient in its sole discretion. Formatted: Indent: Left: -0.5", Hanging: 0.5", Tab stops: 0.56", Left + Not at 1.5" Formatted: Indent: Left: -1.25", Hanging: 1.25", Tab stops: 0.5", Left + 1", Left + 2", Left + 2.5", Left + 3", Left + 3.5", Left + 4", Left + 4.5", Left + 5", Left + 5.5", Left + 6", Left Formatted: Indent: Left: 0", First line: 0", Tab stops: 0", Left + Not at 1.5" DEFINITIONS: II.I. I. Due Process: A fundamental, constitutional guarantee that all legal proceedings will be fair and that one will be given notice of the proceedings and an opportunity to be heard before the government acts to take away one's life, liberty, or property. Pre-Determination Review: A meeting in which an employee is given the opportunity to responds to athe Notice of Intent to Discipline by submitting a written and/or verbal statement to an appointed Reviewer. to an objective party (Reviewer) for review. The employee may present his/her case in writing, in a meeting or both. If the employee chooses to responds, the Reviewer has the responsibility to recommenddetermine whether the proposed action should be upheld, overturned, or modified. The Reviewer s Formatted: Indent: Left: 1.5", No bullets or numbering Formatted: Line spacing: At least 12 pt, Tab stops: Not at -1"

117 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 2 charge is to determine whether or not the proposed action complies with the guidelines for review set forth in Attachment A.meets the Seven Tests of Just Cause? III.II. Reviewer: An impartial and disinterested pre-determination decision maker. The Reviewer Reviewer shall be a the Vice President or other executive responsible for the area where the employee works unless the Vice President is unavailable or it is determined that appointed by the Vice President of Human Resources. was actively involved with the discipline of the employee in which case, the Vice President of Human Resources will appoint another vice president or request the CEO to act as the Reviewer. IV.III. Post-Determination Review: Appeal process after the pre-determination review. PROCEDURE: I. I. Initial Notice of Intent to Discipline IfIn the event that an employee who has passed the initial six (6) months introductory period or extension thereof, is subject to termination, suspension for more than five (5) days or demotion, the managementer of the employee, or the Vice President of Human Resources or designee, shall cause to be served on the employee a written notice ( Notice of Intent to Discipline ). containing all of the following: The following is a recommended list of the items that should be contained in this document, but no Notice of Intent will be invalid if it f does not contain all of the items on this list. The purpose of the document is to provide the employee with an outline of the proposed action along with a fair summary of the reasons for taking the action: A. the proposed action (i.e., termination, suspension for more than five (5) days or demotion) and the effective date of the proposed action; B. the reasons supporting the proposed action; C. a copy of the specific charges upon which the proposed action is based; C.D. a summary of the facts upon which the charges are based; D.E. E.F. a copy of all written materials, documents or reports upon which the proposed action is based, or a statement indicating how this information can be obtainedd; notification that the employee is entitled to a pre-determination meeting to respond, either orally or in writing, to an objective party for review ( Reviewer ). The Reviewer will be appointed by the Vice Formatted: Numbered + Level: 1 + Numbering Style: I, II, III, + Start at: 1 + Alignment: Left + Aligned at: 0.25" + Indent at: 0.75" Formatted: Indent: Left: 0.5" Formatted: Indent: Left: 0.5" Formatted: Indent: Left: 0.5" Formatted: Indent: Left: 1.5", Hanging: 0.5", Tab stops: Not at 0.5" + 1" + 1.5" + 2.5" + 3" + 3.5" + 4" + 4.5" + 5" + 5.5" + 6" Formatted: Indent: Left: 0.5" Formatted: Indent: Left: 0.5" Formatted: Indent: Left: 0.5", Hanging: 0.5", Tab stops: Not at 0.5" + 1" + 1.5" + 2" + 2.5" + 3" + 3.5" + 4" + 4.5" + 5" + 5.5" + 6" Formatted: Indent: Left: 0.5"

118 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 3 President of Human Resources or his/her designee. See definition of Reviewer above; EF.G. the name of the Reviewer and his/her contact information; and FG.H. notification that the proposed discipline action will become final and that the employee will waive his/her rights to a pre-determination review and a post-determination hearing of the matter if the employee does not contact the Reviewer by 4:00 p.m. of the next working day after service of such notice. (A form to be used for such notice will be provided by Human Resources.) "Working day" as used herein shall mean any day, Monday through Friday, holidays excluded. G. The provisions contained in this Section GH. are advisory and within the sole discretion of the District. The District s failure to comply with any of the provisions of this Section shall not invalidate any disciplinary action taken. II. Effective Date The Notice of Intent as described in this document shall become effective when:except in matters involving verbal warnings, written warnings or suspensions of forty (40) scheduled working hours or less, no employment discipline shall be effective until: Formatted: Indent: Left: 0.5" Formatted: Indent: Left: 0.5" Formatted: Numbered + Level: 1 + Numbering Style: A, B, C, + Start at: 7 + Alignment: Left + Aligned at: 0.5" + Indent at: 0.75" Formatted: Indent: Left: 0.25" Formatted: Indent: Left: 1" A. The employee has been served with a copy of the notice specified above and has faileds to contact the assigned Reviewer to schedule a review of the proposed actiondiscipline, by 4:00 p.m. of the next working day after service of the notice; or, B. The employee contacts the assigned Reviewer, the Vice President of Human Resources or his/her designee or the Director of his/herthe Department and explicitly states he/she does not want to schedule a pre-determination review of the proposed actiondiscipline; or, C. The employee properly requests a pre-determination review and the Reviewer issues a written recommendation decision after the predetermination meeting in which he/she recommends upholding the proposed demotion, suspension or termination and the employee does not properly comply with the requirements for requesting a post-determination hearing with a Hearing Officer, or or a review by the CEOthe designated committee of the Board of Directors; D. The employee properly requests and obtains a post-determination hearing where the Hearing Officer upholds the decision of the Reviewer and the employee does not request a review by the CEOdesignated committee of the Board of Directors; or

119 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 4 E. The employee properly requests and obtains appellate review by the CEO and designated committee of the Board of Directors and the committee he/she upholds the decision of the Reviewer. III. Arranging the Pre-determination Meeting A. The Notice of Intent to Discipline will identify the Pre-determination Reviewer Reviewer and provide the Reviewer s contact information. It will advise the employee that he/she may has the right to respond directly to the Pre-determination Reviewer, either orally or in writing, and will set out the time limit within which the response should must be submitted. The Notice of Intent to Discipline will also advise the employee how he/she can contact the Pre-determination Reviewer to arrange a meeting. B. If the employee wishes to meet, it is his/her responsibility to The employee is responsible for contacting the Pre-determination Reviewer and arrangeing the meeting,meeting; if the employee indeed wishes to meet. If an employee properly requests a predetermination Thethe meetinging it shall should be scheduled no later than three (3) calendar days (3) following the date of the request. by the employee. C. The Pre-determination Reviewer has no responsibility to initiate contact with As an alternative to a meeting, an the employee. An employee may submit choose to submit a written response. The Reviewer may disregard an untimely response.in writing or, to submit both a written response and an oral response. Either method is valid as long as the response in whatever form it takes is timely (i.e., within the stated deadline). A Pre-determination Reviewer need not consider an untimely response. Questions about requests to accept an untimely response, or to request an extension of the review period, should be addressed to the Vice President of Human Resources or his/her designee. Formatted: Indent: Hanging: 0.69" D. If it occursit occurs, tthe pre-determination meeting will be informal., once requested, will proceed like any other meeting. The Predetermination The Reviewer will lead the meeting. The employee will meet with the Pre-determination Reviewer, may provide such evidence or information as he/she wishes and tell his/her side of the story. After Subsequent to the meeting, the Pre-determination Reviewer will make a recommendation as to whether the proposed disciplinary action should be upheld, modified, or revoked. Matters related to the Pre-determination Reviewer s recommendation are addressed in Part IV, below. E. On occasionfrom time to time, employees may request that a scheduled pre-determination meeting date be extended, or that the Formatted: Indent: Left: 0.5", Hanging: 0.63", Tab stops: 0.25", List tab

120 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 5 standard pre-determination response period be increased. Although the Pre-determination Reviewer mayhas the discretion to grants or denyiesy these requests, he/she it is recommended that the Predetermination Reviewer should consult with Human Resources prior to doing so. issuing a decision on the issue. Since employees may be on leave with pay during the pre-determination period, it is important to consider the stated need for the extension, along with the financial implications of the request, before issuing a decision. IV. Recommendations for Conducting the Pre-determination Meeting A. PREPARATION PRIOR TO FOR THE MEETING: THE PRE- DETERMINATION REVIEWER SHOULD REVIEW: The Reviewer should read t: notice of the intended action; ssupporting documents; s Policye Pre-determination Protocol; applicable District policies and procedures. Of any relating to the intent; and aany written response submitted by the employee in advance of the Pre-determination Meeting, as well asand any documents the employee has submitted in support of that response. B. THE PRE-DETERMINATION MEETINAt the meeting, tg i. The Pre-determination Reviewer will: a. I iintroduceintroduce all persons present. 1 ; b. explain the purpose of the meeting; c. The Pre-determination Reviewer will begin the meeting by explaining the purpose of the meeting. The Pre-determination Reviewer will also explain that, upon completing the meeting, he/she will consider the information provided and then make a recommendation to uphold, modify, or revoke the proposed disciplinary action.; i. d. explain that his/her recommendations, if any are not binding, but are simply rrecomemendations that may be accepted or rejected by the District. The issues for the Pre-determination Reviewer to determine are: 1) whether there is a reasonable basis to believe the employee engaged in the misconduct charged, and 2) whether the proposed disciplinary action appears to be within the range of reasonable penalties. ii. ii. Next, the Pre-determinationThe Reviewer should then inviteask the employee to respond to the charges and advise that the employee s response may be submitted in writing, if the employee desires, or a combination of verbal and written Formatted: Indent: Left: 0", Hanging: 2", Tab stops: 0.38", Left Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: No underline Formatted: Indent: Left: 0.38" Formatted: Indent: Left: -1.63", Hanging: 2", Bulleted + Level: 1 + Aligned at: 1.25" + Indent at: 1.5", Tab stops: Not at 0.5" Formatted: Indent: Left: -0.13", Tab stops: 2", Left Formatted: Indent: Left: 0.38", No bullets or numbering, Tab stops: 1.56", Left ", Left ", Left + 2", Left Formatted: Indent: Left: 0.38", No bullets or numbering 1 The Reviewer may request the attendance and assistance of a member of Human Resources staff at the meeting.

121 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 6 responses. The rreviewer should allow the employee to present all relevant facts and arguments including documents. iii. iv. iii. The Pre-determination Reviewer should allow the employee to present all relevant facts and arguments non-cumulative information, including documents. a. THE PRE-DETERMINATION REVIEWER SHOULD NOT: 1. Allow the discussion to wander into generalities unrelated to the charges. 2. Argue or try to settle any disputes about the proposed action. 3. Respond to questions about the action or express an opinion about the quality of the action. (The Pre-determination Reviewer may, however, respond to procedural type questions if the answer is known). 4. Indicate during the meeting what his/her recommendation is likely to be. iv. The pre-determination meeting is not a formal hearing and there will be no witnesses testifying under oath. If the employee believes there are other employees who can support his facts/arguments, he/she may, with hthe permission of the Reviewer, bring them to the meeting and ask that the y be heard. Such oral statementstns are in the discretion of the Review. The Revieower may limit the number of witnesses or place time limitations of the length of such verbal statements. v. Neither the District nor the employee shall have the right to be represented by counsel or other person not an employee of the District. The employee is in his/her discretion may bring a current District employee to support him/her at the meeting. v. requiring examination of witnesses. However, if the employee feels that witnesses other than the employee are required in order to demonstrate the likelihood that an error will be made if the proposed action is implemented, witnesses may be called into the meeting. The witnesses should be heard from one at a time as long as, in the discretion of the Pre-determination Reviewer, they are giving relevant non-cumulative information. Witnesses are not sworn. vi. The Pre-determination Reviewer should ask the appropriate questions and then give the employee the opportunity to make a few, brief follow-up statements. Questions should be directed to the Predetermination Reviewer, not to the supervisor or witnesses. Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", No bullets or numbering, Tab stops: 2", Left + Not at 0.88" Formatted: Body Text Indent, Indent: Left: 0.38", Tab stops: 2", Left Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", Tab stops: 3", Left Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 1.69", No bullets or numbering Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.25", No bullets or numbering Formatted: Indent: Left: 0.38", First line: 1.75", No bullets or numbering Formatted: Indent: Left: 0.38", First line: 1.75" Formatted: Indent: Left: 0.38", First line: 1.75", No bullets or numbering vii. Occasionally, a Pre-determination Reviewer will desire to obtain corroboration of information provided during a predetermination meeting. The Pre-determination Reviewer should contact the

122 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 7 Vice President of Human Resources or his/her designee for advice and assistance in obtaining the desired information. viii. Notes: The Pre-determination Reviewer may choose to take notes at the pre-determination meeting. It is not required. If the Pre-determination Reviewer does choose to take notes, the notes must be attached to his/her pre-determination recommendation. ix. It is often helpful to invite the Manager/Supervisor initiating the actiondiscipline to sit in on a pre-determination meeting for the purpose of providing clarification. However, the attendance of any person is at the sole discretion of the Pre-determination Reviewer. The Pre-determination Reviewer may ask questions of the Manager/Supervisor or allow the employee accused of misconduct to ask questions of the Manager/Supervisor. Such questioning, however, should be permitted only if the Pre-determination Reviewer finds it of value, given the limited charge of the Pre-determination Reviewer.. A. AFTER THE PRE-DETERMINATION MEETING i. After the meeting, Tthe Pre-determination Reviewer evaluates all of the information after the meeting.. If the Pre-determination Reviewer concludes that additional information is needed, the he/shepre-determination Reviewer should will contact the Vice President of Human Resources or his/her designee for advice and assistance. in obtaining the information. ii. After reviewing all of the documentation and information provided by the employee, the Pre-determination the Reviewer evaluates whether in his/her judgment there is a reasonable basis to believe the employee engaged in the conduct charged and whether the proposed action disciplinary action is appropriate. within the range of penalties. The Pre-determination Reviewer may confer with the Manager/Supervisor who initiated the actiondiscipline during this evaluation if any factual issues need to be clarified. If this evaluation involves policy issues, the Vice President of Human Resources or his/her designee should be consulted. Depending on the results of his/her evaluation, the Pre-determination Reviewer then makes a recommendation to uphold, modify, or revoke the proposed disciplinary action. iii. The Pre-determination Reviewer will first prepares his/her written recommendation in draft form within three (3) working days of the meeting or such longer time as is necessary. A typical draft recommendation will look substantially as follows: [DRAFT] To: Employee and Vice President of Human Resources (insert names) Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", Tab stops: Not at 0.5" Formatted: Indent: Left: 0.38" Re: Intent to Impose (identify proposed disciplinary action)

123 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 8 I write in consequence of the pre-determination meeting of (date) with respect to the notice of intent to (identify proposed discipline) of (date of notice of intent) with regard to (name of employee). Those present at the predetermination meeting were:. After reviewing the relevant documents made available to me, and after hearing from (employee and/or the employee s representative) at the pre-determination meeting, I am making the following recommendation: Because there appear to be (reasonable/insufficient) grounds to believe (the employee) engaged in the misconduct charged, I recommend that the proposed disciplinary action be (upheld or modified (and explain how) or revoked). Name Title Pre-determination Reviewer cc: Manager enc: All documents presented prior to or at the pre-determination meeting Any other documents considered by the Pre-determination Reviewer Pre-determination Reviewer notes (if any) iv. The Pre-determination Reviewer s draft recommendation should be sent to Human Resources within a reasonable time (generally three working days) after the pre-determination meeting. may be used to speed the process. v. If the Pre-determination Reviewer s draft recommends that the disciplinary action be upheld, the Vice President of Human Resources or his/her designee will ask the Pre-determination Reviewer to finalize the recommendation (along with the attachments) and will then submit it to the Manager/Supervisor within twenty-four (24) hours. The Manager/Supervisor then issues the final corrective action letter to the employee, enclosing a copy of the Predetermination Reviewer s recommendation (along with the attachments). vi. Alternatively, if the Pre-determination Reviewer s draft recommends that the proposed disciplinary action be modified or revoked, Human Resources shall submit the draft recommendation to the Manager/Supervisor and arrange for the Pre-determination Reviewer and the Manager/Supervisor to confer about the recommendation. If their discussion results in an agreement regarding the proposed disciplinary action, the Pre-determination Reviewer finalizes the recommendation to reflect that resolution. The Pre-determination Reviewer then submits the final recommendation (along with the attachments) to the Vice President of Human Resources or his/her designee which, in turn, submits it to the Manager/Supervisor. The Manager/Supervisor then issues the final Formatted: Indent: Left: 0.38", First line: 0" Formatted: Indent: Left: 0.38", First line: 0", Numbered + Level: 1 + Numbering Style: i, ii, iii, + Start at: 1 + Alignment: Right + Aligned at: 1" + Tab after: 1.25" + Indent at: 1.25" Formatted: Indent: Left: 0.38", No bullets or numbering Formatted: Indent: Left: 0.38", First line: 0", Tab stops: Not at 0.5" " + 1.5" Formatted: Indent: Left: 0.38", No bullets or numbering

124 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 9 corrective action letter to the employee, enclosing a copy of the Predetermination Reviewer s recommendation (along with the attachments). vii. If the conference between the Pre-determination Reviewer and the Manager/Supervisor does not result in agreement, the Pre-determination Reviewer finalizes the recommendation and submits it (along with the attachments) to the Vice President of Human Resources or his/her designee who, in turn, submits it to the next level of management above the Manager/Supervisor who initiated the discipline. After reviewing the Predetermination Reviewer s recommendation, the next level of management determines whether the proposed discipline will be implemented, implemented in modified form, or revoked and communicates that decision to the Manager/Supervisor and to the Vice President of Human Resources or his/her designee. The Manager/Supervisor then prepares the final corrective action letter and issues it to the employee, enclosing a copy of the Pre-determination Reviewer s recommendation (along with the attachments).the letter will be hand delivered to the employee on the during the final meeting. If the employee refuses to attend a final meeting with their manager and the Human Resources representative, the letter mustwill be sent to the employee by certified mail, return receipt requested.. B. PAY STATUS In most cases, the employee will continue to remain on pay status until the Predetermination review process is completed and the actiondiscipline is implemented, implemented in modified form, or revoked. Formatted: Indent: Left: 0.38", First line: 0", Numbered + Level: 1 + Numbering Style: i, ii, iii, + Start at: 1 + Alignment: Right + Aligned at: 1" + Tab after: 1.25" + Indent at: 1.25", Tab stops: Not at 0.5" " + 1.5" Formatted: Indent: Left: 0.38", No bullets or numbering V. Requesting a Hearing An employee may appeal the District sreviewer s final determination of substantial actiondiscipline (demotion, suspension of more than five (5) days, termination) by submitting a written answer to the disciplinary charges with a request for appeal to the Vice President of Human Resources or his/her designee. The employee s written answer and request for appeal must be received no later than five (5) calendar days from the date of the document containing the final corrective action.reviewer s determination letter. Formatted: Indent: Left: 0.38", No bullets or numbering If an employee properly submits a written request for a hearing, it shall be scheduled no later than ten (10) working days following the date of the request by the employee. The ten (10) working day time period may be extended by the Vice President of Human Resources or his/her designee at the request of the employee or the District, upon a showing of good cause, provided that the District shall have no obligation to pay back wages beyond the ten (10) day period in the event the proposed termination, suspension of five (5) days or more or the demotion is overturned by the Hearing Officer or the CEOcommittee of the Board if the extension is at the request of the employee. The hearing shall be set for the earliest mutually agreeable date, which shall not be more than thirty (30) calendar days from the date of the request for a

125 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 10 hearing was received. The hearing shall be an informal evidentiary hearing attended by the Vice President of Human Resources or his/her designee and by the employee. The hearing shall be presided over by the Personnel Hearing Officer (who serves by appointment of the Board of Directors), or by a Hearing Officer chosen from a panel pre-approved by the District s Board of Directors and mutually agreed upon by the parties or, in the absence of the Personnel Hearing Officer, by the Chief Executive Officer of the District sitting as a Hearing Officer. At the hearing, both the District and the employee shall have the right to counsel, the right to call and examine witnesses for or against either party, the right to offer appropriate documentary evidence, the right to a reasonable continuance upon a showing of good cause, and all other procedural due process rights applicable to administrative proceedings. Strict rules of evidence shall not apply and the Hearing Officer shall have the discretion to determine what evidence shall be admitted and what weight shall be given to the admitted evidence. At all proceedings before the Hearing Officer, the District shall provide, at the expense of the District, the services of a certified shorthand reporter. The District shall have the burden of going forward and producing by a preponderance of the evidence that the termination, suspension for more than five (5) days or demotion was for good cause. At the conclusion of the hearing the matter will be submitted to the Hearing Officer for decision. Formatted: Indent: Left: 0.38" The decision of the Hearing Officer shall be in writing and ordinarily shall be rendered no later than five (5) calendar days from submission of the matter for decision. The decision of the Hearing Officer shall be filed with the Vice President of Human Resources or his/her designee who shall promptly serve a copy of the decision on the employee or his/her counsel, if any. The decision shall be effective immediately upon filing of the decision with the Vice President of Human Resources or designee, unless the employee properly complies with the requirements for appellate review. The decision of the Hearing Officer shall be a recommendation to the Chief Executive Officer. The Hearing Officer may recommend to uphold, overrule or modify the Action. VI. The Chief Executive Officer s Decision (Appellate Review) Appellate Review The Chief Executive Officer shall review and consider the recommendation of the Hearing Officer. After reviewing the recommendation of the Hearing Officer, the Chief Executive Officer in his/her sole discretion may decide to uphold, revoke or modify the action imposed on the employee. Any party affected by the decision shall have the right to appellate a review of the Chief Executive Officer before the designated committee of the Board of Directors of the District. Written notice of appeal must be filed with the Vice President of Human Resources or his/her designee no later than three (3) calendar days following service of the decision on the party requesting the appeal. Failure to file written notice of appeal within said three (3) calendar day time limit shall constitute a waiver of appeal rights. The Chief Executive Officer shall review

126 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 11 and consider the recommendation of the Hearing Officer. After reviewing the recommendation of the Hearing Officer, the Chief Executive Officer in his/her sole discretion may decide to uphold, revoke or modify the action imposed on the employee. Any party seeking the Chief Executive Officer appellate review of the decision must obtain, at the appellant's own expense, one original and two copies of a transcript of the proceedings held before the Hearing Officer. Failure to file such transcripts with the Vice President of Human Resources or his/her designee at least two (2) working days prior to the date set for appellate appellate review shall constitute a waiver of the appeal. The appellate review before the Chief Executive Officer designated committee of the Board of Directors shall be scheduled no later than ten (10) calendar days following the date of the receipt by the Vice President of Human Resources or his/her designee of the request for appellate review, or as soon thereafter as it can be scheduled taking into consideration the availability of the Chief Executive Officer committee members and/or the transcript of the hearing. The Chief Executive Officer members of the designated committee shall apply the independent judgment test in reviewing the decision of the Hearing Officer. The opposing party shall have five (5) working days to prepare and file a written response to the appeal. The Personnel Chief Executive OfficerCommittee, at its discretion, may determine whether or not it would like to receive any additional oral or written argument. The committee Chief Executive Officer shall not be empowered to receive new or additional evidence. Formatted: Indent: Left: 0.38" Formatted: Indent: Left: 0.38" The designated Chief Executive Officercommittee shall affirm, modify, or reverse the decision of the Hearing Officer, and shall file with the Vice President of Human Resources or his/her designee its written decision within two (2) working days following the conclusion of the appellate review. A vote of both members of the two-member designated committee shall be required to reverse or modify the decision of the Hearing Officer. The vote of at least one member of the two-member committee in favor of the decision of the Hearing Officer shall constitute affirmation of the decision. The decision of the Chief Executive Officerdesignated committee shall become effective immediately upon filing the decision with the Vice President of Human Resources or his/her designee. The decision of the Chief Executive Officercommittee shall constitute the final administrative proceeding which must be exhausted by either party before seeking judicial review, if any. Service of any notice, decision, or any other matter required to be served under these provisions shall be deemed served on the same day it is personally served upon the party to be served, or on the third (3rd) calendar day following deposit in the United States mail of the material to be served, certified mail, Formatted: Indent: Left: 0.38"

127 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 12 return receipt requested, addressed to the last known address of the party to be served. This policy shall not extend to employees during their initial introductory period (i.e., less than six months of employment). Formatted: Indent: Left: 0.38"

128 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 13 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

129 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 14 ATTACHMENT A Seven Tests of Just Cause - guidelines to be applied to the facts of each case Reasonable Policy. Is the policy or standard reasonably related to the orderly, efficient, and safe operation of the business? Is the policy or procedure straightforward and stated in language that is easy to understand? Have you been consistent and unbiased in applying the policy? Is it applied consistently throughout your department? What is your department's discipline record for violation of this policy or standard? Notice. Did the employee receive adequate notice of the policy or performance standard and the possible consequences of failure to comply? Is the violated policy or performance standard published? Is it up to date and relevant to the business needs of your unit? The District? How was the employee made aware of it (bulletin board, desk manual, staff meeting notes, prior oral or written communication, employee's job description card, written standards)? What evidence do you have that the employee is aware of it, and understands it (new employee orientation, signature on an acknowledgement slip)? Has this issue been raised in performance appraisals or previous disciplinary actions? If so, how recently? If so, how is it documented? Have you reviewed the employee's personnel file? Prior notice may not be necessary in cases of serious misconduct such as theft, insubordination, or job abandonment. Sufficient Investigation. Did you conduct an investigation before making a decision about taking disciplinary action? Why do you suspect that a policy violation or performance discrepancy occurred? Can the employee perform the task? Is there a history of successful performance, or could the employee need additional training? Are there witnesses other than you? List others who may have knowledge of the issue through involvement or as witnesses (supervisors, employees, clients). The employee should also be interviewed. Interview the witnesses and take notes. Be sure to include the date of the interview on the interview notes. Formatted: Indent: Left: 2", First line: 0.5" Formatted: Normal, Level 1, Indent: Left: 2", First line: 0.5", Space Before: 0 pt, After: 0 pt, Line spacing: At least 15.6 pt, No bullets or numbering

130 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 15 Are there written records pertinent to the case in your department or elsewhere? Should in-house records be secured under lock and key during the investigation? Are there written processes or procedures which have a bearing on the case? Is there equipment that should be examined? Do you need to call Compliance, Risk Management or Security? If you suspect misappropriation of District resources, you should immediately contact your Employee Relations Consultant. Your own investigation will proceed, but other departments may provide information which becomes part of your evidence. Fair Investigation. Was your investigation fair and objective? How long ago did the alleged infraction occur? (Unnecessary delays may send a message that you don't consider the infraction to be serious.) If you think you already know what happened, have you looked only for evidence to support your theory? Should you conduct the investigation, or are you too close to what happened to be objective? Should the employee remain on the work site during the investigation or put on administrative leave? (Do you fear sabotage, or is the employee a threat to others?) Have you made every effort to reconcile conflicting statements or other conflicting evidence? Are you prepared to discard what you cannot validate? Have you given the employee a chance to tell his/her side of the story and respond to the evidence you have gathered? Proof. During your investigation, did you find proof of misconduct or of a performance discrepancy? What conclusions are clearly supported by the evidence you gathered? Remember that evidence must be truly credible and substantial, not flimsy or slight, to form a basis for taking disciplinary action. Equal Treatment. Have you dealt with your employees equally, without discrimination? Are policies and standards applied consistently? Are all employees held accountable for the performance standards established for their positions? Have similarly situated employees (similar records and infractions) received the same discipline?

131 Notification Requirements and Appeal Process for Involuntary Termination and Demotion 16 What is your department's record for taking disciplinary action for this type of infraction? (Explore this with your Employee Relations Consultant.) Appropriate Discipline. How do you decide what's appropriate? Does the punishment fit the crime Is the discipline you propose to take reasonably related to the seriousness of the problem? (Did the violation pose serious safety problems or create work flow disruptions for the department?) Consider mitigating, extenuating or aggravating circumstances. Is it reasonably related to the employee's record (length of service and overall performance)? Is this violation part of a pattern? Has the employee received previous discipline? If so, what level and what was documented? Do you have the authorization to take this action, or should you have it reviewed by the next level of management? A minor infraction does not merit harsh discipline unless it is a repeat occurrence by the employee. Given the same violation for two or more employees, their respective records of service provide the only basis for administering different disciplinary actions without being subject to a charge of discrimination.

132 Manual Name: Employee Health Date: 6/5/18 Support Staff Name: Routed To: Approved By: Department Director Gloria Simoneti Medical Director N/A Medical Staff Department N/A Pharmacy & Therapeutics N/A Medical Executive Committee N/A Board of Directors Policy/Procedure Title # Status (New, Revised, Reviewed w/no Revision, Deleted) Name and Phone # of person who write the new policy or revised an existing policy Hepatitis A Exposure EH 10 Revised Sarah Amend, RN #2794 Influenza Prevention and Immunization EH 05 Revised Sarah Amend RN #2794

133 Employee Health Policy Number: EH 10 Date Created: No Date Set Document Owner: Sarah Amend (RN-Employee Date Approved: Not Approved Yet Health Nurse) Approvers: Board of Directors (Administration) Hepatitis A Exposure Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: It is the policy of Kaweah Delta Health Care District to control Hepatitis A infections through appropriate follow-up and prophylaxis of staff members. PROCEDURE: I. DEFINITION Hepatitis A is an infectious disease caused by the Hepatitis A Virus. It is an acute disease with gastrointestinal symptoms and is most often accompanied by jaundice. II. TRANSMISSION Transmission occurs through fecal-oral exposure to excretions from an individual infected with Hepatitis A. Incubation period is from fifteen to fifty days, average days. III. OCCUPATIONAL EXPOSURE If a staff member has had direct fecal-oral exposure to excretions from a patient/child found to have been incubating Hepatitis A, Employee Health shall consult with the Medical Director and Infection Prevention Doctor to determine if prophylaxis is needed. V. PROCEDURE FOR MANAGEMENT OF NON WORK-RELATED EXPOSURE Any staff member who has had close contact with a person with Hepatitis A shall notify Employee Health Service as soon as possible. If it is determined that treatment is recommended the staff member will be referred to their physician or the Tulare County Health Department. REFERENCES:

134 Hepatitis A Exposure 2 CDC. Prevention of Hepatitis A Through Active or Passive Immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006: 56 (No. RR-4). The Advisory Committee on Immunization Practices (ACIP) Adult Immunization Schedules United States, 2014 Rezents, KJ; Foster, RB; & Goldstein, MD. The As, Bs, Cs, Ds, & Es of Hepatitis. AAOHN Journal, April 1998, Vol. 46, No. 4. p. 207.

135 Employee Health Policy Number: EHS 05 Date Created: No Date Set Document Owner: Sarah Amend (RN-Employee Date Approved: Not Approved Yet Health Nurse) Approvers: Board of Directors (Administration), Cindy Moccio (Board Clerk/Exec Assist-CEO) Influenza Prevention and Immunization Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: All KDHCD health care personnel are required to receive the seasonal influenza vaccine and disease prevention education annually. This mandatory requirement is a condition of employment. KDHCD recognizes a limited number of clearly defined exemptions from this policy. Definitions: Influenza: An acute viral upper respiratory illness which is characterized by nasal congestion, fever, cough, headache, myalgia, coryza, sore throat, and malaise. Transmission is by droplet spread or hand to mouth contact with respiratory secretions of an infected person. Incubation period is short, usually 1-3 days. Influenza vaccine: The seasonal vaccine product licensed for use and manufactured in accordance with the Advisory Committee on Immunization Practices (ACIP) recommendations for the strains selected for a given season. The vaccine procured will be subject to availability. Manufacturing and supplier constraints may cause this policy to be altered or amended as required during unforeseen disruptions of supply. Health Care Personnel (HCP): All KDHCD employees, medical staff, volunteers, contracted personnel, registered vendors, students from training programs using our facilities for clinical instruction, and licensed independent practitioners affiliated with KDHCD. Licensed independent practitioners (LIP s): Physicians (MD, DO) and midlevel providers who are affiliated with the healthcare facility, but are not directly employed by it. Procedure: 1. The Influenza Prevention & Immunization Program is coordinated by Employee Health Services. 2. All KDHCD employees, volunteers and physicians will be offered the seasonal influenza vaccine, free of charge. 3. All vaccinated Health Care Personnel will be provided and wear a designation on their badge, indicating that they have received a current influenza vaccination.

136 Influenza Prevention and Immunization 2 4. New employees who begin during the Influenza season must be vaccinated at the time of their post-offer physical, present documentation of current seasonal vaccine or submit an exemption application prior to starting work. 5. The scheduled annual influenza timeframe begins November 1 and ends March 31 st unless otherwise determined by the Infection Prevention Team and/or Public Health Officer. 6. In limited circumstances, a seasonal influenza vaccination exemption will be permitted for either medical contraindication or religious/philosophical beliefs. Healthcare Personnel (HCP) who wish to apply for a medical or religious/philosophical exemption to the annual influenza vaccine must submit an exemption application form by November 1st each year. Exemption application forms are available in Employee Health. 7. Individuals who are vaccinated through services other than Employee Health Services (i.e. private physician offices, public clinics, other hospitals) are to provide written proof of current vaccination to Employee Health Services before November 1st. 8. Contracted personnel and vendors will be required to show proof of vaccination in the vendor management system. Students must provide proof of current vaccination through their program. Volunteers, vendors and contracted personnel who are unwilling to take the vaccine will not be allowed on Kaweah Delta Health Care District premises during the influenza season. 9. Healthcare Personnel (HCP) who have been granted an exemption and do not receive the current influenza vaccination, must take other precautions, including wearing a mask during the defined influenza season. A. The mask must be worn upon entering patient care areas and the HCP s work area during all working hours, except during meal breaks, and may be removed once the individual exits the work area at the end of the shift. B. The mask shall be disposed of in the regular trash once removed and shall not be worn around the neck or other part of body once used. A new mask must be applied upon return to the defined work area and if the mask becomes soiled or damp during normal wear. The same mask should not be worn for the entire 8-12 hour shift. C. Department managers, supervisors, team leaders and house supervisors will be responsible for monitoring and enforcing compliance with the masking requirement for non-vaccinated HCP s. 10. Any employee who refuses available seasonal influenza vaccine and does not have an approved exemption by November 1 st of each year will be subject to disciplinary action up to and including termination. 11. Influenza outbreak will be identified by Tulare County Health Officer and/or Daniel Boken, M.D. of Infection Control. EXEMPTIONS: Consideration for exemption from receiving the influenza vaccine will be given to: A. Individuals with documented contraindications to receiving the influenza

137 Influenza Prevention and Immunization 3 vaccine due to allergies to components, previous severe adverse reactions, history of an episode of Guillain-Barre syndrome within 6 weeks of a past influenza vaccination, and/or other medical condition verified by a healthcare provider. B. Individuals may request an exemption from the mandatory vaccination as an accommodation to a sincerely held religious or philosophical belief or practice. HCP who wish to apply for a medical or religious/philosophical exemption to the annual influenza vaccine must obtain an exemption application form from Employee Health Services and submit completed form to Employee Health by November 1st. PROCEDURES: Education: Each year Employee Health Services and Infection Prevention will determine the method and content of the education. Current Vaccine Information Sheet (VIS) from the Center for Disease Control and Prevention (CDC) will be provided for review prior to vaccination. Illness: Health Care Personnel who have symptoms of febrile respiratory tract infection suggestive of influenza will be removed from duties regardless of vaccine status. e.g. temperature of 100 or greater and respiratory symptoms. A. An employee who is afebrile with symptoms of respiratory tract infection will be evaluated by their manager and may work but must follow strict respiratory hygiene precautions while at work regardless of vaccine status. B. Employees with acute influenza are encouraged to see their primary care physicians within 24 hours of onset to consider using antiviral treatment. Vaccinations: Seasonal influenza vaccination campaign will begin once sufficient vaccine supplies are available (usually September or October). All KDHCD employees, volunteers and medical staff will be offered the seasonal influenza vaccine free of charge. In the event of a vaccine shortage, immunization will be prioritized by risk group. Badge Indicator, indicating a current influenza vaccination, must be worn at all times while in KDHCD facilities or performing KDHCD services by vaccinated HCP s. 1) Badge indicator will be obtained from Employee Health Services upon verification of vaccination status. 2) An initial influenza badge designation will be provided free of charge to vaccinated HCP. 3) Badge Indicator must be visible. HCP s not displaying the designated badge indicator will be required to take all other influenza precautions, including wearing a mask during the defined influenza season. Consent: 1) Flu consent form must be signed prior to receiving the flu vaccine.

138 Influenza Prevention and Immunization 4 2) HCP receiving seasonal influenza vaccine at KDHCD Employee Health Services will receive a document that confirms receipt of the vaccine upon request. Contraindications: 1) Hypersensitivity to any component of the vaccine. 2) Other contraindications as listed in the manufacturer s information. Immunization will be delayed due to the following: Acute febrile illness until temporary symptoms and/or signs have abated. Dosage and administration: References: 1) Dosage and the administration of the influenza vaccine will be given per Manufacturer s instructions, Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control (CDC) guidelines. Note: Pregnant and lactating women must provide a private physician note prior to vaccination if the influenza vaccine supply is not pregnancy category A. Benenson, AS. Control of Communicable Diseases in Man, 16th ed. APHA p Centers for Disease Control and Prevention, Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009, MMWR, 58 (2009) Centers for Disease Control and Prevention, Influenza vaccination of health-care personnel, MMWR, 55 (2006) Centers for Disease Control and Prevention, Interventions to increase influenza vaccination of health-care workers- California and Minnesota, MMWR, 54(08) (2005) Joint Commission on Accreditation of Healthcare Organizations, New infection control requirement for offering influenza vaccination to staff and licensed independent practitioners, Joint Commission Perspectives, 26 (2006) National Quality Forum. National Voluntary Consensus Standards for Influenza and Pneumococcal Immunizations. s_standards_for_influenza_and_pneumococcal_immunizations.aspx Washington DC, National Quality Forum "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

139 Memorandum ATTORNEY-CLIENT PRIVILEGE TO: FROM: Medical Executive Committee; Teresa Boyce Glenda M. Zarbock, Esq. DATE: May 16, 2018 RE: Proposed Revisions to Medical Staff Bylaws This memo summarizes the main substantive revisions being proposed to the Medical Staff governance documents. One significant change is the consolidation of the four governance documents (Medical Staff Bylaws, Credentials Policy, Medical Staff Organizational Manual, and Advanced Practice Provider Policy) into one document called the Medical Staff Bylaws. All the proposed revisions are reflected in "tracked changes" in the attached document. Article 1: General 1.A The categories assigned to Advanced Practice Providers (I III) have been eliminated as unnecessary. Article 2: Membership 2.A.1 Eliminates the eligibility criteria that precluded an application from anyone who ever had their medical staff membership or privileges denied, revoked, or terminated or who had resigned or relinquished privileges during an investigation or in exchange for not conducting an investigation. Such individuals may apply, but remain subject to the requirements to provide all requested information. Completed applications from such individuals who meet all other threshold eligibility criteria will be entitled to credentialing consideration. Also, as to initial applicants who are not board certified at the time of application, amends the timeframe in which they must achieve board certification from "five years from the date of completion of their residency or fellowship training" to "within the timeframe determined by the certifying board." Retains the ability to request additional time up to two years to obtain certification or recertification under exceptional circumstances. 2.A.2 Streamlines the process for evaluating requests for waiver of threshold eligibility criteria of medical staff membership. 2.B.1 Removes ambiguity regarding the types of occurrences that must be reported to the Medical Staff Services Department and sets a 14-day timeframe for doing so. Hanson Bridgett LLP 425 Market Street, 26th Floor, San Francisco, CA

140 ATTORNEY-CLIENT PRIVILEGE Memorandum To: Medical Executive Committee; Teresa Boyce May 16, 2018 Page 2 Clarifies that if a medical staff member is asked by two Medical Staff leaders to submit to a physical, mental or behavioral evaluation because of concerns about the individual's ability to provide safe patient care, the member bears the cost of the evaluation and/or testing. This does not change the existing Medical Staff policy that states the Medical Staff will pay up to $5,000 per member for required fit for duty examinations. Eliminates the provision allowing the Medical Staff to stop processing an application if a misstatement or omission is identified and denying the applicant any procedural rights. This revision was proposed because of concerns about its legality and potential for depriving applicants of fair hearing rights. Adds a provision specifying that the failure to comply with the basic responsibilities of medical staff membership may result in disciplinary action. 2.B.2 Eliminates provision preventing an applicant whose application was deemed withdrawn due to incompleteness from reapplying for 2-years. 2.C.1 Due to a conflict with the Business & Professions Code, eliminates the provision requiring an individual who unsuccessfully sues the District over a credentialing or peer review matter to reimburse the District for its defense costs and attorneys' fees. Article 5: Clinical Privileges 5.F Inserts a provision addressing the exercise of clinical privileges in departments that are subject to exclusive contracts. Specifically, for an individual to exercise clinical privileges in such a department, he or she must be affiliated with the contracted group. If that affiliation ends, the individual will be deemed to have voluntarily resigned from the medical staff and relinquished privileges with no right to a hearing, unless the individual holds privileges beyond those encompassed by the exclusive contract. Article 6: Procedure for Reappointment 6.A.5 Eliminates the requirement that the Credentials Committee and/or MEC must meet with a member before making a recommendation for conditional reappointment. 6.A.6 Eliminates the requirement that the Credentials Committee and/or MEC must meet with a member before making a recommendation to deny reappointment or reduce clinical privileges. Article 7: Advanced Practice Providers Replaces the Advanced Practice Provider (APP) Policy with a shortened article that provides that the privileging, credentialing, and peer review functions and the automatic suspension provisions applicable to APPs mirror the provisions applicable to Medical Staff members. Retains the substance of the provisions regarding Supervising Physician responsibilities and requirements. Provides for streamlined process for APPs to appeal adverse privileging decisions, consistent with California law. Further

141 ATTORNEY-CLIENT PRIVILEGE Memorandum To: Medical Executive Committee; Teresa Boyce May 16, 2018 Page 3 details regarding the practice of APPs within the District will be set forth in Medical Staff policies. Article 8: Peer Review Procedures 8.E.2 Removes criminal charge or indictment as grounds for automatic suspension of privileges (while retaining convictions and pleas of no contest or guilty for specified crimes). Clarifies that the failure to timely comply with health screening requirements is grounds for automatic suspension of privileges. Eliminates automatic suspension for failure to satisfy "any" threshold eligibility criteria for membership. 8.E.3 Clarifies when a member's failure to provide requested information will result in automatic suspension. 8.E.6 Adds a provision entitling a member whose privileges are automatically suspended or deemed to be voluntarily relinquished for specified reasons to request a meeting with the Medical Executive Committee before the decision is forwarded to the Board for final action. 8.F Requires that an individual seeking reinstatement from a leave of absence submit a written request along with specified information 30 days before the end of the leave (to afford time the department chair and Chief of Staff to review the request). Article 9: Hearing and Appeal Procedures Numerous revisions have been made to conform the procedural requirements to California's peer review statute, Business and Professions Code section 809 et seq. Other substantive revisions are described below. 9.B.4 Removes the provision allowing lay persons to serve on hearing panels. Adds a provision allowing for appointment of alternates to hearing panels and clarifying that alternates may participate in deliberations, even if they are unable to vote. 9.C.7 Eliminates the right of parties to submit pre-hearing statements to the hearing panel (to streamline the hearing process). 9.D.5 Eliminates the Chief Executive Officer's attendance at peer review hearings. 9.E.2 Clarifies the scope of the hearing panel's authority, which is to accept or reject the Medical Executive Committee's recommendation (and not to modify the recommendation)

142 ATTORNEY-CLIENT PRIVILEGE Memorandum To: Medical Executive Committee; Teresa Boyce May 16, 2018 Page 4 9.F4 Removes the provision allowing lay persons not affiliated with the District to serve on appellate review panels. Adds further details about the available grounds for appellate review of a hearing panel's decision and the process for appellate review. 9.G.1 Eliminates the provision allowing for challenges to the substance of a Medical Staff Bylaw, Rule, or policy to be proper as grounds for an appeal. Article 12: Medical Staff Committees 12.E.1 As to composition of the MEC: removes the CIO, changes the Medical Director of Quality and Patient Safety to ex officio status without a vote, and adds Chief Operating Officer as an ex officio member without a vote. 12.H Removes Bioethics Committee as a Medical Staff Committee. It will be run as a hospital committee. 12.M Adds Advanced Practice Providers as members of the Interdisciplinary Practice Committee (in addition to physicians and registered nurses). 12.O.1 Adds an Advanced Practice Provider, recommended by the CNO and appointed by the Chief of Staff, to serve as a voting member of the Peer Review Committee. 12.Q.1 Modifies the composition of the Professional Staff Quality Committee by removing the Credentials Committee Chair and the Peer Review Committee Chair as voting members and adding the Director of Clinical and Nursing Services as a voting member. Removes the Immediate Past Chief of Staff and KDHCD Board Member as non-voting members. 12.S.1 Adds to the composition of the Well-Being Committee the most recent five Immediate Past Chiefs of Staff who no longer serve on the MEC, and one voting member over the age of 70, when possible. Article 17: Amendments 17.A Removes the requirement that amendments to the bylaws must be voted on by at least 20% of the voting staff. 17.C Adds a provision addressing the process for managing conflicts between the Medical Executive Committee and the Medical Staff. 17.D Adds a provision detailing the voting procedure for bylaws amendments

143 ATTORNEY-CLIENT PRIVILEGE Memorandum To: Medical Executive Committee; Teresa Boyce May 16, 2018 Page 5 I would be happy to participate in the Medical Executive Committee meeting at which the proposed revisions will be considered so that I can assist in fielding questions about the proposed revisions

144 KAWEAH DELTA HEALTH CARE DISTRICT MEDICAL STAFF BYLAWS Adopted by the Medical Staff:, 2018 Approved by the Board of Directors:,

145 TABLE OF CONTENTS Page ARTICLE 1 GENERAL A. DEFINITIONS B. DELEGATION OF FUNCTIONS C. MEDICAL STAFF MEMBERSHIP/PRIVILEGING FEES...4 ARTICLE 2 MEDICAL STAFF MEMBERSHIP A. QUALIFICATIONS A.1 Threshold Eligibility Criteria: A.2 Waiver of Threshold Eligibility Criteria: A.3 Factors for Evaluation: A.4 No Entitlement to Appointment: A.5 Nondiscrimination: B. GENERAL CONDITIONS OF APPOINTMENT AND REAPPOINTMENT B.1 Basic Responsibilities and Requirements: B.2 Burden of Providing Information: C. APPLICATION C.1 Information: C.2 Grant of Immunity and Authorization to Obtain/Release Information:...15 ARTICLE 3 CATEGORIES OF THE MEDICAL STAFF A. ACTIVE STAFF A.1 Qualifications: A.2 Prerogatives: A.3 Responsibilities: B. COURTESY STAFF B.1 Qualifications: B.2 Prerogatives and Responsibilities: C. CONSULTING STAFF...20 i

146 3.C.1 Qualifications: C.2 Prerogatives and Responsibilities: D. COMMUNITY AFFILIATE STAFF D.1 Qualifications: D.2 Prerogatives and Responsibilities: E. HONORARY/ADMINISTRATIVE STAFF E.1 Qualifications: E.2 Prerogatives and Responsibilities:...23 ARTICLE 4 PROCEDURE FOR INITIAL APPOINTMENT A. PROCEDURE FOR INITIAL APPOINTMENT A.1 Application: A.2 Initial Review of Application: A.3 Steps to Be Followed for All Initial Applicants: A.4 Department Chair Procedure: A.5 Credentials Committee Procedure: A.6 MEC Recommendation: A.7 Board Action: A.8 Time Periods for Processing: B. FOCUSED PROFESSIONAL PRACTICE EVALUATION FOR INITIAL PRIVILEGES...27 ARTICLE 5 CLINICAL PRIVILEGES A. CLINICAL PRIVILEGES A.1 General: A.2 Privilege Modifications and Waivers: A.3 Clinical Privileges for New Procedures: A.4 Clinical Privileges That Cross Specialty Lines: A.5 Clinical Privileges for Dentists and Oral and Maxillofacial Surgeons: A.6 Physicians in Training: A.7 Telemedicine Privileges: B. TEMPORARY CLINICAL PRIVILEGES B.1 Eligibility to Request Temporary Clinical Privileges: B.2 Supervision Requirements: B.3 Withdrawal of Temporary Clinical Privileges:...40 ii

147 5.C. EMERGENCY SITUATIONS D. DISASTER PRIVILEGES E. CONTRACTS FOR SERVICES F. PRACTITIONERS IN DEPARTMENTS SUBJECT TO EXCLUSIVE CONTRACTS...43 ARTICLE 6 PROCEDURE FOR REAPPOINTMENT A. PROCEDURE FOR REAPPOINTMENT A.1 Eligibility for Reappointment: A.2 Factors for Evaluation: A.3 Reappointment Application: A.4 Processing Applications for Reappointment: A.5 Conditional Reappointments: A.6 Time Periods for Processing:...48 ARTICLE 7 ADVANCED PRACTICE PROVIDERS A. CATEGORIES B. PRIVILEGES AND RESPONSIBILITIES C. SUPERVISION REQUIREMENTS D. RESPONSIBILITIES OF SUPERVISING PHYSICIAN E. PEER REVIEW PROCEDURES F. AUTOMATIC SUSPENSION G. ADMINISTRATIVE SUSPENSION H. PROCEDURAL RIGHTS OF ADVANCED PRACTICE PROVIDERS...51 ARTICLE 8 8.A. PEER REVIEW PROCEDURES FOR QUESTIONS INVOLVING MEDICAL STAFF MEMBERS...53 COLLEGIAL INTERVENTION B. ONGOING AND FOCUSED PROFESSIONAL PRACTICE EVALUATIONS C. INVESTIGATIONS C.1 Initial Review:...54 iii

148 8.C.2 Initiation of Investigation: C.3 Investigative Procedure: C.4 Recommendation: D. SUMMARY SUSPENSION OR RESTRICTION OF CLINICAL PRIVILEGES D.1 Grounds for Summary Suspension or Restriction: D.2 MEC Procedure: D.3 Care of Patients: E. AUTOMATIC SUSPENSION E.1 Failure to Complete Medical Records: E.2 Action by Government Agency or Insurer/Failure to Satisfy Threshold Criteria: E.3 Failure to Provide Requested Information: E.4 Failure to Complete or Comply with Training or Educational Requirements: E.5 Failure to Attend Special Meeting: E.6 Medical Executive Committee Deliberation F. LEAVES OF ABSENCE...64 ARTICLE 9 HEARING AND APPEAL PROCEDURES A. INITIATION OF HEARING A.1 Grounds for Hearing: A.2 Actions Not Grounds for Hearing: B. THE HEARING B.1 Notice of Recommendation: B.2 Request for Hearing: B.3 Notice of Hearing and Statement of Reasons: B.4 Hearing Panel, Presiding Officer, and Hearing Officer/Arbitrator: B.5 Counsel: C. PRE-HEARING PROCEDURES C.1 General Procedures: C.2 Time Frames: C.3 Witness List: C.4 Provision of Relevant Information: C.5 Pre-Hearing Conference: C.6 Stipulations: C.7 Provision of Information to the Hearing Panel:...75 iv

149 9.D. HEARING PROCEDURES D.1 Rights of Both Sides and the Hearing Panel at the Hearing: D.2 Record of Hearing: D.3 Failure to Appear: D.4 Presence of Hearing Panel Members: D.5 Persons to Be Present: D.6 Order of Presentation: D.7 Admissibility of Evidence: D.8 Post-Hearing Statement: D.9 Postponements and Extensions: E. HEARING CONCLUSION, DELIBERATIONS, AND DECISION E.1 Basis of Hearing Panel Decision: E.2 Deliberations and Decision of the Hearing Panel: E.3 Disposition of Hearing Panel Report: F. APPEAL PROCEDURE F.1 Time for Appeal: F.2 Grounds for Appeal: F.3 Time, Place and Notice: F.4 Appellate Review Procedure: G. BOARD ACTION G.1 Final Decision of the Board: G.2 Further Review: G.3 Right to One Hearing and One Appeal Only:...81 ARTICLE 10 OFFICERS A. DESIGNATION B. ELIGIBILITY CRITERIA C. DUTIES C.1 Chief of Staff: C.2 Vice Chief of Staff: C.3 Secretary-Treasurer: C.4 Immediate Past Chief of Staff: D. NOMINATIONS E. ELECTION...85 v

150 10.F. TERM OF OFFICE G. REMOVAL H. VACANCIES...86 ARTICLE 11 CLINICAL DEPARTMENTS A. DEPARTMENTS B. CREATION AND DISSOLUTION OF CLINICAL DEPARTMENTS AND DIVISIONS C. ASSIGNMENT TO CLINICAL DEPARTMENT D. FUNCTIONS OF CLINICAL SERVICES E. 11.F. QUALIFICATIONS OF CLINICAL DEPARTMENT CHAIRS AND VICE CHAIRS...89 APPOINTMENT AND REMOVAL OF CLINICAL DEPARTMENT CHAIRS AND VICE CHAIRS G. DUTIES OF CLINICAL DEPARTMENT CHAIRS AND VICE CHAIRS...90 ARTICLE 12 MEDICAL STAFF COMMITTEES A. MEDICAL STAFF COMMITTEES AND FUNCTIONS B. EXPECTATIONS AND REQUIREMENTS FOR COMMITTEE MEMBERSHIP C. APPOINTMENT OF COMMITTEE CHAIRS AND MEMBERS D. MEETINGS, REPORTS, AND RECOMMENDATIONS E. MEDICAL EXECUTIVE COMMITTEE E.1 Composition: E.2 Duties: E.3 Meetings: E.4 Removal: F. AD HOC DISPUTE RESOLUTION COMMITTEE ( AHDRC ) F.1 Composition: F.2 Duties: G. BYLAWS COMMITTEE...99 vi

151 12.G.1 Composition: G.2 Duties: H. CASE MANAGEMENT COMMITTEE H.1 Composition: H.2 Duties: I. CREDENTIALS COMMITTEE I.1 Composition: I.2 Duties: J. GRADUATE MEDICAL EDUCATION COMMITTEE ( GMEC ) J.1 Composition: J.2 Duties: K. HEALTH INFORMATION MANAGEMENT COMMITTEE K.1 Composition: K.2 Duties: L. INFECTION PREVENTION COMMITTEE L.1 Composition: L.2 Duties: M. INTERDISCIPLINARY PRACTICE COMMITTEE M.1 Composition: M.2 Duties: N. JOINT CONFERENCE COMMITTEE N.1 Composition: N.2 Duties: O. PEER REVIEW COMMITTEE ( PRC ) O.1 Composition: O.2 Duties: P. PHARMACY AND THERAPEUTICS COMMITTEE P.1 Composition: P.2 Duties: Q. PROFESSIONAL STAFF QUALITY COMMITTEE vii

152 12.Q.1 Composition: Q.2 Duties: R. TRAUMA COMMITTEE R.1 Composition: R.2 Duties: S. WELL-BEING COMMITTEE S.1 Composition: S.2 Duties: T. CREATION OF STANDING COMMITTEES U. SPECIAL COMMITTEES ARTICLE 13 MEETINGS A. MEDICAL STAFF YEAR B. MEDICAL STAFF MEETINGS B.1 Regular Meetings: B.2 Special Meetings: C. DEPARTMENT AND COMMITTEE MEETINGS C.1 Regular Meetings: C.2 Special Meetings: C.3 Executive Sessions: D. PROVISIONS COMMON TO ALL MEETINGS D.1 Notice of Meetings: D.2 Quorum and Voting: D.3 Agenda: D.4 Rules of Order: D.5 Minutes, Reports, and Recommendations: D.6 Confidentiality: D.7 Attendance Requirements: ARTICLE 14 CONFLICT OF INTEREST A. General Principles: B. Immediate Family Members: C. Contractual Relationship with the District: viii

153 14.D. Actual or Potential Conflict Situations: E. Guidelines for Participation in Credentialing and Professional Practice Evaluation Activities: F. Guidelines for Participation in Development of Privileging Criteria: G. Rules for Recusal: H. Other Considerations: ARTICLE 15 CONFIDENTIALITY AND PEER REVIEW PROTECTION A. CONFIDENTIALITY B. PEER REVIEW PROTECTION ARTICLE 16 INDEMNIFICATION ARTICLE 17 AMENDMENTS A. MEDICAL STAFF BYLAWS B. OTHER MEDICAL STAFF DOCUMENTS C. CONFLICT MANAGEMENT PROCESS D. VOTING PROCEDURE FOR AMENDMENTS ARTICLE 18 ADOPTION APPENDIX A HISTORY AND PHYSICAL EXAMINATIONS APPENDIX B APPROVED CATEGORIES OF ADVANCED PRACTICE PROVIDERS ix

154 ARTICLE 1 GENERAL 1.A. DEFINITIONS The following definitions apply to terms used in this Policy: ADVANCED PRACTICE PROVIDERSFESSIONALS ( APPs ) means individuals other than Medical Staff members who are authorized by law and by the District to provide patient care services within the District. All APPs are described as Category I, Category II, or Category III practitioners in the Medical Staff Bylaws documents: CATEGORY I PRACTITIONER means a Licensed Independent Practitioner, a type of Advanced Practice Provider who is permitted by law and by the District to provide patient care services without direction or supervision, within the scope of his or her license and consistent with the clinical privileges granted. Category I practitioners also include physicians who seek to exercise certain limited clinical privileges at the Hospital under the conditions set forth in the Bylaws (e.g., moonlighting residents). See Appendix A to the APP Policy. Formatted: Level 4 Alt CATEGORY II PRACTITIONER means an Advanced Practice Clinician, a type of Advanced Practice Provider who provides a medical level of care or performs surgical tasks consistent with granted clinical privileges, but who is required by law and/or the District to exercise some or all of those clinical privileges under the direction of, or in collaboration with, a Supervising Physician pursuant to a written supervision or collaborative agreement. See Appendix B to the APP Policy. CATEGORY III PRACTITIONER means a Dependent Practitioner, a type of Advanced Practice Provider who is permitted by law or the District to function only under the direction of a Supervising Physician, pursuant to a written supervision agreement and consistent with the scope of practice granted. See Appendix C to the APP Policy. BOARD means the Board of Directors of the District or its designated committee. The Board has the overall responsibility for the District. BYLAWS RELATED DOCUMENTS shall mean the Medical Staff Bylaws, the Medical Staff Credentials Policy, the Medical Staff Rules and Regulations, the Organization Manual, and the Policy on Advanced Practice Providers. CHIEF EXECUTIVE OFFICER ( CEO ) means the individual appointed by the Board to act on its behalf in the overall management of the District. CHIEF MEDICAL OFFICER ( CMO ) means the chief medical officer of the Medical Staff hired by the CEO with the approval of the Board, who serves as a liaison between the Medical Staff and administration with responsibilities as set forth in his/her job description, the Medical Staff Bylaws, and related documents. CLINICAL PRIVILEGES or PRIVILEGES means the authorization granted by the Board, upon recommendation by the Medical Executive Committee and the Credentials Committee, to

155 render specific patient care services, for which the Medical Staff Leaders and Board have developed eligibility and other credentialing criteria and focused and ongoing professional practice evaluation standards. CORE PRIVILEGES means a defined grouping of privileges for a specialty or subspecialty that includes the fundamental patient care services that are routinely taught in residency and/or fellowship training for that specialty or subspecialty and which have been determined by the Medical Staff Leaders and Board to require closely related skills and experience. DAYS means calendar days. DENTIST means a doctor of dental surgery ( D.D.S. ) or doctor of dental medicine ( D.M.D. ). DISTRICT means all Kaweah Delta Health Care District facilities. FOCUSED PROFESSIONAL PRACTICE EVALUATION ( FPPE ) means a time-limited period during which a practitioner s professional performance is evaluated. Focused Professional Practice Evaluation is used in two situations: (i) when privileges are newly granted to confirm the individual s competence to exercise them and (ii) when issues are raised about a practitioner s clinical practice. MEDICAL EXECUTIVE COMMITTEE ( MEC ) means the Executive Committee of the Medical Staff. MEDICAL STAFF means all physicians, dentists, oral surgeons, podiatrists, and clinical psychologists who have been appointed to the Medical Staff by the Board. MEDICAL STAFF LEADER means any Medical Staff officer, department chair, and committee chair. MEMBER means any physician, dentist, oral surgeon, podiatrist, and clinical psychologist who has been granted Medical Staff appointment by the Board. NOTICE means written communication by regular U.S. mail, , facsimile, hospital mail, hand delivery, or other electronic method. ONGOING PROFESSIONAL PRACTICE EVALUATION ( OPPE ) means a process of ongoing review and analysis of practitioner-specific data that helps to identify any issues or trends in practitioners performance that may impact on quality of care and patient safety. ORAL AND MAXILLOFACIAL SURGEON means an individual with a D.D.S. or a D.M.D. degree who has completed additional training in oral and maxillofacial surgery. ORGANIZED HEALTH CARE ARRANGEMENT ( OHCA ) means the term used by the HIPAA Privacy Rule thatwhich permits the District and Medical Staff to use joint notice of privacy practices information when patients are admitted to the District. Practically speaking, being part of an OHCA allows the members of the Medical Staff to rely upon the District notice

156 of privacy practices and therefore relieves Medical Staff members of their responsibility to provide a separate notice when members consult or otherwise treat District inpatients. PATIENT CONTACT includes any admission, consultation, procedure, in-person response to the emergency department, evaluation, treatment, or service performed in the District or its outpatient facilities. PERMISSION TO PRACTICE means the authorization granted to Advanced Practice Providers to exercise clinical privileges or a scope of practice. PHYSICIAN includes both doctors of medicine ( M.D.s ) and doctors of osteopathy ( D.O.s ). PODIATRIST means a doctor of podiatric medicine ( D.P.M. ). PSYCHOLOGIST means an individual with a Psy.D or Ph.D. in clinical psychology. SCOPE OF PRACTICE means the authorization granted to a Category III practitioner to perform certain clinical activities and functions under the supervision of, or in collaboration with, a Supervising Physician. A scope of practice is different from clinical privileges, which are only granted to individuals who provide a medical level of care in the District. SPECIAL NOTICE means hand delivery, certified mail (return receipt requested), or overnight delivery service providing receipt. SPECIAL PRIVILEGES means privileges that fall outside of the core privileges for a given specialty that, which require additional education, training, and/or experience beyond that required for core privileges in order to demonstrate competence. SUPERVISING PHYSICIAN means a member of the Medical Staff with clinical privileges, who has agreed in writing to supervise or collaborate with an Advanced Practice Provider Category II or Category III practitioner and to accept full responsibility for the actions of the Advanced Practice Provider Category II or Category III practitioner while he or she is practicing in the District. SUPERVISION means the supervision of (or collaboration with) an Advanced Practice Provider Category II or Category III practitioner by a Supervising Physician, that may or may not require the actual presence of the Supervising Physician, but that does require, at a minimum, that the Supervising Physician be readily available for consultation. The requisite level of supervision (general, direct, or personal) shall be determined at the time each Advanced Practice ProviderCategory II or Category III practitioner is credentialed and shall be consistent with any applicable written supervision or collaboration agreement that may exist. ( General supervision means that the physician is immediately available by phone,; direct supervision means that the physician is on the District s campus,; and personal supervision means that the physician is in the same room.) TELEMEDICINE means the exchange of medical information from one site to another via electronic communications for the purpose of providing patient care, treatment, and services

157 UNASSIGNED PATIENT means any individual who comes to the District for care and treatment who does not have an attending physician, or whose attending physician or designated alternate is unavailable to attend the patient, or who does not want the prior attending physician to provide him/her care while a patient at the District. 1.B. DELEGATION OF FUNCTIONS (1) When a function is to be carried out by a member of Medical Staff leadership, or by a Medical Staff member, the individual may delegate performance of the function to one or more designees. If a Medical Staff committee cannot act in a timely manner upon a certain task or function, the committee may delegate that particular matter or responsibility to designated individuals to fulfill the function on behalf of the committee. (2) When a Medical Staff member is unavailable or unable to perform a necessary function unrelated to the provision of direct patient care services, and such unavailability has been confirmed by a Medical Staff Leader, one or more of the Medical Staff Leaders may perform the function personally or delegate it to another appropriate individual. 1.C. MEDICAL STAFF MEMBERSHIP/PRIVILEGING FEES (1) Medical Staff membership and/or privileging fees shall be as determined by the MEC and may vary by category or privilege status. (2) Fees shall be payable upon request. Failure to pay fees shall result in ineligibility to apply for Medical Staff reappointment or renewal of clinical privileges. (3) Signatories to the District s Medical Staff account shall be the Chief of Staff, the Vice Chief of Staff, the Secretary-Treasurer, and the Immediate Past Chief of Staff

158 ARTICLE 2 MEDICAL STAFF MEMBERSHIP 2.A. QUALIFICATIONS 2.A.1 Threshold Eligibility Criteria: To be eligible to apply for initial appointment or reappointment to the Medical Staff, physicians, dentists, oral surgeons, podiatrists, and psychologists must: (a) (b) (c) have (or be able to provide documentation that they are in the process of obtaining) a current, unrestricted license to practice in California and have never had a license to practice revoked or suspended by any state licensing agency; where applicable to their practice, have a current, unrestricted full-schedule Drug Enforcement Agency ("DEA") registration; with reasonable and rare exceptions, be available on a continuous basis, either personally or by arranging appropriate coverage, to respond to the needs of their inpatients in a prompt, efficient, and conscientious manner. ( Appropriate coverage means coverage by another member of the Medical Staff with appropriate specialty-specific privileges as determined by the Credentials Committee.) Compliance with this eligibility requirement means that the practitioner must document that he or she is willing and able to: (1) respond within 15 minutes, via phone, to an initial STAT contact from the District and respond within 30 minutes, via phone, to all other initial modes of contact; and (2) appear in person to attend to a patient within 30 minutes of being requested to do so (or more quickly based upon (i) the acute nature of the patient s condition or (ii) as required for a particular specialty as recommended by the MEC and approved by the Board); (d) (e) (f) have (or be able to provide documentation that they are in the process of obtaining) current, valid professional liability insurance coverage in a form and in amounts satisfactory to the MEC and the Board; have never been convicted of, or entered a plea of guilty or no contest to, Medicare, Medicaid, or other federal or state governmental or private third-party payer fraud or program abuse, nor have been required to pay civil monetary penalties for the same; have never been, and are not currently, excluded or precluded from participation in Medicare, Medicaid, or other federal or state governmental health care program;

159 (g) have never had Medical Staff appointment or clinical privileges denied, revoked, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct; (h) have never resigned Medical Staff appointment or relinquished privileges during a Medical Staff investigation or in exchange for not conducting such an investigation; Formatted: Indent: Left: 1", No bullets or numbering (i)(g) have never been convicted of, or entered a plea of guilty or no contest, to any felony; or to any misdemeanor relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, child abuse, elder abuse, or violence; (j)(h) have or agree to make appropriate coverage arrangements (as determined by the Credentials Committee) with other members of the Medical Staff for those times when the individual willshall be unavailable; (k)(i) demonstrate recent clinical activity in their primary area of practice during the last two years; (l)(j) meet any current or future eligibility requirements that are applicable to the clinical privileges being sought; (m)(k) if applying for privileges in an area that is covered by an exclusive contract, meet the specific requirements set forth in that contract; (n)(l) document compliance with all applicable training and/or educational protocols that may be adopted by the MEC, including, but not limited to, those involving electronic medical records, patient safety, and infection control; (o)(m) document compliance with any health screening requirements (i.e., TB testing, mandatory flu vaccines, and infectious agent exposures); (p)(n) have successfully completed: (1) a residency training program approved by the Accreditation Council for Graduate Medical Education ( ACGME ), the American Osteopathic Association ( AOA ), Royal College of Physicians and Surgeons of Canada, or College of Family Medicine Physicians of Canada in the specialty in which the applicant seeks clinical privileges (individuals currently participating in a fellowship training program may apply to the Medical Staff and request clinical privileges in the specialty area in which they have completed residency training); (2) a dental or an oral and maxillofacial surgery training program accredited by the Commission on Dental Accreditation of the American Dental Association ( ADA );

160 (3) a podiatric surgical residency program accredited by the Council on Podiatric Medical Education of the American Podiatric Medical Association; or (4) a clinical psychology training program accredited by the American Psychological Association; (q)(o) be certified in the specialty in which the applicant seeks clinical privileges by the appropriate specialty/subspecialty board of the American Board of Medical Specialties ( ABMS ), the AOA, the American Board of Oral and Maxillofacial Surgery, the ADA, the American Board of Podiatric Surgery, or the American Psychological Association, American Board of Foot and Ankle Surgery, or American Board of Podiatric Medicine, as applicable. Those applicants who are not board certified at the time of application but who have completed their residency or fellowship training within the last five years shall be eligible for Medical Staff appointment. However, in order to remain eligible, those applicants must achieve board certification in their primary area of practice within five years from the date of completion of their residency or fellowship training; Those applicants who are not board certified at the time of application must be actively participating in the examination process leading to board certification within the timeframe determined by the certifying board. Failure to achieve board certification within the required timeframe shall constitute automatic relinquishment of Medical Staff membership and privileges;* and (r)(p) maintain board certification in their primary area of practice at the District on a continuous basis, and satisfy all requirements of the relevant specialty/subspecialty board necessary to do so (board certification status will be assessed at time of reappointment).* * This requirement shall be applicable only to those individuals who apply for initial staff appointment after March 2016the date of adoption of this Article.This requirement is not applicable to Medical Staff members appointed prior to March 2016that date. Those Medical Staff members shall be grandfathered and shall be governed by any board certification requirements that may have been in effect at the time of their initial appointments. * In exceptional circumstances, the five-year time frame for initial applicants who are not board certified and existing Medical Staff members seeking recertification may request additional time to obtain certification or recertification the time frame for recertification by existing members may be extended for one additional period, not to exceed two years, in order to permit an individual an additional opportunity to obtain certification. In order to be eligible to request an extension in these situations, an individual must, at a minimum, satisfy the following criteria: Formatted: _1.0sp Hanging 1" (1) the individual has been on the District s Medical Staff for at least three consecutive years;

161 (2) there have been no adverse actions related to the individual s competence or behavior at the District during the individual s tenure; (2)(3) the individual has not been the subject of an FPPE, formal investigation, or adverse recommendation during the individual s tenure; (3)(4) the individual provides a letter from the appropriate certifying board confirming that the individual remains eligible to take the certification examination within the next two years; (4)(5) the appropriate department chair at the District provides a favorable report concerning the individual s qualifications; and (5)(6) the individual provides at least two letters of support from other members of the Medical Staff who are in good standing, who are not in the same specialty as the individual, and who have had direct experience in observing and working with the individual. 2.A.2 Waiver of Threshold Eligibility Criteria: Insofar as is consistent with applicable laws, the Board has the discretion to deem an applicant to have satisfied a qualification, based upon the recommendation of the applicable clinical department, Credentials Committee, and the MEC, if it determines that the applicant has demonstrated he or she has substantially comparable qualifications and that this waiver is necessary to serve the best interests of the patients and of the District. There is no obligation to grant any such waiver, and applicants have no right to have a waiver considered and/or granted. An applicant who is denied a waiver or consideration of a waiver shall not be entitled to any hearing and appeal rights under these Bylaws. (a) (b) (c) Any applicant who does not satisfy one or more of the threshold eligibility criteria outlined above may request that it be waived. The applicant requesting the waiver bears the burden of demonstrating exceptional circumstances, and that his or her qualifications are equivalent to, or exceed, the criterion in question. A request for a waiver shall be submitted to the Credentials Committee for consideration. In reviewing the request for a waiver, the Credentials Committee may consider the specific qualifications of the applicant in question, input from the relevant department chair, and the best interests of the District and the communities it serves. Additionally, the Credentials Committee may, in its discretion, consider the application form and other information supplied by the applicant. The Credentials Committee s recommendation will be forwarded to the MEC. Any recommendation to grant a waiver must include the specific basis for the recommendation. The MEC shall review the recommendation of the Credentials Committee and make a recommendation to the Board regarding whether to grant or deny the

162 request for a waiver. Any recommendation to grant a waiver must include the specific basis for the recommendation. (d) If the Board acts to deny a waiver, the individual is not entitled to a hearing or an appeal. A determination that an applicant is not entitled to a waiver is not a denial of appointment or clinical privileges. Rather, that individual is ineligible to request appointment or clinical privileges. A determination of ineligibility is not a matter that is reportable to either the State of California or the National Practitioner Data Bank. (e) The granting of a waiver in a particular case does not set a precedent for any other applicant or group of applicants. (f) An application for appointment that does not satisfy an eligibility criterion will not be processed unless and until the Board has determined that a waiver willshould be granted. Formatted: Indent: Left: 0.5", No bullets or numbering Formatted: Indent: Left: 1", No bullets or numbering 2.A.3 Factors for Evaluation: The six ACGME general competencies (patient care, medical knowledge, professionalism, system-based practice, practice-based learning, and interpersonal communications) will be evaluated as part of the appointment and reappointment processes, as reflected in the following factors: (a) (b) (c) (d) (e) (f) relevant training, experience, and demonstrated current competence, including medical/clinical knowledge, technical and clinical skills, and clinical judgment, and an understanding of the contexts and systems within which care is provided; adherence to the ethics of their profession, continuous professional development, an understanding of and sensitivity to diversity, and responsible attitude toward patients and their profession; good reputation and character; ability to safely and competently perform the clinical privileges requested; ability to work harmoniously with others, including, but not limited to, interpersonal and communication skills sufficient to enable them to maintain professional relationships with patients, families, and other members of health care teams; and recognition of the importance of, and willingness to support, the District s and Medical Staff s commitment to quality care and a recognition that interpersonal skills and collegiality are essential to the provision of quality patient care

163 2.A.4 No Entitlement to Appointment: No individual is entitled to receive an application or to be appointed or reappointed to the Medical Staff or to be granted particular clinical privileges merely because he or she: (a) (b) (c) (d) (e) (f) (g) is employed by the District or its subsidiaries or has a contract with the District; is or is not a member or employee of any particular physician group; is licensed to practice a profession in this or any other state; is a member of any particular professional organization; has had in the past, or currently has, Medical Staff appointment or privileges at any hospital or health care facility; resides in the geographic service area of the District; or is affiliated with, or under contract to, any managed care plan, insurance plan, HMO, PPO, or other entity. 2.A.5 Nondiscrimination: No individual shall be denied appointment on the basis of age, gender, race, creed, national origin, citizenship status, sex, color, religion, ancestry, sexual orientation, gender identity or expression, disability that is unrelated to the ability to provide patient care, medical condition, genetic information, marital status, or registered domestic partner status, or veteran status. 2.B. GENERAL CONDITIONS OF APPOINTMENT AND REAPPOINTMENT 2.B.1 Basic Responsibilities and Requirements: As a condition of being granted appointment or reappointment, and as a condition of ongoing membership, every member specifically agrees to the following: (a) (b) (c) to provide continuous and timely quality care to all patients for whom the individual has responsibility, including effective and efficient hand-offs for safe patient care; to abide by all Bylaws, policies, and Rules and Regulations of the Medical Staff that are in force during the term ofime the individual's is appointmented; to participate in Medical Staff affairs through committee service, participation in quality improvement and professional practice evaluation activities, being encouraged to participate in graduate medical education activities and initiatives, and by performing such other reasonable duties and responsibilities as may be assigned;

164 (d) (e) (f) (g) (h) treat all providers (including, but not limited to, Medical Staff members, Advanced Practice Providers, nursing staff, medical residents) and District staff with respect; to comply with clinical practice or evidence-based protocols and pathways that are established by, and must be reported to, regulatory or accrediting agencies, or patient safety organizations, including those related to national patient safety initiatives and core measures, or clearly document the clinical reasons for variance; to comply with clinical practice or evidence-based medicine pathways or protocols, in the form of MEC-approved order sets, pertinent to his or her medical specialty, as may be adopted by the MEC, or clearly document the clinical reasons for variance; to comply with all applicable training and/or educational protocols that may be adopted by the MEC, including, but not limited to, those involving electronic medical records, patient safety, and infection control; to inform the Medical Staff Services Department, in writing, within 14 days of any of the following occurrences: change in the practitioner s status or any change in the information provided on the individual s application form. This information shall be provided with or without request, at the time the change occurs, and shall include, but not be limited to: any and all action taken regarding the practitioner's license or DEA registration or any complaints regarding, or changes in, licensure status or DEA controlled substance authorization, changes in professional liability insurance coverage, the filing of a professional liability lawsuit against the practitioner, or any final malpractice judgment or settlement; limitation, reduction, or loss of changes in the practitioner s Medical Staff membership status (appointment and/or privileges) at any other hospital or health care entity or group affiliation as a result of peer review activities, knowledge of a criminal investigation involving the member, arrest, charge, indictment, conviction, or a plea of guilty or no contest in any criminal matter other than a misdemeanor traffic citation, exclusion or restrictionspreclusion from participation in Medicare/Medicaid or any sanctions imposed, any changes in the practitioner s ability to safely and competently exercise clinical privileges or perform the duties and responsibilities of

165 appointment because of health status issues, including, but not limited to, impairment due to addiction, alcohol use, or other similar issue (all of which shall be referred for review under the Impaired Provider practitioner health ppolicy), and any charge of, or arrest for, driving while intoxicated/under the influence ( DWI ) (Any DWI incident will be reviewed by the Chief of Staff and the CMO so that they may understand the circumstances surrounding it. If they have any concerns after doing so, they will forward the matter for further review under the Impaired Provider Policypractitioner health policy or this Credentials Policy.); (i) (j) (k) (l) (m) (n) (o) (p) to immediately submit to an appropriate evaluation, which may include diagnostic testing (such as a blood and/or urine test), or to a complete physical, mental, and/or behavioral evaluation, if at least two Medical Staff Leaders (or one Medical Staff Leader and the CEOone member of the Administrative team) are concerned with the individual s ability to safely and competently care for patients. The health care professional(s) to perform the testing and/or evaluations shall be determined by the Medical Staff Leaders. and tthe Medical Staff member must execute all appropriate releases to permit the sharing of information with the Medical Staff Leaders and pay for the cost of the requested evaluation(s) and/or testing; to appear for personal or phone interviews in regard to an application for initial appointment or reappointment, if requested; to maintain a current address with the Medical Staff Services Department, which will be the primary mechanism used to communicate all Medical Staff information to the member; to provide a valid mobile phone number with texting capability in order to facilitate physician-to-physician communication, which communication shall be accomplished in a manner consistent with the District s HIPAA policies and procedures; to refrain from illegal fee splitting or other illegal inducements relating to patient referral; to refrain from delegating responsibility for hospitalized patients to any individual who is not qualified or adequately supervised; to refrain from deceiving patients as to the identity of any individual providing treatment or services; to seek consultation whenever required or necessary;

166 (q) (r) (s) (t) (u) (v) (w) (x) (y) to complete in a timely and legible manner all medical and other required records, containing all information required by the District and to utilize the electronic record as required; to cooperate with all utilization oversight activities; to participate in an Organized Health Care Arrangement with the District and to abide by the terms of the District s Notice of Privacy Practices with respect to health care delivered in the District; to perform all services and conduct himself/herself at all times in a cooperative and professional manner; to promptly pay any applicable dues, assessments and/or fines; to satisfy continuing medical education requirements; to refrain from discriminating against another member of either the Medical Staff or Advanced Practice Provider Staff on the basis of age, gender, race, creed, national origin, citizenship status, sex, color, religion, ancestry, sexual orientation, gender identity or expression, disability, medical condition, genetic information, marital status, or registered domestic partner status, or veteran status; to communicate with other Medical Staff members and District staff in a safe and effective manner; and to cooperate with the Chief of Staff, the department chair, the MEC, the CMO, and the CEO in good faith with respect to summary suspensions and restrictions.; and that, if there is any misstatement in, or omission from, the application, the District may stop processing the application, with no entitlement to any hearing or appeal rights contained in these Bylaws. If appointment has been granted prior to the discovery of a misstatement or omission, an individual s appointment and privileges may be deemed to be automatically relinquished by the MEC, with no right to a hearing or appeal pursuant to these Bylaws. The individual will be informed in writing of the nature of the misstatement or omission and permitted to provide a written response for the Credentials Committee s consideration. In the event that this provision is triggered, the individual may not reapply to the Medical Staff for a period of at least three years.the failure of any Medical Staff member to abide by any of the duties specified above shall be grounds for corrective action, including the suspension or termination of privileges and Medical Staff membership. Formatted: Tab stops: Not at 1" 2.B.2 Burden of Providing Information: (a) Individuals seeking appointment and reappointment have the burden of producing information deemed adequate by the District for a proper evaluation of current competence, character, ethics, and other qualifications and for resolving any

167 doubts about an individual s qualifications. Such information must be provided in an appropriate format that is legible and readable. The information to be produced includes such quality data and other information as may be needed to assist in an appropriate assessment of overall qualifications for appointment, reappointment, and current clinical competence for any requested clinical privileges, including, but not limited to, information from other hospitals, information from the individual s office practice, information from insurers or managed care organizations in which the individual participates, and/or receipt of confidential evaluation forms completed by referring/referred to physicians. (b) (c) (d) Individuals seeking appointment and reappointment have the burden of providing evidence that all the statements made and information given on the application are accurate and complete. An application shall be complete when all questions on the application form have been answered, all supporting documentation has been supplied, and all information has been verified from primary sources. An application shall become incomplete if the need arises for new, additional, or clarifying information at any time during the credentialing process. Any application that continues to be incomplete 4590 days after the individual has been notified of the additional information required shall be deemed to be withdrawn. If an applicant seeks to resubmit an application that was determined to have been withdrawn for nonsubstantive missing information, an additional fee of $250 shall be assessed to reinstate the process.; however, if an application was deemed to have been withdrawn on the basis that the applicant failed to provide substantive information, the individual may not reapply for a period of at least two years. Any such termination of the credentialing process shall not entitle the applicant to review or appeal pursuant to the Bylaws. The individual seeking appointment or reappointment is responsible for providing a complete application, including adequate responses from references. An incomplete application shall not be processed. 2.C. APPLICATION 2.C.1 Information: (a) (b) Applications for appointment and reappointment shall contain a request for specific clinical privileges and shall require detailed information concerning the individual s professional qualifications. The applications for initial appointment and reappointment existing now and as may be revised are incorporated by reference and made a part of this Article. In addition to other information, the applications shall seek the following: (1) information as to whether the applicant s medical staff appointment or clinical privileges have been voluntarily or involuntarily relinquished, withdrawn, denied, revoked, suspended, subjected to probationary or other

168 conditions, reduced, limited, terminated, or not renewed at any other hospital or health care facility or are currently being investigated or challenged; (2) information as to whether the applicant s license to practice any relevant profession in any state, DEA registration, or any state s controlled substance license has been voluntarily or involuntarily suspended, modified, terminated, restricted, or relinquished or is currently being investigated or challenged; (3) information concerning the applicant s professional liability litigation experience, including past and pending claims, final judgments, or settlements; the substance of the allegations as well as the findings and the ultimate disposition; and any additional information concerning such proceedings or actions as the Credentials Committee, the MEC, or the Board may request; (4) current information regarding the applicant s ability to safely and competently exercise the clinical privileges requested; and (5) a copy of a government-issued photo identification. (c) The applicant shall sign the application and certify the application is true and correct and that he or she is able to perform the privileges requested and the responsibilities of appointment. 2.C.2 Grant of Immunity and Authorization to Obtain/Release Information: By requesting an application and/or applying for appointment, reappointment, or clinical privileges, the individual expressly accepts the conditions set forth in this Section: (a) Immunity: To the fullest extent permitted by law, the individual releases from any and all liability, extends absolute immunity to, and agrees not to sue the District or the Board, any member of the Medical Staff or the Board, their authorized representatives, and third parties who provide information for any matter relating to appointment, reappointment, clinical privileges, or the individual s qualifications for the same. This immunity covers any actions, recommendations, reports, statements, communications, and/or disclosures involving the individual that are made, taken, or received by the District, its authorized agents, or third parties in the course of credentialing and peer review activities. (b) Authorization to Obtain Information from Third Parties: The individual specifically authorizes the District, Medical Staff Leaders, and their authorized representatives (1) to consult with any third party who may have information bearing on the individual s professional qualifications, credentials,

169 clinical competence, character, ability to perform safely and competently, ethics, behavior, or any other matter reasonably having a bearing on his or her qualifications for initial and continued appointment to the Medical Staff, and (2) to obtain any and all communications, reports, records, statements, documents, recommendations or disclosures of third parties that may be relevant to such questions. The individual also specifically authorizes third parties to release this information to the District and its authorized representatives upon request. Further, the individual agrees to sign necessary consent forms to permit a consumer reporting agency to conduct a criminal background check on the individual and report the results to the District. (c) Authorization to Release Information to Third Parties: The individual also authorizes District representatives to release information to other hospitals, health care facilities, managed care organizations, government regulatory and licensure boards or agencies, and their agents when information is requested in order to evaluate his or her professional qualifications for appointment, privileges, and/or participation at the requesting organization/ facility, and any licensure or regulatory matter. (d) (d) Hearing and Appeal Procedures: The individual agrees that the hearing and appeal procedures set forth in this Policy are the sole and exclusive remedy with respect to any professional review action taken by the Medical Staff or the District. Exhaustion of Remedies: (e) If adverse action is taken with respect to a practitioner's Medical Staff membership or privileges, regardless of whether the practitioner is an applicant or a Medical Staff member, the practitioner must exhaust the remedies afforded by these Bylaws before resorting to legal action challenging the action or procedures used to arrive at the action or asserting any claim against any participants in the decision-making process.legal Actions: If, despite this Section, an individual institutes legal action challenging any credentialing, privileging, peer review, or other action affecting appointment or privileges and does not prevail, he or she shall reimburse the District and any member of the Medical Staff or Board involved in the action for all costs incurred in defending such legal action, including reasonable attorney s fees and lost revenues. Formatted: _1.0sp Left Ind 1", Indent: Left: 0" Formatted: No underline Formatted: Level 4c Alt Formatted: Level 5, Indent: Left: 1" (f)(e) Scope of Section: All of the provisions in this Section 2.C.2 are applicable in the following situations: (i) whether or not appointment or clinical privileges are granted;

170 (ii) (iii) (iv) throughout the term of any appointment or reappointment period and thereafter; should appointment, reappointment, or clinical privileges be revoked, reduced, restricted, suspended, and/or otherwise affected as part of the District s professional review activities; and as applicable, to any third-party inquiries received after the individual leaves the Medical Staff about his/her tenure as a member of the Medical Staff

171 ARTICLE 3 CATEGORIES OF THE MEDICAL STAFF Only those individuals who satisfy the qualifications and conditions for appointment to the Medical Staff contained in the Bylaws are eligible to apply for appointment to one of the categories listed below. All categories, with the respective rights and obligations of each, are summarized in the chart attached as Appendix A to these Bylaws. 3.A. ACTIVE STAFF 3.A.1 Qualifications: The Active Staff shall consist of physicians, dentists, oral surgeons, podiatrists, and psychologists who: (a) (b) are involved in at least 24 patient contacts at the District (as defined in the Bylaws) per two-year appointment term; and have expressed a willingness to contribute to Medical Staff functions and/or demonstrated a commitment to the Medical Staff and District through service on District or Medical Staff committees and/or active participation in performance improvement or professional practice evaluation functions. Guidelines: Unless an Active Staff member can definitively demonstrate to the satisfaction of the Credentials Committee at the time of reappointment that his/her practice patterns have changed and that he/she will satisfy the activity requirements of this category: (a) * Any member who has fewer than 24 patient contacts during his/her twoyear appointment term shall not be eligible to request Active Staff status at the time of his/her reappointment. (b) ** The member will be transferred to another staff category that best reflects his/her relationship to the Medical Staff and the District (options Courtesy, Consulting, or Community Affiliate). Formatted: Level 5, Indent: Left: 0.5", Outline numbered + Level: 5 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.63" + Tab after: 1.13" + Indent at: 1.13", Tab stops: Formatted: Level 5, Indent: Left: 1" 3.A.2 Prerogatives: Active Staff members may: (a) (b) admit patients without limitation, except as otherwise provided in the Bylaws, Rules and Regulations, or policies or Bylaws-related documents; attend and vote inat all general and special meetings of the Medical Staff and applicable department, division, and committee meetings;

172 (c) (d) hold office, serve as department chairs and division chairs, serve on Medical Staff committees, and serve as chairs of committees; and exercise such clinical privileges as are granted to them. 3.A.3 Responsibilities: Active Staff members must assume all the responsibilities of membership on the Active Staff, including: (a) (b) serving on committees, as requested; participating in the evaluation of new members of the Medical Staff; (c) participating in the professional practice evaluation and performance improvement processes (including constructive participation in the development of clinical practice protocols and guidelines pertinent to their medical specialties); (d) (e) (f) accepting inpatient consultations, when requested by another member of the Medical Staff; paying application fees, dues, and assessments; and performing assigned duties. 3.B. COURTESY STAFF 3.B.1 Qualifications: The Courtesy Staff shall consist of physicians, dentists, oral surgeons, podiatrists, and psychologists who: (a) (b) (c) are involved in a minimum of six, but fewer than 24, patient contacts at the District (as defined in the Bylaws) per two-year appointment term; meet all the same threshold eligibility criteria as other Medical Staff members, including specifically those relating to availability and response times with respect to the care of their patients; and at each reappointment time, provide such quality data and other information as may be requested to assist in an appropriate assessment of current clinical competence and overall qualifications for appointment and clinical privileges (including, but not limited to, information from another hospital, information from the individual s office practice, information from insurers or managed care organizations in which the individual participates, and/or receipt of confidential evaluation forms completed by referring/referred to physicians). Guidelines:

173 Unless a Courtesy Staff member can definitively demonstrate to the satisfaction of the Credentials Committee at the time of reappointment that his/her practice patterns have changed and that he/she will satisfy the activity requirements of this category: (a) * Any member who has fewer than six patient contacts during his/her twoyear appointment term shall be transferred to another staff category that best reflects his/her relationship to the Medical Staff and the District (options Consulting or Community Affiliate). (b) ** Any member who has more than 24 patient contacts during his/her twoyear appointment term will be transferred to Active Staff status. Formatted: Level 5, Indent: Left: 0.5", Outline numbered + Level: 5 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 0.63" + Tab after: 1.13" + Indent at: 1.13", Tab stops: Formatted: Level 5, Indent: Left: 1" 3.B.2 Prerogatives and Responsibilities: Courtesy Staff members: (a) (b) (c) (d) (e) (f) may attend and participate in Medical Staff, department, and division meetings (without vote); may not hold office or serve as department chairs, division chairs, or committee chairs (unless waived by the MEC); may be invited to serve on committees (with vote); shall cooperate in the professional practice evaluation and performance improvement processes; shall exercise such clinical privileges as are granted to them; and shall pay application fees, dues, and assessments. 3.C. CONSULTING STAFF 3.C.1 Qualifications: The Consulting Staff shall consist of physicians, dentists, oral surgeons, podiatrists, and psychologists who: (a) (b) are of demonstrated professional ability and expertise who provide a service not otherwise available or in very limited supply on the Active Staff (should the service become readily available on the Active Staff, the Consulting Staff members would not be eligible to request continued Consulting Staff status at the time of their next reappointments and would have to move to a different staff category if they desire continued appointment); provide services at the District only at the request of other members of the Medical Staff; and

174 (c) at each reappointment time, provide such quality data and other information as may be requested to assist in an appropriate assessment of current clinical competence and overall qualifications for appointment and clinical privileges (including, but not limited to, information from another hospital, information from the individual s office practice, information from insurers or managed care organizations in which the individual participates, and/or receipt of confidential evaluation forms completed by referring/referred to physicians). 3.C.2 Prerogatives and Responsibilities: Consulting Staff members: (a) (b) (c) (d) (e) may exercise such clinical privileges as are granted to them to evaluate and treat patients in conjunction with other members of the Medical Staff; may not hold office or serve as department chairs, division chairs, or committee chairs (unless waived by the MEC); may attend meetings of the Medical Staff and applicable department and division meetings (without vote) and applicable committee meetings (with vote); shall cooperate in the professional practice evaluation and performance improvement processes; and shall pay application fees, dues, and assessments. 3.D. COMMUNITY AFFILIATE STAFF 3.D.1 Qualifications: The Community Affiliate Staff consists of those physicians, dentists, oral surgeons, podiatrists, and psychologists who: (a) (b) (c) meet the eligibility criteria set forth in the Bylaws with the exception of Section 2.A.1(c), (d), (j), (k), (l), (n), (o), (q), and (r); desire to be associated with the District, but who do not intend to establish a clinical practice at the District, this District and meet the eligibility criteria set forth in the Medical Staff Credentials Policy with the exception of Section 2.A.1(c), (j), (k), (l), (n), (o), (q), and (r); and have indicated or demonstrated a willingness to assume all the responsibilities of membership on the Community Affiliate Staff as outlined in Section 3.D.2. The primary purpose of the Community Affiliate Staff is to promote professional and educational opportunities, including continuing medical education, and to permit these individuals to access District services for their patients by referral of patients to Active Staff members for admission and care

175 3.D.2 Prerogatives and Responsibilities: Community Affiliate Staff members: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) may attend meetings of the Medical Staff and applicable departments (without vote); may not hold office or serve as department chairs or committee chairs (unless waived by the MEC); shall generally have no staff committee responsibilities, but may be assigned to committees (with vote); may attend educational activities sponsored by the Medical Staff and the District; may refer patients to members of the Active Staff for admission and/or care; are encouraged to submit their outpatient records for inclusion in the District s medical records for any patients who are referred; are also encouraged to communicate directly with Active Staff members about the care of any patients referred, as well as to visit any such patients; may review the medical records and test results (via paper or electronic access) for any patients who are referred in a manner that complies with state and federal health information privacy laws and regulations; may perform history and physical examinations in the office and have those reports entered into the District s medical records; may not: admit patients, attend patients, exercise inpatient or outpatient clinical privileges, write inpatient orders, perform consultations, assist in surgery, or otherwise participate in the provision or management of clinical care to patients at the District; may refer to the District s infusion center and write appropriate orders to the same; may actively participate in the professional practice evaluation and performance improvement processes; may refer patients to the District s diagnostic facilities and order such tests; and must pay application fees, dues, and assessments

176 3.E. HONORARY/ADMINISTRATIVE STAFF 3.E.1 Qualifications: (a) (b) The Honorary/Administrative Staff shall consist of practitioners who: (i) have retired from the practice of medicine in this District after serving on the Medical Staff for more than 10 years, who are in good standing, and/or who have been recommended by the MEC; or (ii) physicians who fulfill administrative functions at the District. Once an individual is appointed to the Honorary/Administrative Staff, that status is ongoing. As such, there is no need for the individual to submit a reappointment application/reappointment processing. 3.E.2 Prerogatives and Responsibilities: (a) Honorary/Administrative Staff members: (1) may not consult, admit, or attend to patients; (2) may attend Medical Staff, department, and division meetings when invited to do so (without vote); (3) may be appointed to committees (with vote); (4) are entitled to attend educational programs of the Medical Staff and the District; and (5) may not hold office or serve as department chairs, division chairs, or committee chairs (unless waived by the MEC). (b) Honorary mmembers of this staff category are not required to pay application fees, dues, or assessments. Administrative Staff members of this category may be required to pay application fees, dues, and assessments and will be informed of the same at the time of appointment

177 ARTICLE 4 PROCEDURE FOR INITIAL APPOINTMENT 4.A. PROCEDURE FOR INITIAL APPOINTMENT 4.A.1 Application: (a) (b) (c) (d) Applications for appointment shall be on forms (which may be electronic) that have been approved by the Board, upon recommendation by the Credentials Committee and the MEC and the Credentials Committee. An individual seeking initial appointment shall be sent a letter that (i) outlines the threshold eligibility criteria for appointment outlined earlier in the Medical Staff Bylaws, the Rules and Regulations, and an, (ii) outlines the applicable criteria for clinical privileges being sought, and (iii) encloses the application form. Applications may be provided to residents or fellows who are nearing the end of the completion of their training. Such applications may be processed, but final action shall not be taken until all applicable threshold eligibility criteria are satisfied. Applications may be processed and reviewed by Medical Staff leadership and approved by the Board contingent upon the applicant providing evidence that a California license, completion of residency/fellowship program, and adequate professional liability insurance have been obtained. Any grant of appointment and/or clinical privileges by the Board shall become effective only upon such demonstration. 4.A.2 Initial Review of Application: (a) (b) (c) A completed application form with copies of all required documents must be returned to the Medical Staff Services Department accompanied by the application fee. As a preliminary step, the application shall be reviewed by the Medical Staff Services Department to determine that all questions have been answered and that the individual satisfies all threshold eligibility criteria. Incomplete applications shall not be processed. Individuals who fail to return completed applications or fail to meet the threshold eligibility criteria shall be notified that their applications shall not be processed. A determination of ineligibility does not entitle the individual to the hearing and appeal rights outlined in the Bylaws. The Medical Staff Services Department shall oversee the process of gathering and verifying relevant information, and confirming that all references and other information or materials deemed pertinent have been received

178 4.A.3 Steps to Be Followed for All Initial Applicants: (a) (b) Evidence of the applicant s character, professional competence, qualifications, behavior, and ethical standing shall be examined. This information may be contained in the application, and obtained from peer references, from the same discipline where practicable and from other available sources, including the applicant s past or current department chairs at other health care entities, residency training director, and others who may have knowledge about the applicant s education, training, experience, and ability to work with others. An interview(s) with the applicant may be conducted. The purpose of the interview is to discuss and review any aspect of the applicant s application, qualifications, and requested clinical privileges. This interview may be conducted by a combination of any of the following: the department chair, the Credentials Committee, a Credentials Committee representative, the MEC, an MEC representative, the CMO, and/or the Chief of Staff. Such interviews, when conducted, shall be conducted by at least two individuals from this list. 4.A.4 Department Chair Procedure: (a) (b) The Medical Staff Services Department shall transmit the completed application and all supporting materials to the chair of each department in which the applicant seeks clinical privileges. Each chair shall prepare a written report regarding whether the applicant has satisfied all of the qualifications for appointment and the clinical privileges requested and that includes a recommendation as to appointment, staff category, clinical privileges to be granted, and any special conditions on a form provided by the Medical Staff Services Department. The department chair shall be available to the Credentials Committee and the MEC to answer any questions that may be raised with respect to the report and findings of the chairat individual. 4.A.5 Credentials Committee Procedure: (a) (b) (c) The Credentials Committee shall review and consider the report prepared by the relevant department chair and shall make a recommendation. The Credentials Committee may use the expertise of the department chair, or any member of the service, or an outside consultant, if additional information is required regarding the applicant s qualifications. The Credentials Committee may recommend the imposition of specific conditions. These conditions may relate to behavior (e.g., personal professionalism) or to clinical issues (e.g., general consultation requirements, appropriate documentation requirements, proctoring, completion of CME requirements). The Credentials Committee may also recommend that appointment be granted for a period of less than two years in order to permit closer monitoring of an individual s compliance with any conditions. Unless these matters involve

179 the specific recommendations set forth in Section 9.A.1(a) of the Bylaws, such conditions do not entitle an individual to request the procedural rights set forth in Article 9 of the Bylaws. 4.A.6 MEC Recommendation: (a) At its next regular meeting after receipt of the written findings and recommendation of the Credentials Committee, the MEC shall: (1) adopt the findings and recommendation of the Credentials Committee, as its own; or (2) refer the matter back to the Credentials Committee for further consideration and responses to specific questions raised by the MEC prior to its final recommendation; or (3) state its reasons in its report and recommendation, along with supporting information, for its disagreement with the Credentials Committee s recommendation. (b) (c) If the recommendation of the MEC is to appoint, the recommendation shall be forwarded to the Board. If the recommendation of the MEC is unfavorable and would entitle the applicant to request a hearing in accordance with Section 9.A.1(a) of the Bylaws, the MEC shall send special notice to the applicant through the Chief of Staff and the application will be held until after the applicant has completed or waived a hearing and appeal. 4.A.7 Board Action: (a) Expedited Review. The Board may delegate to a committee, consisting of at least two Board members, action on appointment, reappointment, and clinical privileges if there has been a favorable recommendation from the Credentials Committee and the MEC and there is no evidence of any of the following: (1) a pending or previous adverse action against the applicant's current or previously successful challenge to any license or DEA registration; (2) an involuntary termination, limitation, reduction, denial, or loss of appointment or privileges at any other hospital or other entity; or (3) an unusual pattern of, or an excessive number of, professional liability actions against the applicant. Any decision reached by a Board committee to appoint shall be effective immediately and shall be forwarded to the Board for ratification at its next meeting

180 (b) Full Board Review. When there has been no delegation to a Board committee, upon receipt of a recommendation that the applicant be granted appointment and clinical privileges, the Board may: (1) appoint the applicant and grant clinical privileges as recommended; or (2) refer the matter back to the Credentials Committee or MEC or to another source inside or outside the District for additional research or information; or (3) reject or modify the recommendation. (c) (d) If the Board determines to reject a favorable recommendation, it should first discuss the matter with the Chair of the Credentials Committee and the Chair of the MEC. If the Board s recommendation remains unfavorable, the Ad Hoc Dispute Resolution process set forth in Section 12.FG of the Bylaws shall be followed. If, following the Ad Hoc Dispute Resolution process, the Board s determination remains unfavorable to the applicant, the CEO shall promptly send special notice to the applicant that the applicant is entitled to request a hearing. Any final decision by the Board to grant, deny, revise or revoke appointment and/or clinical privileges will be disseminated to appropriate individuals and, as required, reported to appropriate entities. 4.A.8 Time Periods for Processing: Once an application is deemed complete, it is expected to be processed within 120 days, unless it becomes incomplete. This time period is intended to be a guideline only and shall not create any right for the applicant to have the application processed within this precise time period. 4.B. FOCUSED PROFESSIONAL PRACTICE EVALUATION FOR INITIAL PRIVILEGES (1) All initial grants of clinical privileges, whether at the time of appointment, reappointment, or during the term of an appointment, will be subject to focused professional practice evaluation ("FPPE") by the department chair or by a physician(s) designated by the department chair. (2) This FPPEfocused professional practice evaluation may include chart review, monitoring, proctoring, external review, and other information. The clinical activity requirements, including numbers and types of cases to be reviewed, will be determined by the clinical department and approved by the Credentials Committee, MEC, and the Board. (3) A newly appointed member s appointment and privileges will expire if he or she fails to do the following within the time frame determinedrecommended by the

181 Credentials Committee, unless the department chair recommends an extension which is granted by the Credentials Committee: (a) (b) participate in the required number of cases (as applicable); or cooperate with the monitoring and review conditions.; or (c) fulfill all requirements of appointment, including but not limited to those relating to completion of medical records. In such case, the individual may not reapply for initial appointment or privileges for one year., unless the department Chair recommends an extension which is acted on favorable by the Credentials Committee. Formatted: Indent: Left: 1.5", No bullets or numbering Formatted: Level 4c Alt (4) If a member who has been granted additional clinical privileges fails to fulfill the clinical activity requirements within the time frame determinedrecommended by the Credentials Committee, unless the department Chair recommends an extension which is granted by the Credentials Committee, the additional clinical privileges will expire and the member may not reapply for the privileges in question for one year, unless the department Chair recommends an extension which is acted on favorably by the Credentials Committee. (5) When, based upon information obtained through the FPPEfocused professional practice evaluation process, a recommendation is made to terminate, revoke, or restrict clinical privileges for more than 30 days or more in a 12-month period for reasons related to clinical competence or professional conduct, the member will be entitled to a hearing and appeal under Article 9 of the Bylaws

182 ARTICLE 5 CLINICAL PRIVILEGES 5.A. CLINICAL PRIVILEGES 5.A.1 General: (a) (b) (c) (d) (e) Appointment or reappointment shall not confer any clinical privileges or right to admit or treat patients at the District. Each individual who has been appointed to the Medical Staff is entitled to exercise only those clinical privileges specifically recommended by the MEC and approved by the Board. For privilege requests to be processed, the applicant must satisfy any applicable threshold eligibility criteria. Requests for clinical privileges that are subject to an exclusive contract shall not be processed except as consistent with the contract. Requests for clinical privileges that have been grouped into core privileges will not be processed unless the individual has applied for the full core and satisfied all threshold eligibility criteria (or has obtained a waiver in accordance with Section 5.A.2). The clinical privileges recommended to the Board shall be based upon consideration of the following factors: (1) education, relevant training, experience, and demonstrated current competence, including medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal and communication skills, and professionalism with patients, families, and other members of the health care team and acceptable peer evaluations relating to these criteria; (2) appropriateness of utilization patterns; (3) ability to perform the privileges requested competently and safely; (4) information resulting from ongoing and focused professional practice evaluation and other performance improvement activities, as applicable; (5) availability of qualified staff members with appropriate privileges (as determined by the Credentials Committee) to provide coverage in case of the applicant s illness or unavailability; (6) adequate professional liability insurance coverage for the clinical privileges requested as may be required by the Board; (7) the District s available resources and personnel;

183 (8) any pending or previous adverse action against the applicant's previously successful or currently pending challenges to any licenseure or DEA registration, or the voluntary or involuntary relinquishment of such licensure or DEA registration; (9) any information concerning professional review actions or voluntary or involuntary termination, limitation, reduction, or loss of appointment or clinical privileges at another hospital; (10) practitioner-specific data as compared to aggregate data, when available; and (11) morbidity and mortality data related to the specific individual, and when statistically and qualitatively significant and meaningful, when available; and Formatted: Indent: Left: 1.5", No bullets or numbering (12)(11) professional liability actions, especially any such actions that reflect an unusual pattern or excessive number of actions. (f) (g) The applicant has the burden of establishing his or her qualifications and current competence for all clinical privileges requested. The report of the chair of the clinical department in which privileges are sought shall be forwarded to the Chair of the Credentials Committee and processed as a part of the initial application for staff appointment. 5.A.2 Privilege Modifications and Waivers: (a) (b) (c) (d) Scope. This Section applies to all requests for modification of clinical privileges during the term of appointment (increases and relinquishments), resignation from the Medical Staff, and waivers related to eligibility criteria for privileges. Submitting a Request. Requests for privilege modifications and waivers must be submitted in writing to the Medical Staff Services Department. Increased Privileges. (1) Requests for increased privileges must state the specific additional clinical privileges requested and provide information sufficient to establish eligibility, as specified in applicable criteria, and current clinical competence. (2) If the individual is eligible and the application is complete, it will be processed in the same manner as an application for initial clinical privileges. Waivers. Formatted: Underline Formatted: Underline

184 (1) Any individual who does not satisfy one or more eligibility criteria for clinical privileges may request that it be waived. Such requests will be processed in accordance with Section 2.A.2 of the Bylaws.. The individual requesting the waiver bears the burden of demonstrating exceptional circumstances, and that his or her qualifications are equivalent to, or exceed, the criterion in question. (2) If the individual is requesting a waiver of the requirement that each member apply for the full core of privileges in his or her specialty, the process set forth in this paragraph shall apply. (i) (ii) Written Request: The individual must forward a written request to the Medical Staff Services Department which must indicate the specific patient care services within the core that the member does not wish to provide, state a good cause basis for the request, and include evidence that the individual does not provide the patient care services at issue in any health care facility. Review Process: A request for a waiver shall be submitted to the Credentials Committee for consideration. In reviewing the request for a waiver, the Credentials Committee shall specifically consider the factors outlined in Paragraph (f) below and may obtain input from the relevant service chair. The Credentials Committee s recommendation will be forwarded to the MEC, which shall review the recommendation of the Credentials Committee and make a recommendation to the Board regarding whether to grant or deny the request for a waiver. Any recommendation to grant a waiver must include the specific basis for the recommendation. (e) Relinquishment and Resignation of Privileges. (1) Relinquishment of Individual Privileges. A request to relinquish any individual clinical privilege, whether or not part of the core, must provide a good cause basis for the modification of privileges. All such requests shall be processed in the same manner as a request for waiver, as described above. (2) Resignation of Appointment and Privileges. A request to resign Medical Staff appointment and relinquish all clinical privileges must specify the desired date of resignation. Relinquishment and resignation requests shall be submitted to the Credentials Committee, MEC, and the Board as information. (f) Factors for Consideration. The Medical Staff Leaders and Board may consider the following factors, among others, when deciding whether to recommend or grant a modification (increases and/or relinquishments) or waiver related to privileges:

185 (1) the District s mission and ability to serve the health care needs of the community by providing timely, appropriate care within its facilities; (2) whether sufficient notice has been given to provide a smooth transition of patient care services; (3) fairness to the individual requesting the modification or waiver, including past service and the other demands placed upon the individual; (4) fairness to other Medical Staff members who serve on the call roster in the relevant specialty, including the effect that the modification would have on them; (5) the expectations of other members of the Medical Staff who are in different specialties but who rely on the specialty in question in the care of patients who present to the District; (6) any perceived inequities in modifications or waivers being provided to some, but not others; (7) any gaps in call coverage that might/would result from an individual s removal from the call roster for the relevant privilege and the feasibility and safety of transferring patients to other facilities in that situation; and (8) how the request may affect the District s ability to comply with applicable regulatory requirements, including the Emergency Medical Treatment and Active Labor Act. (g) (h) Effective Date. If the Board grants a modification or waiver related to privileges, it shall specify the date that the modification or waiver will be effective. Failure of a member to request and obtain privilege modifications or waivers in accordance with this section shall, as applicable, result in the member retaining Medical Staff appointment and clinical privileges and all associated responsibilities. Procedural Rights. No individual is entitled to a modification or waiver related to privileges. Individuals are also not entitled to a hearing or appeal or other process if a waiver or a modification related to a relinquishment of privileges is not granted. 5.A.3 Clinical Privileges for New Procedures: (a) Requests for clinical privileges to perform either a procedure not currently being performed at the District or a new technique to perform an existing procedure (hereafter, new procedure ) shall not be processed until (1) a determination has been made by District administration that the procedure shall be offered by the District and (2) criteria to be eligible to request those clinical privileges have been established as set forth in this Section

186 (b) As an initial step in the process, the individual seeking to perform the new procedure will prepare and submit a report to the CMO and shall address the following: (1) the appropriate education, training, and experience necessary to perform the new procedure safely and competently; (2) clinical indications for when the new procedure is appropriate; (3) whether there is empirical evidence of improved patient outcomes with the new procedure or other clinical benefits to patients; (4) whether proficiency for the new procedure is volume-sensitive and if the requisite volume would be available; (5) whether the new procedure is being performed at other similar hospitals and the experiences of those institutions; and (6) whether the District currently has the resources, including space, equipment, personnel, and other support services, to safely and effectively perform the new procedure. District administration shall review this report and consult with the Chief of Staff, the department chair, and the Credentials Committee (any of which may conduct additional research as may be necessary) and shall make a preliminary determination as to whether the new procedure should be offered to the community. (c) If the preliminary determination of the District is favorable, the relevant clinical department(s) will then develop threshold credentialing criteria to determine those individuals who are eligible to request the clinical privileges at the District. In developing the criteria, the Credentials Committee may conduct additional research and consult with experts, as necessary, and develop recommendations regarding: (1) the minimum education, training, and experience necessary to perform the procedure or service; (2) the clinical indications for when the procedure or service is appropriate; (3) the extent (time frame and mechanism) of focused monitoring and supervision that should occur if the privileges are granted in order to confirm competence; and (4) the manner in which the procedure would be reviewed as part of the District s ongoing and focused professional practice evaluation activities

187 (d) The Credentials Committee will forward its recommendations to the MEC, which will review the matter and forward its recommendations to the Board for final action. (e) The Board will make a reasonable effort to render the final decision within 60 days of receipt of the MEC s recommendation. If the Board determines to offer the procedure or service, it will then establish the minimum threshold qualifications that an individual must demonstrate in order to be eligible to request the clinical privileges in question. (f) Once the foregoing steps are completed, specific requests from eligible Medical Staff members who wish to perform the procedure or service may be processed. 5.A.4 Clinical Privileges That Cross Specialty Lines: (a) (b) (c) (d) Requests for clinical privileges that have previously been exercised at the District only by individuals from another specialty shall not be processed until the steps outlined in this Section have been completed and a determination has been made regarding the individual s eligibility to request the clinical privileges in question. As an initial step in the process, the individual seeking the privilege will prepare and submit a report to the Credentials Committee that specifies the minimum qualifications needed to perform the procedure safely and competently, whether others in the individual s specialty are performing the same privilege at other similar hospitals, and the experiences of those other hospitals in terms of patient care outcomes and quality of care. The Credentials Committee shall then conduct additional research and consult with experts, as necessary, including those on the Medical Staff (e.g., department chairs, individuals on the Medical Staff with special interest and/or expertise) and those outside the District (e.g., other hospitals, residency training programs, specialty societies). The Credentials Committee may or may not recommend that individuals from different specialties be permitted to request the privileges at issue. If it does, the Committee may develop recommendations regarding: (1) the appropriate education, training, and experience necessary to perform the clinical privileges in question; (2) the clinical indications for when the procedure is appropriate; (3) the manner of addressing the most common complications that arise which may be outside of the scope of the clinical privileges that have been granted to the requesting individual;

188 (4) the extent (time frame and mechanism) of focused monitoring and supervision that should occur if the privileges are granted in order to confirm competence; (5) the manner in which the procedure would be reviewed as part of the District s ongoing and focused professional practice evaluation activities (which may include assessment of both long-term and short-term outcomes for all relevant specialties); and (6) the impact, if any, on emergency call responsibilities. (e) (f) The Credentials Committee shall forward its recommendations to the MEC, which shall review the matter and forward its recommendations to the Board for final action. The Board shall make a reasonable effort to render the final decision within 60 days of receipt of the MEC s recommendation. Once the foregoing steps are completed, specific requests from eligible Medical Staff members who wish to exercise the privileges in question may be processed. 5.A.5 Clinical Privileges for Dentists and Oral and Maxillofacial Surgeons: Dentists and oral and maxillofacial surgeons shall be responsible for the dental and oral surgery care of the patient (as relevant), including the appropriate history and physical examination, as well as all other appropriate elements of the patient s record. Dentists and oral and maxillofacial surgeons may write orders within the scope of their licenses and consistent with the Medical Staff Rules and Regulations. They must, nevertheless, have a relationship with a physician on the Medical Staff (established and declared in advance) who is available to respond should any medical issue arise with a patient outside of the individual s scope of privileges. 5.A.6 Physicians in Training: (a) (b) Physicians in training at the District shall not hold appointments to the Medical Staff and shall not be granted specific privileges. The program director, clinical faculty, and/or attending staff member shall be responsible for the direction and supervision of the on-site and/or day-to-day patient care activities of each trainee, who shall be permitted to perform only those clinical functions set out in curriculum requirements, affiliation agreements, and/or training protocols approved by the District. The applicable program director shall be responsible for verifying and evaluating the qualifications of each physician in training. A physician in training at the fellowship level may request clinical privileges in an area for which he or she has already completed residency training if he or she can demonstrate that all necessary eligibility criteria as set forth in the Bylaws have been met. Requests for privileges shall be reviewed in accordance with the initial credentialing process outlined in the Bylaws and, if granted, shall be subject to all relevant oversight provisions, including OPPE and FPPE. Clinical

189 privileges may not be granted in the specialty area in which they are currently in training as part of their training program. 5.A.7 Telemedicine Privileges: (a) (b) (c) A qualified individual may be granted telemedicine privileges regardless of whether the individual is appointed to the Medical Staff. Telemedicine privileges include diagnostic or treatment services provided by physicians from a distant site to hospital patients via telemedicine devices (audio, video, or data communications). Telemedicine does not include telephone or electronic mail communications Requests for initial or renewed telemedicine privileges shall be processed through one of the following options, as determined by the CEO in consultation with the Chief of Staff: (1) A request for telemedicine privileges may be processed through the same process for Medical Staff applications, as set forth in the Bylaws. In such case, the individual must satisfy all qualifications and requirements set forth in the Bylaws, except those relating to geographic location, coverage arrangements, and emergency call responsibilities. (2) If the individual requesting telemedicine privileges is practicing at a distant hospital that participates in Medicare or a telemedicine entity (as that term is defined by Medicare), a request for telemedicine privileges may be processed using an abbreviated process that relies on the credentialing and privileging decisions made by the distant hospital or telemedicine entity. In such cases, the District must ensure through a written agreement that the distant hospital or telemedicine entity will comply with all applicable Medicare regulations and accreditation standards. The distant hospital or telemedicine entity must provide: (i) (ii) (iii) (iv) (v) confirmation that the practitioner is licensed in California; a current list of privileges granted to the practitioner; information indicating that the applicant has actively exercised the relevant privileges during the previous 12 months and has done so in a competent manner; a signed attestation that the applicant satisfies all of the distant hospital or telemedicine entity s qualifications for the clinical privileges granted; a signed attestation that all information provided by the distant hospital or telemedicine entity is complete, accurate, and up-todate; and

190 (vi) any other attestations or information required by the agreement or requested by the District. This information shall be provided to the Credentials Committee and MEC for review and recommendation to the Board for final action. Notwithstanding the process set forth in this subsection, the District may determine that an applicant for telemedicine privileges is ineligible for appointment or clinical privileges if the applicant fails to satisfy the threshold eligibility criteria set forth in the Bylaws. (d) (e) (f) Telemedicine privileges, if granted, shall be for a period of not more than two years. Individuals granted telemedicine privileges shall be subject to the District s peer review activities. The results of the peer review activities, including any adverse events and complaints filed about the practitioner providing telemedicine services from patients, other practitioners or staff, will be shared with the hospital or entity providing telemedicine services. Telemedicine privileges granted in conjunction with a contractual agreement shall be incident to and coterminous with the agreement. 5.B. TEMPORARY CLINICAL PRIVILEGES 5.B.1 Eligibility to Request Temporary Clinical Privileges: (a) Applicants. Temporary privileges for an applicant for initial appointment may be granted by the CEO, upon recommendation of the Department Chair, Chief of Staff, and Chief Medical Officer, under the following conditions: (1) the applicant has submitted a complete application, along with the application fee; (2) the verification process is complete, including verification of current licensure, relevant training or experience, current competence, ability to exercise the privileges requested, and current professional liability coverage; compliance with privileges criteria; and consideration of information from the National Practitioner Data Bank, from a criminal background check, and from OIG queries; (3) the applicant demonstrates that (i) there are no pending or previous adverse action against the applicant's current or previously successful challenges to his or her licenseure or DEA registration, and (ii) he or she has not been subject to involuntary termination of Medical Staff membership or involuntary limitation, reduction, denial, or loss of clinical privileges, at another health care facility;

191 (4) the Chief of Staff determines that extenuating circumstances exist and that an urgent patient care need supports the need to grant temporary privileges for the new applicant; (5) the application is pending review by the MEC and the Board, following a favorable recommendation by the Credentials Committee after considering the evaluation of the department chair; and (6) temporary privileges for a Medical Staff applicant will be granted for a maximum period of 120 consecutive days. (b) Locum Tenens. The CEO, upon recommendation of the Chief of Staff, the CMO, and the applicable department chair, may grant temporary privileges to an individual serving as a locum tenens for a member of the Medical Staff who is on vacation, attending an educational seminar, or ill, or when necessary to prevent a lack or lapse of services in a needed specialty area. and/or otherwise needs coverage assistance for a period of time, under tthe following conditions apply: (1) the applicant has submitted an appropriate application, along with the application fee; (2) the verification process is complete, including verification of current licensure, relevant training or experience, current competence (verification of good standing in the most recent one to two hospitals where the individual practiced during the past year), ability to exercise the privileges requested, and current professional liability coverage; compliance with privileges criteria; and consideration of information from the National Practitioner Data Bank, from a criminal background check, and from OIG queries; (3) the applicant demonstrates that (i) there are no pending or previous adverse action against the applicant's current or previously successful challenges to his or her licenseure or DEA registration, and (ii) he or she has not been subject to involuntary termination of Medical Staff membership or involuntary limitation, reduction, denial, or loss of clinical privileges, at another health care facility; (4) the applicant will be subject to any focused professional practice requirements established by the District; and (5) the individual may exercise locum tenens privileges for a maximum of 120 days, consecutive or not, anytime during the 24-month period following the date they are granted, on subject to the following condition that the individual must inform the Medical Staff Services Department of any material change that has occurred to any of the information provided on the initial application for locum tenens privileges:

192 (i) the individual must notify the Medical Staff Services Department prior to each time that he or she will be exercising these privileges; and Formatted: Indent: Left: 2", No bullets or numbering (ii) along with this notification, the individual must inform the Medical Staff Services Department of any change that has occurred to any of the information provided on the initial application for locum tenens privileges. If an individual who has been granted locum tenens privileges has reason to exceed the 120-day maximum time frame referenced above, he or she may request a renewal of locum tenens privileges for an additional time period, not to exceed 120 days. Such requests shall be granted by the CEO, following review and favorable recommendation by the Chief of Staff and the relevant department chair. If any of those individuals have any concerns about the renewal request, it shall be forwarded to the full Credentials Committee for review and recommendation. If an individual is granted an additional 120-day renewal and still requires additional time, he or she must apply for full appointment to the Medical Staff. (c) Visiting. Temporary privileges may also be granted in other limited situations by the CEO, upon recommendation of the Chief of Staff, the CMO, and the applicable department chair, when there is an important patient care, treatment, or service need. Specifically, temporary privileges may be granted for situations such as the following: (1) the care of a specific patient; or (2) when a proctoring or consulting physician is needed, but is otherwise unavailable.; or (3) when necessary to prevent a lack or lapse of services in a needed specialty area. The following factors will be considered and verified prior to the granting of temporary privileges in these situations: current licensure, relevant training or experience, current competence (verification of good standing in the most recent one to two hospitals where the individual practiced during the past year), current professional liability coverage acceptable to the District, and results of a query to the National Practitioner Data Bank, from a criminal background check, and from OIG queries. The grant of clinical privileges in these situations will not exceed 60 days. In exceptional situations, this period of time may be extended in the discretion of the CEO and the Chief of Staff. (d) Automatic Expiration. All grants of temporary privileges shall automatically expire upon the date specified at the time of initial granting unless further affirmative action is taken by the relevant department chair, the Chair of the

193 Credentials Committee, the Chief of Staff, and the CEO with approval of the Board to renew such temporary privileges. (e) (f) Compliance with Bylaws and Policies. Prior to any temporary privileges being granted, the individual must agree in writing to be bound by the bylaws, rules and regulations, policies, procedures, and protocols of the Medical Staff and the District. FPPE. Individuals who are granted temporary privileges will be subject to the District policy regarding focused professional practice evaluation. 5.B.2 Supervision Requirements: Special requirements of supervision and reporting may be imposed on any individual granted temporary clinical privileges. 5.B.3 Withdrawal of Temporary Clinical Privileges: (a) (b) The CEO may, at any time after consulting with the Chief of Staff, withdraw temporary privileges. Clinical privileges shall then expire as soon as alternate care has been arranged. A withdrawal of temporary privileges shall not give a practitioner the right to a hearing and appeal under the Bylaws unless the withdrawal was for reasons that mandate an 805 report. If the care or safety of patients might be endangered by continued treatment by the individual granted temporary privileges, the department chair, the Chief of Staff, the CMO, or the CEO may immediately withdraw all temporary privileges. The department chair or the Chief of Staff shall assign to another member of the Medical Staff responsibility for the care of such individual s patients until they are discharged or an appropriate transfer arranged. Whenever possible, consideration shall be given to the wishes of the patient in the selection of a substitute physician. 5.C. EMERGENCY SITUATIONS (1) For the purpose of this section, an emergency is defined as a condition which could result in serious or permanent harm to a patient(s) and in which any delay in administering treatment would add to that harm. (2) In an emergency situation, a member of the Medical Staff may administer treatment to the extent permitted by his or her license, regardless of clinical service status or specific grant of clinical privileges. (3) When the emergency situation no longer exists, the patient shall be assigned by the department chair or the Chief of Staff to a member with appropriate clinical privileges, considering the wishes of the patient

194 5.D. DISASTER PRIVILEGES (1) When the District's ddisaster pplan has been implemented and the immediate needs of patients in the facility cannot be met, the CEO or the Chief of Staff may use a modified credentialing process to grant disaster privileges to eligible volunteer licensed independent practitioners ( volunteers ). Safeguards must be in place to verify that volunteers are competent to provide safe and adequate care. (2) Disaster privileges are granted on a case-by-case basis after verification of identity and licensure. (a) (b) A volunteer s identity may be verified through a valid government-issued photo identification document (i.e., driver s license or passport). A volunteer s license may be verified in any of the following ways: (i) current hospital picture ID card that clearly identifies the individual s professional designation; (ii) current license to practice; (iii) primary source verification of the license; (iv) identification indicating that the individual has been granted authority to render patient care in disaster circumstances or is a member of a Disaster Medical Assistance Team, the Medical Resource Corps, the Emergency System for Advance Registration of Volunteer Health Professionals, or other recognized state or federal organizations or groups; or (v) identification by a current District employee or Medical Staff member who possesses personal knowledge regarding the individual s ability to act as a volunteer during a disaster. (3) Primary source verification of a volunteer s license will begin as soon as the immediate situation is under control and must be completed within 72 hours from the time the volunteer begins to provide service at the District. (4) In extraordinary circumstances when primary source verification cannot be completed within 72 hours, it should be completed as soon as possible. In these situations, there must be documentation of the following: (a) the reason primary source verification could not be performed in the required time frame; (b) evidence of the volunteer s demonstrated ability to continue to provide adequate care; and (c) an attempt to obtain primary source verification as soon as possible. If a volunteer has not provided care, then primary source verification is not required. (5) The Medical Staff will oversee the care provided by volunteer licensed independent practitioners. This oversight shall be conducted through direct observation, mentoring, clinical record review, or other appropriate mechanism developed by the Medical Staff and District. (6) Disaster Privileges shall automatically expire after 72 hours, unless extended by the CEO or the Chief of Staff

195 5.E. CONTRACTS FOR SERVICES (1) From time to time, the District may enter into contracts with practitioners and/or groups of practitioners for the performance of clinical and administrative services at the District. All individuals providing clinical services pursuant to such contracts will obtain and maintain clinical privileges at the District, in accordance with the terms of the Bylaws. (2) To the extent that: (a) (b) any such contract confers the exclusive right to perform specified services to one or more practitioners or groups of practitioners, or the Board by resolution limits the practitioners who may exercise privileges in any clinical specialty to employees of the District or its affiliates, no other practitioner except those authorized by or pursuant to the contract or resolution may exercise clinical privileges to perform the specified services while the contract or resolution is in effect. This means that only authorized practitioners are eligible to apply for appointment to the Medical Staff and for the clinical privileges in question. No other applications will be processed. When an exclusive provider contract is terminated, parties to the exclusive contract shall lose their clinical privileges unless they become parties to the new exclusive provider agreement. (3) Prior to the District signing any exclusive contract and/or passing any Board resolution described in paragraph (2) in a specialty area that has not previously been subject to such a contract or resolution, the Board will request the MEC s review of the matter. The MEC (or a subcommittee of its members appointed by the Chief of Staff) will review the quality of care and service implications of the proposed exclusive contract or Board resolution, and provide a report of its findings and recommendations to the Board within 30 days of the Board s request. As part of its review, the MEC (or subcommittee) may obtain relevant information concerning quality of care and service matters from (i) members of the applicable specialty involved, (ii) members of other specialties who directly utilize or rely on the specialty in question, and (iii) District administration. However, the actual terms of any such exclusive arrangement or employment contract, and any financial information related to them, including but not limited to the remuneration to be paid to Medical Staff members who may be a party to the arrangement or practitioners of the contracting group, are not relevant and shall neither be disclosed to the MEC nor discussed as part of the MEC s review. (4) After receiving the MEC s report, the Board shall determine whether or not to proceed with the exclusive contract or Board resolution. If the Board determines to do so, and if that determination would have the effect of preventing an existing Medical Staff member from exercising clinical privileges that had previously been

196 granted, the affected member is entitled to the following notice and review procedures (Note: If more than one physician in a relevant specialty area will be affected by the determination of the Board, the following procedures will be coordinated to address all requested meetings in a combined and consolidated manner): (a) (b) (c) (d) (e) The affected member shall be given at least 30 days advance notice of the exclusive contract or Board resolution and have the right to meet with the Board (or a committee designated by the Board) to discuss the matter prior to the signing of the contract in question by the District or the Board resolution becoming effective. Any such meetings shall be held within 30 days of the notice to the affected member. At the meeting, the affected member shall be entitled to present any information that he or she deems relevant to the decision to enter into the exclusive contract or enact the Board resolution. If, following this meeting, the Board confirms its initial determination to enter into the exclusive contract or enact the Board resolution, the affected member shall be notified that he or she is ineligible to continue to exercise the clinical privileges covered by the exclusive contract or Board resolution. In that circumstance, the ineligibility begins as of the effective date of the exclusive contract or Board resolution and continues for as long as the contract or Board resolution is in effect. The affected member shall not be entitled to any procedural rights beyond those outlined above with respect to the Board s decision or the effect of the decision on his or her clinical privileges, notwithstanding the provisions in Article 8 of the Bylaws. The inability of a physician to exercise clinical privileges because of an exclusive contract or resolution is not reportable to the California licensure board or to the National Practitioner Data Bank. (5) Except as provided in paragraph (1), in the event of any conflict between the Medical Staff Bylaws and the terms of any contract, the terms of the contract shall control. 5.F. PRACTITIONERS IN DEPARTMENTS SUBJECT TO EXCLUSIVE CONTRACTS In order to exercise clinical privileges in any service or department that is subject to an exclusive contract with the DistrictHospital, a practitioner must be a member of the mmedical sstaff, hold the applicable clinical privileges, and be an employee, partner, contractor, or associate (hereinafter "affiliate") of the group, individual, or entity that holds the exclusive contract (hereinafter "contracted entity"). Upon (1) the departure of the affiliate from the contracted entity, (2) notice from the contracted entity that a practitioner will no longer provide services at the DistrictHospital, or (3) the termination

197 of the exclusive contract with the DistrictHospital, whichever occurs first, when all of the affiliate's clinical privileges are encompassed by the exclusive contract, the affiliate shall be deemed to have voluntarily resigned from the mmedical sstaff and to have voluntarily relinquished his or her clinical privileges. Such a resignation and relinquishment shall not entitle the practitioner to the procedural rights described in Article 9 of the Bylaws. To the extent the practitioner holds clinical privileges beyond those encompassed by the exclusive contract, his or her departure from the contracted entity or the termination of the exclusive contract will not result in the practitioner's voluntary resignation from the mmedical sstaff and the practitioner's remaining clinical privileges will remain intact

198 ARTICLE 6 PROCEDURE FOR REAPPOINTMENT 6.A. PROCEDURE FOR REAPPOINTMENT All terms, conditions, requirements, and procedures relating to initial appointment shall apply to continued appointment and clinical privileges and to reappointment. 6.A.1 Eligibility for Reappointment: To be eligible to apply for reappointment and renewal of clinical privileges, an individual must have, during the previous appointment term: (a) (b) (c) (d) (e) (f) completed all medical records and be current at the time of reappointment; completed any continuing medical education requirements; satisfied all Medical Staff responsibilities, including payment of dues, fines, and assessments; continued to meet all qualifications and criteria for appointment and the clinical privileges requested as set forth in Section 2.A.1 of the Bylaws; if applying for clinical privileges, had sufficient patient contacts to enable the assessment of current clinical judgment and competence for the privileges requested. Any individual seeking reappointment who has minimal activity at the District must submit such information as may be requested (such as a copy of his/her confidential quality profile from his/her primary hospital, clinical information from the individual s private office practice, and/or a quality profile from a managed care organization or insurer), before the application shall be considered complete and processed further; and paid the reappointment processing fee, if any. 6.A.2 Factors for Evaluation: In considering an individual s application for reappointment, the factors listed in Section 2.A.3 of the Bylaws will be considered. Additionally, the following factors shall be evaluated as part of the reappointment process: (a) (b) compliance with the Bylaws, rules and regulations, and policies of the Medical Staff; participation in Medical Staff duties, including committee assignments, consultation requests, quality of medical record documentation, cooperation with case management, participation in quality improvement, utilization, and professional practice evaluation activities, and such other reasonable duties and responsibilities as assigned;

199 (c) (d) (e) (f) the results of the District s performance improvement and professional practice evaluation activities, taking into consideration practitioner-specific information compared to aggregate information concerning other individuals in the same or similar specialty (provided that, other practitioners shall not be identified); any focused professional practice evaluations; verified complaints received from patients, families, and/or staff; and other reasonable indicators of continuing qualifications. 6.A.3 Reappointment Application: (a) (b) (c) (d) (e) (f) An application for reappointment shall be furnished to members at least four months prior to the expiration of their current appointment term. A completed reappointment application must be returned to the Medical Staff Services Department within 30 days. Failure to return a completed application at least two months prior to the expiration of the member s current term, allowing adequate time for processing, may result in automatic expiration of appointment and clinical privileges at the end of the then current term of appointment unless the application can still be processed in the normal course, without extraordinary effort on the part of the Medical Staff Services Department and the Medical Staff Leaders. Reappointment shall be for a period of not more than two years. If an application for reappointment is submitted timely, but the Medical Staff and/or Board has not acted on it prior to the end of the current term, the individual s appointment and clinical privileges shall expire at the end of the then current term of appointment. Subsequent Board action may be to grant reappointment and renewal of clinical privileges using the filed application in accordance with the expedited process set forth in Section 4.A.7. The application shall be reviewed by the Medical Staff Services Department to determine that all questions have been answered and that the individual satisfies all threshold eligibility criteria for reappointment and for the clinical privileges requested. The Medical Staff Services Department shall also oversee the process of gathering and verifying relevant information and shall be responsible for confirming that all relevant information has been received. 6.A.4 Processing Applications for Reappointment: (a) The Medical Staff Services Department shall forward the application to the relevant department chair and the application for reappointment shall be processed in a manner consistent with applications for initial appointment

200 (b) Additional information may be requested from the applicant if any questions or concerns are raised with the application or if new privileges are requested. 6.A.5 Conditional Reappointments: (a) (b) (c) Recommendations for reappointment and renewed privileges may be contingent upon an individual s compliance with certain specific conditions. These conditions may relate to behavior (e.g., personal code of conduct) or to clinical issues (e.g., general consultation requirements, proctoring, completion of CME requirements). Unless the conditions involve the matters set forth in Section 9.A.1(a) of the Bylaws, the imposition of such conditions does not entitle an individual to the procedural rights set forth in Article 9. In addition, reappointments may be recommended for periods of less than two years in order to permit closer monitoring of an individual s compliance with any conditions that may be imposed. A recommendation for reappointment for a period of less than two years does not, in and of itself, entitle an individual to the procedural rights set forth in Article 9. In the event the applicant for reappointment is the subject of an unresolved professional practice evaluation concern, a formal investigation, or a hearing at the time reappointment is being considered, a conditional reappointment for a period of less than two years may be granted pending the completion of that process. (d) If the Credentials Committee or the MEC is considering recommending a conditional reappointment, the committee chairperson will notify the member of the possible recommendation and invite the member to meet and discuss the matter prior to any final recommendation being made. 6.A.6 Potential Adverse Recommendation: (a) If the Credentials Committee or the MEC is considering a recommendation to deny reappointment or to reduce clinical privileges, the committee chairperson will notify the member of the possible recommendation and invite the member to meet prior to any final recommendation being made. Formatted: Indent: Left: 1.13", No bullets or numbering Formatted: Level 5, Indent: Left: 1.13" Formatted: Indent: Left: 1.13", No bullets or numbering (b) Prior to this meeting, the member will be notified of the general nature of the information supporting the recommendation contemplated. (c) At the meeting, the member will be invited to discuss, explain, or refute this information. A summary of the interview will be made and included with the committee s recommendation. This meeting is not a hearing, and none of the procedural rules for hearings will apply. The member will not have the right to be accompanied by legal counsel at this meeting and no recording (audio or video) of the meeting shall be permitted or made. Formatted: Indent: Left: 1.13"

201 6.A.76.A.6 Time Periods for Processing: Once an application is deemed complete and verified, it is expected to be processed within 120 days, unless it becomes incomplete. This time period is intended to be a guideline only and shall not create any right for the applicant to have the application processed within this precise time period

202 ARTICLE 7 ADVANCED PRACTICE PROVIDERS 7.A. CATEGORIES Subject to approval by the Board, the MEC shall determine those categories of Advanced Practice Providers (APPs) that shall be eligible to exercise privileges within the District. Such APPs shall be subject to the supervision requirements developed in each department and approved by the Interdisciplinary Practice Committee, the Credentials Committee, the MEC, and the Board. A current listings of the categories of APP functioning in the District is set forth in Appendix B to these Bylaws. 7.B. PRIVILEGES AND RESPONSIBILITIES (a) (b) (c) (d) 7.B.7.C. (a) (b) APPs may exercise only those privileges specifically granted them by the Board. The range of privileges for which each APP may apply and any special limitations or conditions to the exercise of such privileges shall be based on recommendations of the Interdisciplinary Practice Committee, subject to approval by the Credentials Committee, the MEC, and the Board. Applications for initial granting of APP privileges and biennial renewal thereof shall be submitted and processed in a parallel manner to that provided for Medical Staff members. To qualify for credentialing consideration, APPs must have a supervision agreement with a physician who is appointed to the Medical Staff (the Supervising Physician ). Each APP shall be assigned to the department(s) appropriate to his or her occupational or professional training and, unless otherwise specified in these Bylaws, shall be subject to terms, conditions, and responsibilities paralleling those specified for Medical Staff members as they may logically be applied to APPs and appropriately tailored to the particular APP's profession. Each APP may attend department meetings without a vote and serve on Medical Staff committees with a vote as appointed by the Chief of Staff. APPs shall not be appointed to the Medical Staff or entitled to the rights, privileges, and/or prerogatives of Medical Staff appointment. SUPERVISION REQUIREMENTS Any activities permitted to be performed by APPs at the District shall be performed only under the supervision or direction of a Supervising Physician. APPs may function at the District only so long as (i) they are supervised by a Supervising Physician who is currently appointed to the Medical Staff, and (ii) they have a current, written supervision agreement with the Supervising Physician

203 (c) As a condition of clinical privileges, the APP and the Supervising Physician must provide the District with a copy of any written supervision agreement required by state law as well as notice of any revisions or modifications that are made to such agreements. This notice must be provided to the Medical Staff Services Department within three days of any such change. 7.D. RESPONSIBILITIES OF SUPERVISING PHYSICIAN (a) (b) (c) (d) (e) Physicians who wish to utilize the services of an APP in their clinical practice at the District must notify the Medical Staff Services Department in advance and must ensure that the individual has been appropriately credentialed in accordance with this Article before the APP participates in clinical or direct patient care of any kind in the District. The Supervising Physician will remain responsible for all care provided by the APP in the District. Supervising Physicians who wish to utilize the services of APPs in the inpatient setting specifically agree to abide by applicable standards of practice set forth in Medical Staff and hospital policies. The number of APPs acting under the supervision of one Supervising Physician, as well as the care they may provide, will be consistent with applicable state statutes and regulations and any other policies adopted by the District. The Supervising Physician will make any appropriate filings with the Medical Board of California regarding the supervision and responsibilities of the APP, to the extent that such filings are required. It will be the responsibility of the Supervising Physician to ensure that the APP maintains professional liability insurance coverage in amounts required by the Board. The insurance must cover any and all activities of the APP in the District. The Supervising Physician will furnish evidence of such coverage to the District. The APP will act in the District only while such coverage is in effect. 7.E. PEER REVIEW PROCEDURES APPs are subject to peer review procedures paralleling those specified for Medical Staff members in Article 8, as they may be logically be applied to APPs and appropriately tailored to the particular APP's profession. 7.F. AUTOMATIC SUSPENSION An APP's privileges shall be automatically suspended, without review under Section 7.H or any other section of these Bylaws, for the same reasons that apply to Medical Staff members in Section 8.E. In addition, the APP's privileges shall be automatically suspended without review in the event: Formatted: Indent: Left: 0.5", First line: 0"

204 (a) (b) The Medical Staff membership or clinical privileges of the Supervising Physician is terminated, whether such termination is voluntary or involuntary; or The Supervising Physician no longer agrees to act as the Supervising Physician for any reason, or the relationship between the APP and the Supervising Physician is otherwise terminated, regardless of the reason. In the event of (a) or (b), the APP will have thirty (30) days from the date of the automatic suspension to submit notice of a new Supervising Physician, to include appropriate documentation, or the APP s privileges shall be automatically terminated without review under Section 7.H or any other section of these Bylaws. 7.G. ADMINISTRATIVE SUSPENSION (a) (b) (c) The Chief of Staff, the relevant department chair, the Chair of the Interdisciplinary Practice Committee, the CEO, the CMO, and the MEC each has the authority to impose an administrative suspension of all or any portion of the clinical privileges of any APP whenever a question has been raised about such individual s clinical care or professional conduct. An administrative suspension will become effective immediately upon imposition, will immediately be reported to the CMO, the CEO, and the Chief of Staff, and will remain in effect unless or until modified by the MEC. The imposition of an administrative suspension does not entitle an APP to the procedural rights set forth in Section 7.H. Upon receipt of notice of the imposition of an administrative suspension, the Chief of Staff will forward the matter to the MEC, which will review and consider the question(s) raised and thereafter make a recommendation to the Board. 7.H. PROCEDURAL RIGHTS OF ADVANCED PRACTICE PROVIDERS (a) (b) Nothing contained in the Medical Staff Bylaws shall be interpreted to entitle an APP to the procedural rights set forth in Article 9. An APP shall have a right to informal hearing and appeal proceedings to challenge any recommendation or action by the MEC not to grant or renew clinical privileges or to restrict or terminate clinical privileges by filing a written grievance with the MEC within fifteen (15) days of notice of such recommendation or action. Upon receipt of the grievance, the MEC shall arrange an informal hearing to be conducted by one or more persons appointed by the MEC or its designee. The hearing committee may, but need not, be comprised of APPs or members of the Medical Staff, however, in cases involving clinical competency or performance, and subject to feasibility, the MEC should attempt to include at least one individual who is a professional peer of the affected APP. This informal hearing need not be conducted in accordance with the provisions of Article 9. Rather, the following provisions shall apply: The APP shall be informed of the general nature and circumstances giving rise to the action and the APP may

205 present information relevant thereto at the informal hearing. Evidence in support of the adverse recommendation will be presented by a representative of the MEC, the Credentials Committee, or the Interdisciplinary Practice Committee, as determined by the Chief of Staff. Neither the APP nor Medical Staff may be represented by counsel at the informal hearing. A record of the proceeding shall be made. The hearing committee's findings and conclusion shall be reported to the APP and MEC, and shall be appealable to an appeal committee appointed by the Board. (c) (d) Appeals shall be based solely upon the record of the informal hearing. The recommendation of the appeal committee shall be forwarded to the Board (or authorized committee thereof) for final action. The rights afforded by this Section shall not apply to any decision regarding whether a category of APP shall or shall not be eligible for privileges and the terms, prerogatives, or conditions of such decision. (b)(e) The employment of an APP by the District shall be governed by the District s employment policies and manuals and the terms of the individual s employment relationship and/or written contract. To the extent that the District s employment policies or manuals, or the terms of any applicable employment contract, conflict with this Section, the employment policies, manuals and descriptions and terms of the individual s employment relationship and/or written contract shall control

206 ARTICLE 8 PEER REVIEW PROCEDURES FOR QUESTIONS INVOLVING MEDICAL STAFF MEMBERS 8.A. COLLEGIAL INTERVENTION (1) This Article encourages the use of progressive steps by Medical Staff Leaders and District management, beginning with collegial and educational efforts, to address questions relating to an individual s clinical practice and/or professional conduct. The goal of these efforts is to arrive at voluntary, responsive actions by the individual to resolve questions that have been raised. (2) Collegial intervention efforts are a part of ongoing and focused professional practice evaluation activities. (3) Collegial intervention efforts involve reviewing and following up on questions raised about the clinical practice and/or conduct of Medical Staff members and pursuing counseling, education, and related steps, such as the following: (a) (b) advising colleagues of all applicable policies, such as policies regarding appropriate behavior, communication issues, emergency call obligations, and the timely and adequate completion of medical records; and sharing comparative quality, utilization, and other relevant information, including any variations from clinical protocols or guidelines, in order to assist individuals to conform their practices to appropriate norms. (4) A log of collegial intervention efforts shall be maintained. In addition, if the relevant Medical Staff Leader(s), in consultation with the CMO, determines that it is necessary to formally document a collegial intervention effort, such documentation shall be maintained in a confidential file. The individual shall have an opportunity to review any such documentation that is prepared and to respond in writing. The response shall be maintained in that individual s file along with the original documentation. (5) Collegial intervention efforts are encouraged, but are not mandatory, and shall be within the discretion of the appropriate Medical Staff Leaders and District management. (6) Should a recommendation be made or an action taken that entitles a Medical Staff member to a hearing in accordance with Article 9, the member is entitled to be accompanied by legal counsel at that hearing. However, Medical Staff members do not have the right to be accompanied by counsel when the Medical Staff leadership is engaged in collegial intervention efforts or other progressive steps. These efforts are intended to resolve issues in a constructive manner and do not involve the formal hearing process. In addition, there shall be no recording (audio or video) of any meetings that involve collegial intervention or progressive steps activities

207 (7) The relevant Medical Staff Leader(s), in consultation with the CMO, shall determine whether to direct that a matter be handled in accordance with another policy (e.g., ddisruptive mmedical Staff Member/Advanced Practice Provider staff member ppolicy, Impaired Provider Policypractitioner health policy, ppeer rreview Process ppolicy), or to direct it to the MEC for further review. 8.B. ONGOING AND FOCUSED PROFESSIONAL PRACTICE EVALUATIONS All ongoing and focused professional practice evaluations shall be conducted in accordance with the peer review policy and the ongoing professional practice evaluation policy. Matters that cannot be appropriately resolved through collegial intervention or through the peer review or ongoing professional practice evaluation policy shall be referred to the MEC for its review in accordance with Section 8.C below. Such interventions and evaluations, however, are not mandatory prerequisites to MEC review. 8.C. INVESTIGATIONS 8.C.1 Initial Review: (a) Whenever a serious question has been raised, or where collegial efforts or actions under the professional practice evaluation policy have not resolved an issue, regarding: (1) the clinical competence or clinical practice of any member of the Medical Staff, including the care, treatment or management of a patient or patients; (2) the safety or proper care being provided to patients; (3) the known or suspected violation by any member of the Medical Staff of applicable ethical standards or the Bylaws, rules and regulations, and policies of the District or the Medical Staff; and/or (4) conduct by any member of the Medical Staff that is considered lower than the standards of the District or disruptive to the orderly operation of the District or its Medical Staff, including the inability of the member to work harmoniously with others, the matter may be referred to the Chief of Staff, the chair of the department, the chair of a standing committee, or the CMO. No member of the Medical Staff who makes such a referral confidentially and in good faith shall be subject to retaliation, or other disciplinary action. (b) In addition, if the Board becomes aware of information that raises concerns about any Medical Staff member, the matter shall be referred to the Chief of Staff, the chair of the department, the chair of a standing committee, or the CMO for review and appropriate action in accordance with this Article

208 (c) (d) The person to whom the matter is referred shall conduct or arrange for an inquiry, which shall include the Chief of Staff (if the Chief of Staff was not the individual to whom the matter was originally forwarded), to determine whether the question raised has sufficient credibility to warrant further review and, if so, shall forward it in writing to the MEC. If the Chief of Staff is the subject of the concern, the matter shall be referred to the Vice Chief of Staff for further inquiry. No action taken pursuant to this Article shall constitute an investigation. 8.C.2 Initiation of Investigation: (a) (b) (c) (d) When a question involving clinical competence or professional conduct is referred to, or raised by, the MEC, the MEC shall review the matter and determine whether to conduct an investigation, to direct the matter to be handled pursuant to another policy (e.g., Ddisruptive mmedical Staff Member/Advanced Practice Provider staff member ppolicy, Impaired Provider Policypractitioner health policy, ppeer rreview Process ppolicy), or to proceed in another manner. In making this determination, the MEC may discuss the matter with the individual. An investigation shall begin only after a formal determination by the MEC to do so. The MEC shall inform the individual that an investigation has begun. Notification may be delayed if, in the MEC s judgment, informing the individual immediately would compromise the investigation or disrupt the operation of the District or Medical Staff. The Chief of Staff shall update the CMO on actions taken in connection with an investigation and the CMO shall, in turn, update the CEO. In the event that the MEC fails to initiate an investigation in response to concerns raised about a Medical Staff member s competence, performance, or professional conduct in accordance with this Article and the Board determines that such decision is contrary to the weight of the evidence, the Board may direct the MEC to initiate such an investigation. Prior to doing so, the Board shall first consult with the MEC about the matter after providing its reasons for requesting the investigation to the MEC in writing, and shall not act in an unreasonable manner. 8.C.3 Investigative Procedure: (a) Once a determination has been made to begin an investigation, after notifying the CEO and the CMO, the MEC shall either investigate the matter itself, request that the Credentials Committee conduct the investigation, or appoint an ad hoc committee to conduct the investigation, keeping in mind the conflict of interest guidelines outlined in Article 14. Any ad hoc committee may include individuals not on the Medical Staff. Whenever the questions raised concern the clinical competence of the individual under review, the ad hoc committee shall include a peer of the individual (e.g., physician, dentist, oral surgeon, or podiatrist)

209 (b) The committee conducting the investigation ( investigating committee ) shall have the authority to review relevant documents and interview individuals. It shall also have available to it the full resources of the Medical Staff and the District, as well as the authority to use outside consultants, if needed. An outside consultant or agency may be used whenever a determination is made by the District and investigating committee that: (1) no available member of the Medical Staff possesses the clinical expertise needed to conduct the review; (2) the individual under review is likely to raise, or has raised, questions about the objectivity of other practitioners on the Medical Staff; (3) the individuals with the necessary clinical expertise on the Medical Staff would not be able to conduct a review without risk of allegations of bias, even if such allegations are unfounded; or (4) the thoroughness and objectivity of the investigation would be aided by such an external review. If the investigating committee determines that it is necessary to obtain an external review, the individual shall be informed of the same and shall be given the opportunity to review and provide written comments on the external reviewer report. (c) (d) The investigating committee may require a physical, mental, and/or behavioral examination of the individual by health care professional(s) acceptable to it. The individual being investigated shall execute a release (in a form approved or provided by the investigating committee) allowing (i) the investigating committee (or its representative) to discuss with the health care professional(s) conducting the examination the reasons for the examination; and (ii) the health care professional(s) conducting the examination to discuss and provide documentation of the results of such examination directly to the investigating committee. The cost of such health examination shall be borne by the individual. Failure to execute necessary releases or to obtain the requested evaluation shall result in the automatic relinquishment of the individual s clinical privileges in accordance with Section 8.E.3. The individual shall have an opportunity to meet with the investigating committee before it makes its report. Prior to this meeting, the individual shall be informed of the general questions being investigated. At the meeting, the individual shall be invited to discuss, explain, or refute the questions that gave rise to the investigation. No recording (audio or video) or transcript of the meeting shall be permitted or made. A summary of the interview shall be prepared by the investigating committee and included with its report. This meeting is not a hearing, and none of the procedural rules for hearings shall apply. The individual

210 being investigated shall not have the right to be accompanied by legal counsel at this meeting. (e) (f) (g) The investigating committee shall make a reasonable effort to complete the investigation and issue its report within 30 days of the commencement of the investigation, provided that an outside review is not necessary. When an outside review is necessary, the investigating committee shall make a reasonable effort to complete the investigation and issue its report within 30 days of receiving the results of the outside review. These time frames are intended to serve as guidelines and, as such, shall not be deemed to create any right for an individual to have an investigation completed within such time periods. In the event the investigating committee is unable to complete the investigation and issue its report within these time frames, it shall inform the individual and the CMO of the reasons for the delay and the approximate date on which it expects to complete the investigation. At the conclusion of the investigation, the investigating committee shall prepare a report with its findings, conclusions, and recommendations. In making its recommendations, the investigating committee shall strive to achieve a consensus as to what is in the best interests of patient care and the smooth operation of the District, while balancing fairness to the individual, recognizing that fairness does not require that the individual agree with the recommendation. Specifically, the committee may consider: 8.C.4 Recommendation: (1) relevant literature and clinical practice guidelines, as appropriate; (2) all of the opinions and views that were expressed throughout the review, including report(s) from any outside review(s); (3) any information or explanations provided by the individual under review; and (4) other information as deemed relevant, reasonable, and necessary by the investigating committee. (a) The MEC may accept, modify, or reject any recommendation it receives from an investigating committee. Specifically, the MEC may: (1) determine that no action is justified; (2) issue a letter of guidance, counsel, warning, or reprimand; (3) impose conditions for continued appointment; (4) impose a requirement for monitoring, proctoring, or consultation;

211 (5) impose a requirement for additional training or education; (6) impose a summary suspension and/or restriction; (7) recommend reduction of clinical privileges; (8) recommend suspension of clinical privileges for a term; (9) recommend revocation of appointment and/or clinical privileges; or (10) make any other recommendation that it deems necessary or appropriate. (b) (c) (d) (e) If the MEC makes a recommendation that would entitle the individual to request a hearing, the MEC shall send special notice to the individualapplicant through the Chief of Staff and the recommendation shall be held until after the individual has completed or waived a hearing and appeal unless the action taken is to impose a summary suspension, in which case the process set forth in Section 8.D shall apply. If the MEC makes a recommendation that does not entitle the individual to request a hearing, it shall take effect immediately and shall remain in effect unless modified by the Board. In such case, the individual may provide a written response to the action, which shall be maintained in the individual s confidential file, and may request that the MEC reconsider the matter; however, it is within the discretion of the MEC to grant any such request. In the event the Board considers a modification to the recommendation of the MEC that would entitle the individual to request a hearing, the Ad Hoc Dispute Resolution process set forth in Section 12.FG shall be followed. If, following that process, the Board s recommendation remains unfavorable, the Chief of Staff shall inform the individual by special notice. No final action shall occur until the individual has completed or waived a hearing and appeal. When applicable, any recommendations or actions that are the result of an investigation or hearing and appeal shall be monitored by Medical Staff Leaders on an ongoing basis through the District s performance improvement activities or pursuant to the applicable policies regarding conduct, as appropriate. 8.D. SUMMARY SUSPENSION OR RESTRICTION OF CLINICAL PRIVILEGES 8.D.1 Grounds for Summary Suspension or Restriction: (a) Whenever, in their sole discretion, failure to take such action may result in imminent danger to the health and/or safety of any individual, the MEC, or the Chief of Staff, the chair of a clinical department, the CMO, or the CEO shall have the authority to (1) afford an individual an opportunity to voluntarily refrain from exercising privileges pending an investigation;* or (2) summarily suspend or restrict all or any portion of an individual s clinical privileges as a precaution

212 (b) (c) (d) (e) (f) In the event that no individuals or committees authorized to impose a summary suspension are available under the circumstances referenced above, the Board may impose a summary suspension, provided that attempts have first been made to contact the individuals listed in paragraph (a) above. A summary suspension imposed by the Board must be reviewed and ratified by the MEC within two working days of imposition (excluding weekends and holidays) or it shall terminate automatically. If the MEC declines to ratify such a summary suspension, it may opt to initiate an investigation in accordance with Section 8.C. A summary suspension or restriction can be imposed at any time including, but not limited to, immediately after the occurrence of an event that causes concern, following a pattern of occurrences that raises concern, or following a recommendation of the MEC that would entitle the individual to request a hearing. Summary suspension or restriction is an interim step in the professional review activity, but it is not a complete professional review action in and of itself. It only reflects a determination based on the information available at the time that it was imposed and is subject to change when all information has been considered. A summary suspension or restriction will become effective immediately upon imposition, will immediately be reported in writing to the CEO, CMO, and the Chief of Staff, and will remain in effect unless it is modified by the MEC. The MEC shall provide the individual in question with a brief written description of the reason(s) for the summary suspension, including the names and medical record numbers of the patient(s) involved (if any), within one working day of the imposition of the suspension. * An agreement to voluntarily refrain from exercising privileges in such situations may require an 805 report if it extends for a cumulative total of 30 days or more for any 12-month period and is agreed to on the basis of a medical disciplinary cause or reason. 8.D.2 MEC Procedure: (a) (b) The MEC will review the matter resulting in a summary suspension or restriction (or the individual s agreement to voluntarily refrain from exercising clinical privileges) within a reasonable time under the circumstances, not to exceed seven days. Prior to, or as part of, this review, the individual may be given an opportunity to meet with the MEC. The individual may propose ways other than summary suspension or restriction to protect patients and/or employees, depending on the circumstances. Neither the MEC nor the individual shall be accompanied by counsel at this meeting, and no recording (audio or video) or transcript of the meeting shall be permitted or made. After considering the matters resulting in the suspension or restriction and the individual s response, if any, the MEC shall determine the appropriate next steps,

213 which may include, but not be limited to, commencing a focused review or a formal investigation or recommending some other action that is appropriate under the circumstances. The MEC shall also determine whether the summary suspension or restriction should be continued, modified, or terminated pending the completion of the focused review or investigation (and hearing and appeal, if applicable). (c) If a summary suspension extends for more than 14 days, the individual shall receive formal notice of the right to request a hearing pursuant to Article 9. 8.D.3 Care of Patients: (a) (b) Immediately upon the imposition of a summary suspension or restriction, the Chief of Staff, the relevant department chair, or the CMO will assign to another individual with appropriate clinical privileges responsibility for care of the suspended individual s hospitalized patients, or to aid in implementing the summary restriction, as appropriate. The assignment will be effective until the patients are discharged. The wishes of the patient will be considered in the selection of a covering physician. All members of the Medical Staff have a duty to cooperate with the Chief of Staff, the department chair, the MEC, and the CMO in enforcing summary suspensions or restrictions. 8.E. AUTOMATIC SUSPENSIONRELINQUISHMENT 8.E.1 Failure to Complete Medical Records: Failure to complete medical records after notification by the medical records department of delinquency shall result in automatic suspensionrelinquishment of all clinical privileges. SuspensionRelinquishment shall continue until all delinquent records are completed and reinstatement accomplished in accordance with the Medical Staff applicable policies and rrules and rregulations. Failure to complete the medical records that caused the suspensionrelinquishment within the time required by applicable policies and the rrules and rregulations shall result in automatic resignation from the Medical Staff. 8.E.2 Action by Government Agency or Insurer/Failure to Satisfy Threshold Criteria: (a) Any action taken by any licensing board, professional liability insurance company, court or government agency regarding any of the matters set forth below, or any failure to satisfy any of the threshold eligibility criteria set forth in Section 2.A.1, must be promptly reported by the Medical Staff member to the Medical Staff Services Department. Formatted: Indent: Left: 1", No bullets or numbering (b)(a) An individual s appointment and clinical privileges shall be automatically suspendedrelinquished, without the right to a hearing and appeal, immediately upon the occurrence of if any of the following occur:

214 (1) Licensure: Revocation, expiration, suspension, or the placement of restrictions on an individual s license. Formatted: Underline (i) (ii) Revocation, suspension, or expiration. Whenever a member's license or other legal credential authorizing practice in this state is revoked, suspended or expired without an application pending for renewal, Medical Staff membership and privileges shall be automatically revoked as of the date such action becomes effective. 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 privileges that are within the scope of such limitation or restriction shall be automatically limited or restricted in a similar manner as of the date such action becomes effective and throughout its term. Formatted: Level 7 Formatted: Underline (1)(iii) Probation. Whenever a member is placed on probation by the applicable licensing or certifying authority, his or her membership status and privileges shall automatically become subject to the same terms and conditions of the probation as of the date such action becomes effective and throughout its term. (2) Controlled Substance Authorization: Revocation, expiration, suspension or the placement of restrictions on an individual s DEA controlled substance authorization. Formatted: Underline (i) Revocation, restriction, suspension, or expiration. Whenever a member's DEA certificate is revoked, limited, suspended, or expired, the member shall automatically be divested of the right to prescribe medications covered by the certificate as of the date such action becomes effective and throughout its term. Formatted: Level 7 (2)(ii) Probation. Whenever a member's DEA certificate is subject to probation, the member's right to prescribe medications shall automatically become subject to the same terms of the probation as of the date such action becomes effective and throughout its term. (3) Insurance Coverage: Termination or lapse of an individual s professional liability insurance coverage or other action causing the coverage to fall below the minimum required by the District or cease to be in effect, in whole or in part. (4) Medicare and Medicaid Participation: Termination, exclusion, or preclusion by government action from participation in the Medicare/Medicaid or other federal or state health care programs. (5) Criminal Activity: Charge,* indictment,* cconviction or a plea of guilty or no contest pertaining to any felony, or to any misdemeanor involving (i)

215 controlled substances; (ii) illegal drugs; (iii) Medicare, Medicaid, or insurance or health care fraud or abuse; (iv) child abuse; (v) elder abuse; or (vi) violence against another. (DWIs will be addressed in the manner outlined in Section 2.B.1(h).) * Individuals who are charged or indicted with crimes as set forth in this section shall first be given the opportunity to voluntarily refrain from practicing or to request a leave of absence. If they refuse such voluntary options, the MEC shall then determine whether the criteria for automatic relinquishment have been met. (c)(6) Health Screening Requirements. Failure to submit required documentation demonstrating compliance with health screening requirements within the timelines established in the Medical Staff policies.an individual s appointment and clinical privileges shall be automatically relinquished, without entitlement to the procedural rights outlined in Article 9, if the individual fails to satisfy any of the other threshold eligibility criteria set forth in Section 2.A.1, except for board certification, which shall be assessed at the time of reappointment. Formatted: Level 6, Indent: Left: 1.5" Formatted: Level 6 (d)(b) Notice of Automatic Suspension. Special Notice of an automatic suspension shall be given to the affected individual, but such notice shall not be required for the suspension to become effective under paragraphs (1) through (4) above.automatic relinquishment shall take effect immediately upon notice to the Medical Staff and continue until the matter is resolved and the individual is reinstated, if applicable. (e)(c) If the occurrence giving underlying matterrise leading to the automatic suspensionrelinquishment is resolved within 60 days, the individual may request reinstatement. If the occurrence is notfailure to resolved or the individual has not requested reinstatement the matter within 60 days of the date of automatic suspension, the individual shall be deemed to have voluntarily resigned relinquishment shall result in an automatic resignation from the Medical Staff. Special Notice of the voluntary resignation shall be given to the affected physician, and regular notice of this occurrence will be given to the MEC, CEO, and Board. (f)(d) Request for Reinstatement. (1) Requests for reinstatement following the expiration of a license, controlled substance authorization, and/or insurance coverage, or suspension for failure to comply with health screening requirements will be processed by the Medical Staff Services Department. If any questions or concerns are noted, the Medical Staff Services Department will refer the matter for further review in accordance with (e)(2) below. (2) All other requests for reinstatement shall be reviewed by the relevant department chair, the Chair of the Credentials Committee, the Chief of

216 Staff, and the CMO. If all these individuals make a favorable recommendation on reinstatement, the Medical Staff member may immediately resume clinical practice at the District. This determination shall then be forwarded to the Credentials Committee, the MEC, and the Board for ratification. If, however, any of the individuals reviewing the request have any questions or concerns, those questions shall be noted and the reinstatement request shall be forwarded to the full Credentials Committee, MEC, and Board for review and recommendation. 8.E.3 Failure to Provide Requested Information: Failure to timely satisfy a special request for provide information pertaining to an individual s qualifications for continued appointment and/or privileges or to a specific event appointment, reappointment, or clinical privileges, in response to a written request from the Credentials Committee, the MEC, the Peer Review Committee,or any other committee authorized to request such information, or a request from the CMO or the CEO at the request of one of those committees, shall result in automatic suspensionrelinquishment of all clinical privileges. The information must be provided within the time frame established by the requesting party. TheAny suspensionrelinquishment will continue in effect until the information is provided to the satisfaction of the requesting party. If the requested information is not provided within 30 days of the date of the automatic suspensionrelinquishment, the individual shall be deemed to have voluntarily resigned it shall result in automatic resignation from the Medical Staff. 8.E.4 Failure to Complete or Comply with Training or Educational Requirements: Failure to complete and/or comply with training or educational requirements that are adopted by the MEC and apply to the Medical Staff at large (or to those members of the Medical Staff who have been granted clinical privileges), including, but not limited to, those pertinent to electronic medical records, patient safety, and infection control, shall result in the automatic suspensionrelinquishment of all clinical privileges. The Any suspensionrelinquishment will continue in effect until documentation of compliance is provided to the satisfaction of the requesting party. If documentation of compliancethe requested information is not receivedprovided by the medical staff office within 30 days after communication per medical staff notification policyof the date of relinquishment, the individual shall be deemed to have voluntarily resigned it shall result in automatic resignation from the Medical Staff. 8.E.5 Failure to Attend Special Meeting: (a) Whenever there is a concern regarding the clinical practice or professional conduct involving any individual, a Medical Staff Leader may require the individual to attend a special meeting with one or more of the Medical Staff Leaders and/or with a standing or ad hoc committee of the Medical Staff. Formatted: Level 4, Indent: Left: 0.5"

217 (b) (c) No legal counsel shall be present at this meeting, and no recording (audio or video) or transcript shall be permitted or made. The notice to the individual regarding this meeting shall be given by Sspecial Nnotice at least three days prior to the meeting and shall inform the individual of the issues to be discussed at the meeting as well as the fact that attendance at the meeting is mandatory. (d) Failure of the individual to attend the meeting without good cause shall result in the automatic suspensionrelinquishment of all clinical privileges until such time as the individual complies with does attend the special meeting request. If the individual does not attend the special meeting within 30 days of the date of automatic suspensionrelinquishment, the individual shall be deemed to have voluntarily resigned it shall result in automatic resignation from the Medical Staff. 8.E.6 Medical Executive Committee Deliberation When a member's Medical Staff membership and/or clinical privileges are automatically suspended, or the member is deemed to have voluntarily resigned from the Medical Staff under Sections 8.E.3 through 8.E.5, the member is not entitled to hearing rights under Article 9. However, the member may request a meeting with the Medical Executive Committee to address the limited question of whether grounds for the action occurred. The formal hearing procedures described at Article 9 shall not apply, and the decision of the Medical Executive Committee shall then become and remain effective pending the final decision of the Board. Formatted: Indent: Left: 1", No bullets or numbering Formatted: Level 3 Formatted: Font: Not Bold Formatted: Level 3 Alt, Indent: Left: 0.5" 8.F. LEAVES OF ABSENCE (1) An individual appointed to the Medical Staff may request a leave of absence by submitting a written request to the relevant department chair, through the Medical Staff Services Department. Except in extraordinary circumstances, Whenever possible, members are expected to submit this request will be submitted at least 30 days prior to the anticipated start of the leave in order to permit the individual to make adequate coverage arrangements necessary for patient care and assure adequate coverage of any administrative activities. The request must state the beginning and ending dates of the leave, which shall not exceed one year, and the reasons for the leave. (2) The Chief of Staff shall determine whether a request for a leave of absence shall be granted. In determining whether to grant a request, the Chief of Staff shall consult with the relevant department chair. The granting of a leave of absence, or reinstatement, as appropriate, may be conditioned upon the individual s completion of all medical records. (3) Except for maternity leaves, members of the Medical Staff must report to the Medical Staff Services Department any time they are away from Medical Staff and/or patient care responsibilities for longer than 30 days and the reason for such absence is related to their physical or mental health or otherwise to their ability to

218 care for patients safely and competently. Under such circumstances, the Chief of Staff may trigger an automatic medical leave of absence. (4) During the leave of absence, the individual shall not exercise any clinical privileges, but may continue to access the electronic medical record as appropriate. In addition, the individual shall be excused from all Medical Staff responsibilities (e.g., meeting attendance, committee service, and any applicable emergency service call obligations) during this period. (5) Individuals seekingrequesting reinstatement from a leave of absence shall submit a written request at least 30 days before the end of the leave, accompanied by a summary of their professional activities during the leave, and any other information that may be requested by the District. Requests for reinstatement shall then be reviewed by the relevant department chair and the Chief of Staff. If all these individuals make a favorable recommendation on reinstatement, the Medical Staff member may immediately resume clinical practice at the District. If, however, eitherany of the individuals reviewing the request hasve any questions or concerns, those questions shall be noted and the reinstatement request shall be forwarded to the Credentials Committee, MEC, and Board for review and recommendation. If a request for reinstatement is not granted, for reasons related to clinical competence or professional conduct, the individual shall be entitled to request a hearing and appeal under Article 9. (6) If the leave of absence was for health reasons (except for maternity leave), the request for reinstatement must be accompanied by a report from the individual s physician indicating that the individual is physically and/or mentally capable of resuming a hospital practice and safely exercising the clinical privileges requested. (7) Absence for longer than one year shall result in automatic relinquishment of Medical Staff appointment and clinical privileges unless an extension is granted by the relevant department chair, the Chief of Staff, and the CMO. Extensions shall be considered only in extraordinary cases where the extension of a leave is in the best interest of the District. (8) If an individual s current appointment is due to expire during the leave, the individual must apply for reappointment, otherwiser appointment and clinical privileges shall lapse at the end of the appointment period. (9) Failure to request reinstatement from a leave of absence in a timely manner shall be deemed a voluntary resignation of Medical Staff appointment and clinical privileges. (10) Leaves of absence are matters of courtesy, not of right. In the event that it is determined that an individual has not demonstrated good cause for a leave, or where a request for extension is not granted, the determination shall be final, with no rightecourse to a hearing and appeal under Article

219

220 ARTICLE 9 HEARING AND APPEAL PROCEDURES 9.A. INITIATION OF HEARING 9.A.1 Grounds for Hearing: (a) An individual is entitled to request a hearing whenever the MEC or the Board makes one of the following recommendations for a medical disciplinary cause or reason: (1) denial of initial appointment to the Medical Staff; (2) denial of reappointment to the Medical Staff; (3) revocation of appointment to the Medical Staff; (4) denial of requested clinical privileges; (5) revocation of clinical privileges; (6) suspension of clinical privileges if it requires an 805 Report;* (7) summary suspension of clinical privileges if it requires an 805 Report;* (8) restrictions of clinical privileges, if it requires an 805 Report;* or (9) denial of reinstatement from a leave of absence if the reasons relate to clinical competence or professional conduct. * Suspensions or restrictions shall not entitle the practitioner to request a hearing unless they remain in effect for a cumulative total of 30 days or more for any 12-month period (or, in the case of a summary suspension, if it extends for more than 14 days), and thus must be reported to the Medical Board of California. (b) (c) No other recommendations shall entitle the individual to a hearing. If the Board makes any of these determinations without an adverse recommendation by the MEC, an individual would also be entitled to request a hearing. For simplicityease of use, this Article refers to adverse recommendations of the MEC. When a hearing is triggered by an adverse recommendation of the Board, any reference in this Article to the MEC shall be interpreted as a reference to the Board. 9.A.2 Actions Not Grounds for Hearing: None of the following actions or determinations shall constitute grounds for a hearing, and they shall take effect without hearing or appeal., provided that tthe individual shall

221 be entitled to submit a written explanation or rebuttal to the action or determination to be placed into his or her file: (a) (b) (c) (d) (e) (f) (g) (h) issuance of a letter of guidance, counsel, warning, or reprimand; withdrawal of temporary privileges; automatic relinquishment or expiration of appointment or privileges; denial of a request for leave of absence, for an extension of a leave, or for reinstatement from a leave if the reasons do not relate to clinical competence or professional conduct; summary suspension of less than 14 days; the voluntary acceptance of a performance improvement plan option; determination that an application is incomplete; determination that an application shall not be processed due to a misstatement or omission; (i)(h) termination of any contract or from a contracted group; (j)(i) determination of ineligibility for membership or clinical privileges based on a failure to meet threshold eligibility criteria, a lack of need or resources, or because of an exclusive contract; (k)(j) change in assigned staff category; (l)(k) any requirement to complete a health assessment or evaluation pursuant to any Bylaws-related document; and (m)(l) grant of conditional appointment or reappointment or of an appointment or reappointment period that is less than two years. 9.B. THE HEARING 9.B.1 Notice of Recommendation: The Chief of Staff shall promptly give sspecial nnotice of a recommendation thatwhich entitles an individual to request a hearing. This notice shall contain: (a) (b) a description statement of the action or recommendation; a statement that the action or recommendation, and if adopted, shall be taken and will be reported to the Medical Board of California pursuant to Business and Professions Code section 805;

222 (a)(c) the general reasons for the recommendation or actionit; (b)(d) a statement that the individual has the right to request a hearing on the recommendation within 30 days of receipt of theis notice and that failure to request such a hearing shall result in the waiver of the right to a hearing; and (c)(e) a copy of this Article. 9.B.2 Request for Hearing: An individual has 30 days following receipt of the Special nnotice to request a hearing. The request shall be in writing to the Chief of Staff and shall include the name, address, and telephone number of the individual s counsel, if any. Failure to timely request a hearing shall constitute waiver of the right to a hearing and be deemed an acceptance of the recommendation or action, and the recommendation or action shall be transmitted to the Board for final action. 9.B.3 Notice of Hearing and Statement of Reasons: (a) The Chief of Staff shall schedule the hearing and provide, by sspecial nnotice to the individual requesting the hearing, the following: (1) the time, place, and date of the hearing; (2) a proposed list of witnesses who are expected to shall give testimony at the hearing and a brief summary of the anticipated testimony; (3) the names of the Hearing Panel members (or Hearing Officer) and/or Presiding Officer if known; and (4) a statement of the specific reasons for the recommendation, including the acts or omissions with which the individual is charged, including a list of patient records (if applicable), and a general description of the information supporting the recommendation. This statement does not bar presentation of additional evidence or information at the hearing, so long as the additional material is relevant to the recommendation or the individual s qualifications and the individual has a sufficient opportunity to review and rebut the additional information. A supplemental notice may be issued at any time, provided the individual is given sufficient time to prepare to respond. (b) The hearing shall begin no sooner than 30 days, nor longer than 60 days after receipt of the request for notice of the hearing, unless a hearing date outside of this time frame has been specifically agreed to in writing by the parties. A hearing is deemed to have commenced when Hearing Panel members undergo voir dire questioning and are seated

223 9.B.4 Hearing Panel, Presiding Officer, and Hearing Officer/Arbitrator: (a) Hearing Panel: The Chief of Staff shall appoint a Hearing Panel in accordance with the following guidelines: (1) The Hearing Panel shall consist of at least three members and may include any combination of: (i) (ii) Medical Staff members, provided such members have not actively participated in the matter at any previous level; and/or physicians or laypersons not connected with the District (i.e., physicians not on the Medical Staff or laypersons not affiliated with the District); however, the majority of any such Panel must be comprised of members of the Medical Staff. (2) Where feasible, the Panel shall include an individual practicing the same specialty as the individual requesting the hearing. (2)(3) Knowledge of the underlying peer review matter, in and of itself, shall not preclude the individual from serving on the Panel. (3)(4) Employment by, or other contractual arrangement with, the District or an affiliate shall not preclude an individual from serving on the Panel. (4)(5) The Panel shall not include any individual who is in direct economic competition with the individual requesting the hearing. (5)(6) The Panel shall not include any individual who is professionally associated with, related to, or involved in a referral relationship with, the individual requesting the hearing, members of the MEC, or key witnesses. (6)(7) The Panel shall not include any individual who is demonstrated to have an actual bias, prejudice, or conflict of interest that would prevent the individual from fairly and impartially considering the matter. (8) In addition, the appointment of the Hearing Panel shall comply with the guidelines set forth in the conflict of interest provisions found in Article 14. (7)(9) The Chief of Staff shall appoint one or more alternates to the Hearing Panel who meet the standards described in this section and who can serve if a Hearing Panel member becomes unavailable. The alternate(s) may attend all sessions of the hearing and may attend and participate in deliberations. The alternate(s) shall not vote unless a Hearing Panel

224 member is absent from or otherwise unable to vote due to failure to meet the attendance requirements of Section 9.D.4. (b) Presiding Officer: (1) The Chief of Staff shall appoint a Presiding Officer who shall be an attorney, subject to the approval of the Board. The Presiding Officer may not be, or represent clients who are, in direct economic competition with the individual requesting the hearing and may not currently represent or have previously represented the District in any legal matters. The Presiding Officer shall also not act as an advocate for either side at the hearing. (2) The Presiding Officer shall: (i) (ii) (iii) (iv) (v) (vi) allow the participants in the hearing to have a reasonable opportunity to be heard and to present evidence, subject to reasonable limits on the number of witnesses and duration of direct and cross-examination; prohibit conduct or presentation of evidence that is cumulative, excessive, irrelevant or abusive or that causes undue delay; maintain decorum throughout the hearing; determine the order of procedure; rule on all objections to the service of Hearing Panel members, the Hearing Officer, and the Presiding Officer and all matters of law, procedure, access to information and documentation, and the admissibility of evidence; considerconduct argument by counsel on procedural points within or outside the presence of the Hearing Panel at the Presiding Officer s discretion. (vi)(vii) take any action(s) warranted by the circumstances if he or she determines that either party is not proceeding in an efficient and expeditious manner. (3) The Presiding Officer may participate in the private deliberations of the Hearing Panel and be a legal advisor to it, but shall not be entitled to vote on its recommendations. (c) Hearing Officer/Arbitrator: (1) As an alternative to a Hearing Panel, for matters limited to issues involving professional conduct, and with the specific agreement of the

225 (d) (e) affected practitioner and the approval of the Board, the Chief of Staff may exercise his/her discretion to schedule the hearing before appoint a Hearing Officer, selected by a process mutually acceptable to the affected practitioner and the MECpreferably an attorney, to perform the functions of a Hearing Panel. The Hearing Officer may not be, or represent clients who are, in direct economic competition with the individual requesting the hearing. (2) If a Hearing Officer is appointed instead of a Hearing Panel, all references in this Article to the Hearing Panel or Presiding Officer shall be deemed to refer to the Hearing Officer, except that in this circumstance the Hearing Officer shall make the decision. Voir Dire: (d) The subject physician shall be entitled to a reasonable opportunity to question and object to the impartiality of the Hearing Panel members, Hearing Officer, and the Presiding Officer. Objections: Any objection to any member of the Hearing Panel, or the Hearing Officer or Presiding Officer, shall be made in writing, within 10 days of receipt of notice, to the Chief of Staff and must include the basis for the objection. The Chief of Staff shall be given a reasonable opportunity to comment. The Presiding Officer shall rule on anythe objections and give notice to the parties. Compensation: The Hearing Panel, Presiding Officer, and/or Hearing Officer may be compensated for their service by the District. Such compensation shall not be dependent on the outcome of the hearing. The individual requesting the hearing shall be informed of such compensation and may opt to contribute to any such compensation should the individual wish to do so. Formatted: Underline Formatted: Indent: Left: 1", No bullets or numbering, Tab stops: 1", List tab 9.B.5 Counsel: The Presiding Officer, Hearing Officer, and counsel for either party may be an attorney at law who is licensed to practice, in good standing, in California. 9.C. PRE-HEARING PROCEDURES 9.C.1 General Procedures: The pre-hearing and hearing processes shall be conducted in an informal manner, but, consistent with California law. Formal rules of evidence or procedure shall not apply

226 9.C.2 Time Frames: The following time frames, unless modified by the Presiding Officer or by mutual written agreement of the parties, shall govern the timing of pre-hearing procedures: (a) (b) (c) the pre-hearing conference shall be scheduled at least 21 days prior to the hearing; the parties shall exchange witness lists and proposed documentary exhibits at least 10 days prior to the pre-hearing conference; and any objections to witnesses and/or proposed documentary exhibits must be provided at least five days prior to the pre-hearing conference. 9.C.3 Witness List: (a) (b) (c) At least 10 days before the pre-hearing conference, the individual requesting the hearing shall provide a written list of the names of witnesses expected to offer testimony on his or her behalf. The witness list shall include a brief summary of the anticipated testimony. The witness list of either party may, in the discretion of the Presiding Officer, be amended at any time during the course of the hearing, provided that notice of the change is given to the other party. 9.C.4 Provision of Relevant Information: (a) (b) Prior to receiving any confidential documents, the individual requesting the hearing must agree that all documents and information shall be maintained as confidential and shall not be disclosed or used for any purpose outside of the hearing. The individual must also provide a written representation that his/her counsel and any expert(s) have executed Business Associate agreements in connection with any patient Protected Health Information contained in any documents provided. Upon receipt of the above agreement and representation, the individual requesting the hearing shall be provided, at his or his expense, with a copy of the following at least 30 days prior to the hearing: (1) copies of, or reasonable access to, all patient medical records referred to in the statement of reasons, at the individual s expense; (2) reports of experts relied upon by the MEC; (3) copies of relevant minutes (with portions regarding other physicians and unrelated matters deleted); and

227 (4) copies of any other documents relied upon by the MEC and/or relevant to the statement of reasons in the MEC's possession or under its control. The provision of this information is not intended to waive any privilege under the state peer review protection statute.the failure to provide access to this information at least 30 days before the hearing shall constitute good cause for a continuance. (c) The individual shall have no right to discovery beyond the above information. No information shall be provided regarding other practitioners on the Medical Staff. In addition, there is no right to depose, interrogate, or interview witnesses or other individuals prior to the hearing. (c)(d) The MEC shall have the right to inspect and copy, at its expense, any documentary information relevant to the charges and that the individual has in his or her possession or control as soon as practicable after receipt of the MEC's request therefor. (e) The Presiding Officer shall rule on any disputes regarding access to information and documentation. When ruling on such disputes, the Presiding Officer shall, among other factors, consider the following: (1) Whether the information sought may be introduced to support or defend the charges. Formatted: Level 6 (2) The exculpatory or inculpatory nature of the information sought, if any. (3) The burden imposed on the party in possession of the information sought, if access is granted. (4) Any previous requests for access to information submitted or resisted by the parties to the same proceeding. (d)(f) At least 10 days prior to the pre-hearing conference (or as otherwise agreed upon by both sides), each party shall provide the other party with its proposed exhibits. All objections to documents or witnesses shall be submitted in writing at least five days in advance of the pre-hearing conference. The Presiding Officer shall not entertain subsequent objections unless the party offering the objection demonstrates good cause. (e)(g) Evidence unrelated to the reasons for the recommendation or to the individual s qualifications for appointment or the relevant clinical privileges shall be excluded. (f)(h) Neither the individual, nor any other person acting on behalf of the individual, may contact District employees or Medical Staff members whose names appear on the MEC s witness list or in documents provided pursuant to this section concerning the subject matter of the hearing, until the District has been notified and has contacted the individuals about their willingness to be interviewed. The

228 District will advise the individual who has requested the hearing once it has contacted such employees or Medical Staff members and confirmed their willingness to meet. Any employee or Medical Staff member may agree or decline to be interviewed by or on behalf of the individual who requested a hearing. If an employee or Medical Staff member agrees to be interviewed, a representative of the MEC may also be present. If a District employee agrees to be interviewed and requests counsel be present, District counsel may also be present. 9.C.5 Pre-Hearing Conference: (a) (b) (c) (d) The Presiding Officer shall require the individual and MEC or their representatives (who may be counsel) to participate in a pre-hearing conference, which shall be held no later than 21 days prior to the hearing. At the pre-hearing conference, the Presiding Officer shall addressresolve any all procedural questions, including any objections to exhibits or witnesses. The Presiding Officer shall establish the time to be allotted to each witness s testimony and cross-examination. It is expected that the hearing shall last no more than 15 hours, with each side being afforded approximately seven and a half hours to present its case, in terms of both direct and cross-examination of witnesses. Both parties are required to prepare their case so that a hearing shall be concluded after a maximum of 15 hours. In addition, it is expected that all live testimony in the hearing will be concluded within a day time period. The Presiding Officer may, after considering any objections, grant limited extensions upon a demonstration of good cause and to the extent compelled by fundamental fairness. 9.C.6 Stipulations: The parties and their counsel, if applicable, shall use their best efforts to develop and agree upon stipulations, so as to provide for an more orderly and efficient hearing by narrowing the issues on which live testimony is reasonably required. 9.C.7 Provision of Information to the Hearing Panel: The following documents shall be provided to the Hearing Panel in advance of the hearing: (a) a pre-hearing statement that either party may choose to submit; (b) exhibits offered by the parties following the pre-hearing conference, except those to which an objection has been sustained by the Presiding Officer; and (cb) stipulations agreed to by the parties

229 9.D. HEARING PROCEDURES 9.D.1 Rights of Both Sides and the Hearing Panel at the Hearing: (a) At a hearing, both sides shall have the following rights, subject to reasonable limits determined by the Presiding Officer: (1) to call and examine witnesses, to the extent they are available and willing to testify; (2) to introduce exhibits; (3) to cross-examine any witness on any matter relevant to the issues; (4) to present and rebut evidence determined by the Presiding Officer to be relevant; (3)(5) to be provided with all evidence provided to the Hearing Panel; and (4) to submit proposed findings, conclusions and recommendations to the Hearing Panel, in writing, after the conclusion of the hearing session(s); and (5)(6) to have representation by counsel who may call, examine, and crossexamine witnesses and present the case. If the affected practitioner is not accompanied by legal counsel at the hearing, the MEC may also not be accompanied by legal counsel at the hearing (however, either party may consult with legal counsel in preparation for the hearing and appeal process, including having legal counsel participate in the pre-hearing conference). (b) (c) If the individual who requested the hearing elects does not to testify, he or she may be called and questioned by the MEC. The Hearing Panel may question witnesses, request the presence of additional witnesses, and/or request documentary evidence, all of which must occur during the hearing session, subject to objections by either party, which shall be resolved by the Presiding Officer. 9.D.2 Record of Hearing: A certified shorthand reporter shall be present to make a record of the hearing. The cost of the reporter's attendance shall be borne by the District. The cost of preparing the transcript shall be borne by the requesting party. Copies of the transcript shall be available at the individual s expense. Oral evidence shall be taken only on oath or affirmation administered by any person entitled to notarize documents in this state

230 9.D.3 Failure to Appear: Failure, without good cause (as determined by the Hearing Panel), to appear and proceed at the hearing shall constitute a waiver of the right to a hearing and the matter shall be transmitted to the Board for final action. 9.D.4 Presence of Hearing Panel Members: A majority of the Hearing Panel shall be present throughout the hearing. In unusual circumstances when a Hearing Panel member must be absent from any part of the hearing, he or she shall read the entire transcript of the portion of the hearing from which he or she was absent. 9.D.5 Persons to Be Present: Attendance at Tthe hearing shall be restricted to those individuals involved in the proceeding and, the Chief of Staff (or designee)., and the CEO. In addition, administrative personnel, who are not testifying as witnesses in the matter, may be present as requested by the CEO or the Chief of Staff, subject to their agreement to maintain the confidentiality of the proceeding. 9.D.6 Order of Presentation: The MEC shall first present evidence in support of its recommendation or action. Thereafter, the burden shall shift to the individual who requested the hearing to present evidence. Initial applicants shall not be permitted to introduce information not produced upon request of the MEC during the application process, unless the initial applicant establishes that the information could not have been produced previously in the exercise of reasonable diligence. 9.D.7 Admissibility of Evidence: The hearing shall not be conducted according to rules of evidence. Evidence shall not be excluded merely because it is hearsay. Any relevant evidence shall be admitted if it is the sort of evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of such evidence in a court of law. The guiding principle shall be that the record contains information sufficient to allow the Hearing Panel and Board to decide whether the individual is qualified for appointment and clinical privileges. 9.D.8 Post-Hearing Statement: Each party shall have the right to submit a written statement, and the Hearing Panel may request that statements be filed, following the close of the hearing

231 9.D.9 Postponements and Extensions: Postponements and extensions of time may be requested by anyone, but shall be permitted only by the Presiding Officer or the Chief of Staff on a showing of good cause, or by mutual agreement of the parties. 9.E. HEARING CONCLUSION, DELIBERATIONS, AND DECISIONRECOMMENDATIONS 9.E.1 Basis of Hearing Panel DecisionRecommendation: If the hearing involves the denial of an application for initial appointment, the applicant bears the burden of persuadingshowing the Hearing Panel, by a preponderance of the evidence, of their that the individual satisfies all criteria and qualifications by producing information that allows for adequate evaluation and resolution of reasonable doubts concerning their current qualifications for initial appointment and clinical privileges. For all other hearings, the MEC bears the burden of persuading the Hearing Panelshowing, by a preponderance of the evidence, that the recommendation or action iswas reasonable and warranted. 9.E.2 Deliberations and DecisionRecommendation of the Hearing Panel: Within 20 days after final adjournment of the hearing (which may be designated as the time the Hearing Panel hears closing arguments or receives the hearing transcript or any post-hearing statements, whichever is later), the Hearing Panel shall conduct its deliberations outside the presence of any other person except the Presiding Officer. Thereafter, the Hearing Panel shall render a written decision affirming or rejecting the action(s) or recommendation(s) that are the subject of the appeal. recommendation, accompanied by a report, which shall The report shall contain findings of fact, a conclusion articulating the connection between the evidence produced at the hearing and the decision reached, and a concise statement of the basis for its recommendation.an explanation of the procedure for appealing the decision. 9.E.3 Disposition of Hearing Panel Report: The Hearing Panel shall deliver its report to the Chief of Staff. The Chief of Staff shall send by sspecial nnotice a copy of the decisionreport to the individual who requested the hearing. The Chief of Staff shall also provide a copy of the report to the MEC. 9.F. APPEAL PROCEDURE 9.F.1 Time for Appeal: Within 10 days after receipt notice of the Hearing Panel s reportrecommendation, either party may request an appeal. The request shall be in writing, delivered to the Chief of Staff either in person or by certified mail, return receipt requested, and shall include a statement of the reasons for appeal and the specific facts or circumstances thatwhich justify further review. If an appeal is not requested within 10 days, an appeal is deemed to

232 be waived and the Hearing Panel s report and recommendation shall be forwarded to the Board for final action. 9.F.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. The grounds for appeal shall be limited to the following: (a) (b) there was substantial failure by the Hearing Panel to comply with the procedures outlined in this Policy and/or the Medical Staff Bylaws during the hearing, so as to deny a fair hearing; and/or the findings or recommendations of the Hearing Panel arewere not supported by substantial evidence. 9.F.3 Time, Place and Notice: Whenever an appeal is requested as set forth in the preceding Ssections, the BoardChief of Staff shall schedule and arrange for an appeal. Within fifteen (15) days after receipt of the request for appeal, Tthe individual shall be given sspecial nnotice of the time, place, and date of the appeallate review. The appeallate review shall be held not less than 30 nor more than 60 days from the date notice was provided; however, when the request for appeal involves an individual subject to a summary suspension, the appellate review shall be held as soon as arrangements can reasonably be made, not to exceed 15 days from the date of the notice. The time for appellate review may be extended by the appeal board for good cause. 9.F.4 Nature of Appellate Review Procedure: (a) (b) The Board may serve as the Review Panel or the Chair of the Board may appoint a Review Panel composed of not less than three persons, either members of the Board or others, including but not limited to reputable persons outside the District, to consider the record upon which the recommendation before it was made and recommend final action to the Board. Knowledge of the matter involved shall not preclude any person from serving as a member of the Review Panel, so long as that person did not take part in a prior hearing on the same matter. The proceedings by the Review Panel shall be in the nature of an appellate review based upon the record of the Hearing Panel, the Hearing Panel's report, the written statements, if any, submitted as provided below, and such other material as may be presented and accepted within the terms of this section. (a)(c) The Chair of the Review Panel or a hearing officer shall be the Presiding Officer. The Presiding Officer shall determine the order of procedure during the review, make all required rulings, and maintain decorum, and shall endeavor to assure that the appeal is conducted in an efficient and expeditious manner. If the Presiding

233 Officer determines that either party is not proceeding in an efficient and expeditious manner, the Presiding Officer may take such discretionary action as seems warranted by the circumstances. (b)(d) 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, Each party shall have the right to present a written statement in support of its position on appeal. The party requesting the appeal shall submit a statement first and the other party shall then have ten days to respond. The parties or their representatives shall have the right to personally appear and make oral statements not to exceed 30 minutes in favor of their positions at the appellate review. In its sole discretion, the Review Panel may allow each party or its representative to appear personally and make oral argument not to exceed 30 minutes. (e) When requested by either party, the Review Panel may, in its discretion, accept additional oral or written evidence subject to the same rights of cross-examination provided at the Hearing Panel proceedings. Such additional evidence shall be accepted only if the Review Panel determines that the party seeking to admit it has demonstrated that it is relevant, new evidence that could not have been presented at the hearing or that any opportunity to admit it at the hearing was improperly denied. (c)(f) The Review Panel board shall present to the Board, the MEC, and the party requesting the appeal, its written recommendations as to whether the Board should affirm, modify, or reverse the Hearing Panel's decision, or remand the matter to the Hearing Panel for further review and decision. 9.G. BOARD ACTION 9.G.1 Final Decision of the Board: (a) (b) (c) Within 30 days after the Board (i) considers the appeal as a Review Panel, (ii) receives a recommendation from a separate Review Panel, or (iii) receives the Hearing Panel s report and recommendation when no appeal has been requested, the Board shall consider the matter and take final action. The Board may review all relevant information, including the findings and recommendations of the MEC, Hearing Panel, and Review Panel (if applicable). The Board may affirm, modify, reverse the Hearing Panel's decision, or remand the matter for further review by the Hearing Panel or any other individual or body designated by the Board for reconsideration, stating the purpose for the referral. The Board shall give great weight to the Hearing Panel's decision recommendation, and shall not act arbitrarily or capriciously. The Board shall sustain the decision of the Hearing Panel unless it finds that the decision is not supported by substantial evidence or that there has been a substantial failure to follow the procedures outlined in the Bylaws so as to deny a fair hearing. The Board may, however, exercise its independent judgment in determining whether

234 a practitioner was afforded a fair hearing for issues not related to clinical competence (e.g., compliance matters, behavioral issues), whether the decision was reasonable and warranted, and whether any Bylaw, Rule and Regulation, or policy relied upon by the Hearing Panel is unreasonable and unwarranted. If the Board determines that the practitioner was not afforded a fair hearing in compliance with this ArticlePolicy, the Board shall remand the matter. In matters related to clinical competence, the Board s discretion shall be limited to determining whether the Hearing Panel s decision was supported by substantial evidence. (d) The Board shall render its final decision in writing, including specific reasons, and forward copies thereof to each side involved in the appeal.shall send special notice to the individual. A copy shall also be provided to the MEC for its information. 9.G.2 Further Review: Except where the matter is referred by the Board to any individual or committee for further action and recommendation, the final decision of the Board shall be effective immediately and shall not be subject to further review. If the matter is referred for further action and recommendation, such recommendation shall be promptly made to the Board in accordance with the instructions given by the Board. 9.G.3 Right to One Hearing and One Appeal Only: No member of the Medical Staff shall be entitled to more than one hearing and one appellate review on any matter. If the Board denies initial appointment to the Medical Staff or reappointment or revokes the appointment and/or clinical privileges of a current member of the Medical Staff, that individual may not apply for staff appointment or for those clinical privileges for a period of five years unless the Board provides otherwise

235 ARTICLE 10 OFFICERS 10.A. DESIGNATION The officers of the Medical Staff shall be the Chief of Staff, the Vice Chief of Staff, the Secretary-Treasurer, and the Immediate Past Chief of Staff. 10.B. ELIGIBILITY CRITERIA Only those members of the Active Staff who satisfy the following criteria initially and continuously shall be eligible to serve as an officer of the Medical Staff, unless an exception is recommended by the MEC. They must: (1) at the time of nomination, be appointed in good standing to the Active Staff, and have served on the Active Staff for at least two years; (2) be certified by an appropriate specialty board or possess comparable competence, as determined through the credentialing and privileging process; (3) have no pending adverse recommendations concerning Medical Staff membership or clinical privileges at the District; (4) not presently be serving as Medical Staff officers, Board members, department chairs, or committee chairs at any other hospital and shall not so serve during their term of office; (5) be willing to faithfully discharge the duties and responsibilities of the position; (6) have experience in a leadership position, or other involvement in performance improvement functions; (7) have demonstrated an ability to work well with others; and (8) disclose any financial relationship (i.e., an ownership or investment interest or a compensation arrangement) with an entity that competes with the District or any affiliate. This does not apply to services provided within a practitioner s office and billed under the same provider number used by the practitioner. The MEC shall evaluate any such disclosed financial relationships to determine whether they are significant enough that the individual should be disqualified from serving in the relevant leadership position. All such individuals are encouraged to obtain education relating to Medical Staff leadership, credentialing, and/or professional practice evaluation functions prior to or during the term of the office

236 10.C. DUTIES 10.C.1 Chief of Staff: The Chief of Staff shall: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) act in coordination and cooperation with the CEO in matters of mutual concern involving the care of patients throughout the District; represent and communicate the views, policies, concerns, and needs, and report on the activities, of the Medical Staff to the CEO and the Board; be accountable to the Board, in conjunction with the MEC, for the quality and efficiency of clinical services and performance throughout the District and for the effectiveness of the performance improvement, professional practice evaluation, and case management program functions; call and preside at all regular and special meetings of the general Medical Staff and the MEC, and assume responsibility for the agenda of all such meetings; appoint all committee chairs and members; serve as chair of the MEC (with vote, only as necessary to break a tie), be a member of the Joint Conference Committee, and be a member of all other Medical Staff committees, ex officio (without vote); be a signatory on the District s Medical Staff fund/account; promote adherence to the Bylaws, policies, and Rules and Regulations of the Medical Staff and to the policies and procedures of the District; recommend Medical Staff representatives to District committees; act on behalf of the MEC in urgent situations that occur in intervals between MEC meetings; and perform all functions authorized in all applicable policies, including collegial intervention as set forth in the Credentials Policy. 10.C.2 Vice Chief of Staff: The Vice Chief of Staff shall: (a) (b) assume all duties of the Chief of Staff and act with full authority as Chief of Staff in his or her absence; serve as the vice chair of the MEC;

237 (c) (d) (e) (f) (g) be expected to succeed the Chief of Staff at the conclusion of the term of Vice Chief of Staff, subject to an affirmation vote of the MEC; serve as chair of the Professional Staff Quality Management Committee and be a member of the Joint Conference Committee and the Bylaws Committee; act on behalf of the MEC in urgent situations that occur in intervals between MEC meetings; be a signatory on the District s Medical Staff fund/account; and assume all such additional duties as are assigned by the Chief of Staff or the MEC. 10.C.3 Secretary-Treasurer: The Secretary-Treasurer shall: (a) (b) (c) (d) (e) (f) serve as a member of the MEC, the Joint Conference Committee, and other Medical Staff or District committees as may be requested; attend to all appropriate correspondence and notices on behalf of the Medical Staff, as may be requested; be expected to succeed the Vice Chief of Staff at the conclusion of the term of Secretary-Treasurer, subject to an affirmation vote of the MEC; be a signatory on the District s Medical Staff fund/account; oversee expenditures from the District s Medical Staff fund/account; and perform such additional duties as are assigned by the Chief of Staff or the MEC. 10.C.4 Immediate Past Chief of Staff: The Immediate Past Chief of Staff shall: (a) (b) (c) (d) serve as an advisor and mentor to the Chief of Staff and the other officers; serve as a voting member of the MEC, the Chair of the Nominating Committee and the Bylaws Committee, and a member of the Joint Conference Committee; be a signatory on the District s Medical Staff fund/bank account(s); and perform such additional duties as are assigned by the Chief of Staff or the MEC

238 10.D. NOMINATIONS (1) The Nominating Committee shall consist of the five most recent Past Chiefs of Staff, including the Immediate Past Chief of Staff (who shall serve as Chair). (2) The Nominating Committee shall convene at least 60 days prior to the election (which shall occur during the month of May) and shall select the names of one or more qualified nominees for the office of Secretary-Treasurer and, when necessary, Vice Chief of Staff (e.g., should the MEC not affirm the succession of the Secretary-Treasurer to the position or the Secretary-Treasurer opts not to succeed to the position of Vice Chief of Staff). All nominees must meet the eligibility criteria in Section 10.B and agree to serve, if elected. Notice of the nominees shall then be provided to the Medical Staff at least 30 days prior to the election. (3) Additional nominations may be submitted to the Nominating Committee by members of the Active Staff at least 15 days prior to the election. Such petitions shall be submitted to the Nominating Committee via the relevant department chair(s). In order for a nomination to be added to the ballot, the candidate must meet the qualifications in Section 10.B. (4) Nominations from the floor shall not be accepted if an election is held at an official meeting nor shall write-in candidates be accepted if the election is accomplished by written or electronic ballot. 10.E. ELECTION (1) The election shall be held solely by written or electronic ballot returned to the Medical Staff Office. Ballots shall be returned in the manner designated on the ballot which may include in person, by mail, by facsimile, or by . All ballots must be received in the Medical Staff Office by the day of the election. Those who receive a majority of the votes cast shall be elected. (2) In the alternative, at the discretion of the MEC, elections may be held at an official meeting. Such decision must be made by the MEC at the time that the Nominating Committee is convened (i.e., 60 days prior to the election). Candidates receiving a majority of written or verbal votes cast at the official meeting shall be elected. If no candidate receives a simple majority vote on the first ballot, a run-off election shall be held promptly between the two candidates receiving the highest number of votes. 10.F. TERM OF OFFICE Officers shall serve for a term of two years or until a successor is elected

239 10.G. REMOVAL (1) Removal of an elected officer may be effectuated by a two-thirds vote of the MEC or by a two-thirds vote of the Active Staff. Grounds for removal shall be: (a) (b) (c) (d) (e) failure to comply with applicable policies, Bylaws, or Rules and Regulations; failure to continue to satisfy any of the criteria in Section 10.B; failure to perform the duties of the position held; suspected conduct that the MEC has determined is detrimental to the interests of the District and/or its Medical Staff; or an infirmity that renders the individual incapable of fulfilling the duties of that office. (2) At least 10 days prior to the initiation of any removal action, the individual shall be given written notice of the date of the meeting at which action is to be considered. The individual shall be afforded an opportunity to speak to the MEC or the Active Staff, as applicable, prior to a vote on removal. 10.H. VACANCIES A vacancy in the office of Chief of Staff shall be filled by the Vice Chief of Staff and a vacancy in the office of Vice Chief of Staff shall be filled by the Secretary-Treasurer. In the event there is a vacancy in the office of Secretary-Treasurer, the MEC shall appoint an individual to fill that office for the remainder of the term or until a special election can be held, at the discretion of the MEC

240 ARTICLE 11 CLINICAL DEPARTMENTS 11.A. DEPARTMENTS The Medical Staff shall be organized into the following departments: Anesthesiology Cardiovascular Services Critical Care, Pulmonary & Adult Hospitalists Emergency Medicine Family Medicine Internal Medicine Obstetrics and Gynecology Pathology Pediatrics Psychiatry Radiology Surgery 11.B. CREATION AND DISSOLUTION OF CLINICAL DEPARTMENTS AND DIVISIONS (1) Clinical departments and divisions shall be created and may be consolidated or dissolved by the MEC upon approval by the Board as set forth below. (2) The following factors shall be considered in determining whether a clinical department or division should be created: (a) (b) there exists a number of members of the Medical Staff who are available for appointment to, and are reasonably expected to actively participate in, the proposed new department or division (this number must be sufficiently large to enable the department or division to accomplish its functions as set forth in Section 11.D); the level of clinical activity that will be affected by the new department or division is substantial enough to warrant imposing the responsibility to accomplish departmental functions on a routine basis;

241 (c) (d) (e) a majority of the voting members of the proposed department or division vote in favor of the creation of a new department or division; it has been determined by the Medical Staff leadership and the CEO that there is a clinical and administrative need for a new department or division; and the voting Medical Staff members of the proposed department or division have offered a reasonable proposal for how the new department or division will fulfill all of the designated responsibilities and functions, including, where applicable, meeting requirements. (3) The following factors shall be considered in determining whether the dissolution of a clinical department or division is warranted: (a) (b) (c) (d) (e) there is no longer an adequate number of members of the Medical Staff in the clinical department or division to enable it to accomplish the functions set forth in the Bylaws and related policies; there is an insubstantial number of patients or an insignificant amount of clinical activity to warrant the imposition of the designated duties on the members in the department or division; the department or division fails to fulfill all designated responsibilities and functions, including, where applicable, its meeting requirements; no qualified individual is willing to serve as chair of the department or chief of the division; or a majority of the voting members of the department or division vote for its dissolution. 11.C. ASSIGNMENT TO CLINICAL DEPARTMENT (1) Upon initial appointment to the Medical Staff, each member shall be assigned to a clinical department. Assignment to a particular clinical department does not preclude an individual from seeking and being granted clinical privileges typically associated with another clinical department. (2) An individual may request a change in clinical department assignment to reflect a change in the individual s clinical practice. 11.D. FUNCTIONS OF CLINICAL SERVICES The clinical departments shall be organized for the purpose of implementing processes (i) to monitor and evaluate the quality and appropriateness of the care of patients served by the clinical departments, and (ii) to monitor the practice of all those with clinical

242 privileges or a scope of practice in a given service area, consistent with the provisions in these Bylaws and related documents. 11.E. QUALIFICATIONS OF CLINICAL DEPARTMENT CHAIRS AND VICE CHAIRS Each clinical department chair and vice chair shall satisfy all the eligibility criteria outlined in Section 10.B, unless waived by the MEC after considering the recommendation of the Chief of Staff. 11.F. APPOINTMENT AND REMOVAL OF CLINICAL DEPARTMENT CHAIRS AND VICE CHAIRS (1) Clinical department chairs and vice chairs shall be elected by the voting members of the department via an electronic or sealed written ballot, with the outcome subject to approval by the MEC. (2) Any department chair or vice chair may be removed by a two-thirds vote of the clinical department members or by a two-thirds vote of the MEC. Grounds for removal shall be: (a) (b) (c) (d) (e) failure to comply with applicable policies and Bylaws; failure to continue to satisfy any of the criteria in Section 10.B; failure to perform the duties of the position held; suspected conduct that the MEC has determined is detrimental to the interests of the District and/or its Medical Staff; or an infirmity that renders the individual incapable of fulfilling the duties of that office. (3) At least 10 days prior to the initiation of any removal action, the individual shall be given written notice of the date of the meeting at which such action is to be considered. The individual shall be afforded an opportunity to speak to the department or the MEC, as applicable, prior to a vote on removal. (4) Clinical department chairs and vice chairs shall serve for a term of two years or until a successor is elected. Department chairs may be re-elected. (5) The chairs of Anesthesiology, Pathology, Pediatrics, Psychiatry, Surgery, and Radiology shall be elected in even-numbered years and the chairs of Cardiovascular Services, Critical Care, Pulmonology, & Adult Hospitalists Medicine, Emergency Medicine, Family Medicine, Internal Medicine, and Obstetrics & Gynecology shall be elected in odd-numbered years. Chairs serving at the time of the adoption of these Bylaws shall not be required to stand again for election until their current terms would have expired under the prior Bylaws

243 11.G. DUTIES OF CLINICAL DEPARTMENT CHAIRS AND VICE CHAIRS (1) Clinical department chairs and vice chairs shall work in collaboration with Medical Staff Leaders and other District personnel to collectively be responsible for the following: (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) coordinating all clinically-related activities of the department; coordinating all administratively-related activities of the department; continuing surveillance of the professional performance of all individuals in the department who have delineated clinical privileges, including performing ongoing and focused professional practice evaluations (OPPE and FPPE), as outlined in the Medical Staff peer review and ongoing professional practice evaluation policies; recommending criteria for clinical privileges that are relevant to the care provided in the department; evaluating requests for clinical privileges for each member of the department; assessing and recommending off-site sources for needed patient care, treatment, and services not provided by the clinical department or the District; integrating the department into the primary functions of the District; coordinating and integrating the services provided; developing and implementing policies and procedures that guide and support the provision of care, treatment, and services in the clinical department; making recommendations for a sufficient number of qualified and competent persons to provide care, treatment, and services; assisting in the evaluation of the qualifications and competence of department personnel who are not licensed independent practitioners and who provide patient care, treatment, and services; continuously assessing and improving the quality of care, treatment, and services provided within the clinical department; maintaining quality monitoring programs, as appropriate; providing for the orientation and continuing education of all persons in the clinical department;

244 (o) (p) (q) making recommendations for space and other resources needed by the department; cooperating with the preparation of an Emergency Department on-call roster to ensure appropriate coverage; and performing all functions authorized in the Bylaws, including collegial intervention efforts. (2) Clinical department vice chairs shall carry out any and all functions that may be delegated by the relevant department chair which shall include, at a minimum, serving as members of the Credentials and Peer Review Committees

245 ARTICLE 12 MEDICAL STAFF COMMITTEES 12.A. MEDICAL STAFF COMMITTEES AND FUNCTIONS (1) This Article outlines the Medical Staff committees that carry out ongoing and focused professional practice evaluations and other performance improvement functions that are delegated to the Medical Staff by the Board.. (2) Procedures for the appointment of committee chairs, appointment of committee members, and terms of appointment are set forth in Section 12.B. (3) This Article details the standing members of each Medical Staff committee. However, other Medical Staff members or District personnel may be invited to attend a particular Medical Staff committee meeting in order to assist such committee in its discussions and deliberations regarding the issues on its agenda. All such individuals are an integral part of the credentialing, quality assurance, and professional practice evaluation process and are bound by the same confidentiality requirements as the standing members of such committees. (4) Unless otherwise provided in a specific committee composition, voting members of committees are limited to Medical Staff members. 12.B. EXPECTATIONS AND REQUIREMENTS FOR COMMITTEE MEMBERSHIP To be eligible to serve on a Medical Staff committee, members must acknowledge and agree to the following: (1) have the willingness and ability to devote the necessary time and energy to committee service, recognizing that the success of a committee is highly dependent upon the full participation of its members; (2) complete any orientation, training, and/or education related to the functions of the committee in advance of the first meeting; (3) come prepared to each meeting review the agenda and any related information provided in advance so that the committee s functions may be performed in an informed, efficient, and effective manner; (4) attend meetings on a regular basis to promote consistency and good group dynamics; (5) participate in discussions in a meaningful and measured manner that facilitates deliberate thought and decision-making, and avoid anecdotal or sidebar conversations; (6) voice disagreement in a respectful manner that encourages consensus-building;

246 (7) understand and strive for consensus decision-making, thereby avoiding the majority vote whenever possible; (8) speak with one voice as a committee and support the actions and decisions made (even if they were not the individual s first choice); (9) be willing to complete assigned or delegated committee tasks in a timely manner between meetings of the committee; (10) bring any conflicts of interest to the attention of the committee chair, in advance of the committee meeting, when possible; (11) if the individual has any questions about his or her role or any concerns regarding the committee functioning, seek guidance directly from the committee chair outside of committee meetings; (12) participate in the development of an annual committee work plan and ensure that the committee plans are in alignment with the strategic goals of the District and Medical Staff; and (13) maintain the confidentiality of all matters reviewed and/or discussed by the committee. 12.C. APPOINTMENT OF COMMITTEE CHAIRS AND MEMBERS (1) Unless otherwise indicated, all committee chairs and members shall be appointed by the Chief of Staff. Committee chairs shall be selected based on the criteria set forth in Section 10.B, unless such criteria are waived by the MEC, and must signify their willingness to meet basic expectations of committee membership as set forth in Section 12.B. The MEC shall review the composition of Medical Staff committees at least once a year and may make recommendations for changes or additions to the constitution of each committee. (2) Unless otherwise indicated, committee chairs and members shall be appointed for initial terms of two years, but may be reappointed for additional terms. All appointed chairs and members may be removed and vacancies filled by the Chief of Staff, at his/her discretion, subject to the approval of the MEC. (3) Unless otherwise indicated, all District and administrative representatives on the committees shall be appointed by the CEO, in consultation with the Chief of Staff. If nursing representatives are appointed to Medical Staff committees, such individuals will be appointed by the Chief Nursing Officer ("CNO"). All such representatives shall serve on the committees, without vote. (4) Unless otherwise indicated, the Chief of Staff, the CMO, and the CEO (or their respective designees) shall be members, ex officio, without vote, on all committees

247 12.D. MEETINGS, REPORTS, AND RECOMMENDATIONS Unless otherwise indicated, each committee described in these Bylaws shall meet as necessary to accomplish its functions and shall maintain a permanent record of its findings, proceedings, and actions. Each committee shall make a timely report after each meeting to the MEC and the Board and to other committees and individuals as may be indicated. 12.E. MEDICAL EXECUTIVE COMMITTEE 12.E.1 Composition: (a) The MEC shall consist of: the Chief of Staff; the Vice Chief of Staff; the Secretary-Treasurer of the Medical Staff; the Immediate Past Chief of Staff; the Chairs of the Credentials, Peer Review, and Graduate Medical Education Committees; and the Medical Director of Performance Improvement; and the department chairs (in the event that a department chair cannot attend a meeting, he or she may request that the vice chair attend in his or her absence and serve as a voting member of the MEC at that meeting). (b) (c) (d) The Chief of Staff will chair the MEC. The CEO, CIO, COO, CMO, and CNO, and Medical Director of Quality and Patient Safety shall be ex officio members of the MEC, without vote. Other Medical Staff members or District personnel may be invited to attend a particular MEC meeting (as guests, without vote) in order to assist the MEC in its discussions and deliberations regarding an issue(s) on its agenda. These individuals shall be present only for the relevant agenda item(s) and shall be excused for all others. Such individuals are an integral part of the professional practice evaluation process and are bound by the same confidentiality requirements as the standing members of the MEC, including a requirement to sign any necessary confidentiality agreement

248 12.E.2 Duties: (a) (b) The MEC is delegated the primary authority over activities related to the functions of the Medical Staff and for performance improvement of the professional services provided by individuals with clinical privileges. This authority may be removed by amending these Bylaws and related policies. The MEC is responsible for the following: (1) acting on behalf of the Medical Staff in the intervals between Medical Staff meetings; (2) recommending directly to the Board on at least the following: (i) (ii) (iii) (iv) (v) (vi) (vii) the Medical Staff s structure; the mechanism used to review credentials and to delineate individual clinical privileges; applicants for Medical Staff appointment and reappointment; delineation of clinical privileges for each eligible individual; participation of the Medical Staff in District performance improvement activities and the quality of professional services being provided by the Medical Staff; the mechanism by which Medical Staff appointment may be terminated; hearing procedures; and (viii) reports and recommendations from Medical Staff committees, departments, and other groups, as appropriate; (3) consulting with aadministration on quality-related aspects of contracts for patient care services; (4) reviewing (or delegating the review of) quality indicators to ensure uniformity regarding patient care services; (5) providing leadership in activities related to patient safety; (6) collaborating in the process of analyzing and improving patient satisfaction; (7) ensuring that, at least every five years, the Bylaws, policies, and associated documents of the Medical Staff are reviewed and updated;

249 12.E.3 Meetings: (8) providing and promoting effective liaison among the Medical Staff, Administration, and the Board; (9) complying with reasonable requests from the Board directed to the MEC as a whole that are seeking assistance with Medical Staff matters; and (10) performing such other functions as are assigned to it by these Bylaws or other applicable policies. The MEC shall meet at least ten times a year, and shall maintain a permanent record of its proceedings and actions. 12.E.4 Removal: (a) Removal of a member of the MEC may be effectuated by a two-thirds vote of the MEC. Grounds for removal shall be: (1) failure to comply with applicable policies, Bylaws, or Rules and Regulations; (2) failure to continue to satisfy any of the criteria in Section 10.B; (3) failure to perform the duties of the position held; (4) suspected conduct that the MEC has determined is detrimental to the interests of the District and/or its Medical Staff; or (5) an infirmity that renders the individual incapable of fulfilling the duties of that office. (b) At least 10 days prior to the initiation of any removal action, the individual shall be given written notice of the date of the meeting at which action is to be considered. The individual shall be afforded an opportunity to speak to the MEC prior to a vote on removal. 12.F. PERFORMANCE IMPROVEMENT FUNCTIONS (1) The Medical Staff is actively involved in the measurement, assessment, and improvement of at least the following: Formatted: Indent: Left: 0.5", No bullets or numbering (r) (s) patient safety, including processes to respond to patient safety alerts, meet patient safety goals, and reduce patient safety risks; the District s and individual practitioners performance on Joint Commission and Centers for Medicare & Medicaid Services ( CMS ) core measures;

250 (t) (u) (v) (w) (x) (y) (z) (aa) (bb) (cc) (dd) (ee) (ff) (gg) (hh) (ii) (jj) medical assessment and treatment of patients; medication usage, including review of significant adverse drug reactions, medication errors, and the use of experimental drugs and procedures; the utilization of blood and blood components, including review of significant transfusion reactions; operative and other invasive procedures, including tissue review and review of discrepancies between pre-operative and post-operative diagnoses; appropriateness of clinical practice patterns; significant departures from established patterns of clinical practice; use of information about adverse privileging determinations regarding any practitioner; the use of developed criteria for autopsies; sentinel events, including root cause analyses and responses to unanticipated adverse events; nosocomial infections and the potential for infection; unnecessary procedures or treatment; appropriate resource utilization; education of patients and families; coordination of care, treatment, and services with other practitioners and District personnel; accurate, timely, and legible completion of medical records; the required content and quality of history and physical examinations, as well as the time frames required for completion, all of which are set forth in Appendix B of these Bylaws; review of findings from the ongoing and focused professional practice evaluation activities that are relevant to an individual s performance; and (kk) communication of findings, conclusions, recommendations, and actions to improve performance to appropriate Medical Staff members, the MEC, and the Board. Formatted: Indent: Left: 1.5", No bullets or numbering

251 12.G.12.F. AD HOC DISPUTE RESOLUTION COMMITTEE ( AHDRC ) 12.G.112.F.1 Composition: The Ad Hoc Dispute Resolution Committee shall be composed of two members appointed by the Board and two members appointed by the MEC. The four members shall appoint a fifth member. In even numbered years, the AHDRC chair shall be designated by the Board Chair and in odd numbered years the AHDRC chair shall be designated by the Chief of Staff. 12.G.212.F.2 Duties: (a) (b) (c) (d) All disputes between the Board/aAdministration and the Medical Staff (the Parties ) relating to the Medical Staff s rights of self-governance as defined in California Business & Professions Code Section ( Disputes ) that, which have not been resolved by informal meetings and discussions, as well as conflicts between the MEC and the Medical Staff as defined in Section 17.C that are not fully resolved pursuant to that section, shall be addressed and resolved in accordance with the meet and confer process of an AHDRC, as described in this section. In the event either Party determines that a Dispute exists, such Party shall give written notice to the other Party, stating the nature of the Dispute and, that describinges the matter in detail. Within 30 days following receipt of such notice, both Parties shall appoint representatives to an AHDRC, as described above. A separate AHDRC shall be established for each Dispute for which notice is given pursuant to this section. Accordingly, more than one AHDRC may be operative at a time. Neither Party shall initiate any legal action related to the Dispute until the AHDRC has completed its efforts to resolve the Dispute. When formed, an AHDRC shall promptly receive and review written requests for initiation of the meet and confer/dispute resolution process. The AHDRC, with such assistance and input as it may request, shall then meet in good faith to recommend a resolution of the Dispute. Such efforts shall continue, as necessary, for up to 60 days. The AHDRC shall report the results of its efforts and its recommendations to both the MEC and the Board. Both Parties are obligated to consider the AHDRC's recommendations carefully and to give them great weight. Unless requested by the Parties to continue its deliberations, the AHDRC shall dissolve 30 business days following the reporting of its results and recommendations. Each Party shall bear its own legal expenses. Unless the Parties agree otherwise, approved expenses of the AHDRC (such as consulting fees or expenses related to the appointment of the fifth committee member) shall be paid by the District

252 12.H. BIOETHICS COMMITTEE 12.H.1 Composition: The Bioethics Committee shall be comprised of members of the Medical Staff and such other members as necessary. It may include nurses, lay representatives, social workers, clergy, ethicists, attorneys, and administrators, all of whom shall serve as voting members. 12.H.2 Duties: The Bioethics Committee shall participate in the development of guidelines for evaluation and management of cases having bioethical implications, review institutional policies regarding care and treatment of such cases, retrospectively review cases for consistency with principles, and educate District staff, Medical Staff, and the general public on bioethics-related matters. The Bioethics Committee, or a subset of the committee, shall provide consultative services to patients and families, Medical Staff and District staff upon request; however, the content of such consultations shall not be made a part of the patient medical record. 12.I.12.G. BYLAWS COMMITTEE 12.I.112.G.1 Composition: The Bylaws Committee shall consist of at least five members of the Active Staff, including at least the Vice Chief of Staff, the Immediate Past Chief of Staff, and a senior member of management, who shall serve as an ex officio member at the invitation of the chair. The Immediate Past Chief of Staff shall serve as chair. 12.I.212.G.2 Duties: The Bylaws Committee shall: (a) (b) 12.J.12.H. conduct an annual review of the Medical Staff Bylaws and related governance documents, submitting recommendations to the MEC for changes in these documents as necessary to reflect the District s current practice with respect to Medical Staff organization and functions; and receive and evaluate for recommendation to the MEC suggestions for modification of the items specified in the annual review. CASE MANAGEMENT COMMITTEE 12.J.112.H.1 Composition: The Case Management Committee shall consist of at least three Active Staff members, selected to be broadly representative of the clinical specialties on the Medical Staff

253 12.J.212.H.2 Duties: The Case Management Committee shall: (a) (b) (c) (d) (e) 12.K.12.I. conduct utilization management studies designed to evaluate the appropriateness of admissions to the Hospital, lengths of stay, discharge practices, use of medical and hospital services and related factors thatwhich may contribute to the effective utilization of services; communicate the results of its studies and other pertinent data to the MEC and shall make recommendations for the utilization of resources and facilities commensurate with quality patient care and safety; establish a utilization review plan which shall be approved by the MEC; obtain, review, and evaluate information and raw statistical data obtained or generated by the Hospital s case management system; and be responsible for overseeing the conditions of participation for Medicare and Medicaid (in California Medi-Cal) for, Section Uutilization Rreview and Section Ddischarge Pplanning. CREDENTIALS COMMITTEE 12.K.112.I.1 Composition: The Credentials Committee shall be comprised of at least five members of the Active Staff which shall include, when possible, the vice chairs of the clinical departments and which may include additional Active Staff members as necessary, selected on a basis that will ensure representation of the clinical departments. The Ccommittee shall also include, as ex officio members without vote, the Vice Chair of the Peer Review Committee, the CMO, and a member of the Board, as ex officio members, without vote. 12.K.212.I.2 Duties: The Credentials Committee shall: (a) (b) (c) in accordance with the Bylaws, review the credentials of all applicants for Medical Staff appointment, reappointment, and clinical privileges, conduct a thorough review of the applications, interview such applicants as may be necessary, and make reports of its findings and recommendations to the MEC and to the Board, through the MEC; in accordance with the Credentials Policy, review requests for waivers of any threshold eligibility criteria and make recommendations on the same to the MEC; in accordance with the Policy on Advanced Practice Providers, review the credentials of all applicants seeking to practice as Advanced Practice Providers,

254 conduct a thorough review of the applications, interview such applicants as may be necessary, and make reports of its findings and recommendations; (d) (e) 12.L.12.J. review, as may be requested by the MEC, all information available regarding the current clinical competence and behavior of persons currently appointed to the Medical Staff and, as a result of such review, make a report of its findings and recommendations.; and review and make recommendations regarding appropriate threshold eligibility criteria for clinical privileges throughout the District, including specifically as set forth in Section 4.A.3 ( Clinical Privileges for New Procedures ) and Section 4.A.4 ( Clinical Privileges That Cross Specialty Lines ) of the Credentials Policy. GRADUATE MEDICAL EDUCATION COMMITTEE ( GMEC ) 12.L.112.J.1 Composition: The GMEC shall be comprised of the Chief Resident one resident representative from each program, and two residents elected by their peers and appointed by the Chief of Staff (all resident members must be in good standing with the residency program during the course of appointment), the Program Directors, the Secretary-Treasurer of the Medical Staff, the ACGME Designated Institutional Official ("DIO"), the Director of Graduate Medical Education ("GME"), the CMO, the COO, a Board representative, the Director of Performance Improvement, and representatives of any necessary departments, which may include Emergency Medicine, Family Medicine, Internal Medicine, Pediatrics, Psychiatry, Critical Care/Pulmonary/Critical Care/Adult Hospitalists, and Surgery, who shall be elected by the relevant department and appointed by the Chief of Staff. The GMEC shall recommend one of its members to serve as the chair (who shall be a member of the Medical Staff) and the Chief of Staff shall appoint the chair to a twoyear term. The chair shall be eligible for reappointment. 12.L.212.J.2 Duties: In collaboration with the GMEC, the DIO has authority and responsibility for oversight and administration of the Sponsoring Institution s ACGME accredited programs as well as responsibility for ensuring compliance with the ACGME Institutional, Common, and Specialty/Subspecialty specific program requirements. It is the purpose of the GMEC to provide a high quality and safe educational environment conducive to preparing physicians for the independent practice of medicine. 12.M.12.K. HEALTH INFORMATION MANAGEMENT COMMITTEE 12.M.112.K.1 Composition: The Health Information Management Committee, when possible, shall be comprised of the Director of Health Information Management and at least one representative from each clinical department, the nursing service, the medical records department, and hhospital administration, all of whom are voting members

255 12.M.212.K.2 Duties: The Health Information Management Committee shall: (a) (b) (c) 12.N.12.L. review and evaluate medical records, or a representative sample, to determine whether they meet the standards of the Medical Staff and relevant regulatory and accreditation requirements; review and make recommendations for Medical Staff and Hospital policies, rules and regulations relating to medical records, including completion, forms and formats, filing, indexing, storage, destruction, availability and methods of enforcement; and provide liaison with Hospital administration and medical records personnel in the employ of the Hospital on matters relating to medical records practices. INFECTION PREVENTION COMMITTEE 12.N.112.L.1 Composition: The Infection Prevention Committee shall be comprised of at least three members, including representatives from the departments of medicine, surgery, obstetrics/gynecology, pediatrics, pathology, nursing service, administration, and the Infection Control Coordinator. It may include non-voting consultants in microbiology and non-voting representatives from relevant hospital services. 12.N.212.L.2 Duties: The Infection Prevention Committee shall: (a) (b) (c) (d) (e) (f) develop a hospital-wide infection prevention program and maintain surveillance over the program; develop a system for reporting, identifying, and analyzing the incidence and cause of nosocomial infections, including assignment of responsibility for the ongoing collection and analytic review of such data, and follow-up activities; develop and implement a preventive and corrective program designed to minimize infection hazards, including establishing, reviewing and evaluating aseptic, isolation and sanitation techniques; develop written policies defining special indications for isolation requirements; coordinate action on findings from the Medical Staff s review of the clinical use of antibiotics; act upon recommendations related to infection prevention received from the Chief of Staff, the MEC, departments and other committees; and

256 (g) 12.O.12.M. review sensitivities of organisms specific to the facility. INTERDISCIPLINARY PRACTICE COMMITTEE 12.O.112.M.1 Composition: The Interdisciplinary Practice Committee shall be comprised of an equal number of physicians and/or Advanced Practice Providers appointed by the MEC and registered nurses appointed by the CNOhief Nursing Officer and the CEO. Licensed or certified health professionals other than registered nurses who are performing or will perform functions shall also be included as members. The CMO shall be an ex officio member of the committee, with vote. 12.O.212.M.2 Duties: The Interdisciplinary Practice Committee shall be responsible for overseeing the establishment and administration of standardized procedures for registered nurses and oversee the practice of Advanced Practice Providers. Specifically, the committee shall: (a) establish and administer standardized procedures for registered nurses as follows: (i) (ii) (iii) (iv) (v) (vi) prescribe a required form for standardized procedures, including the subject to be covered; identify the nursing functions that require the adoption of standardized procedures and ensure that registered nurses perform them only in accordance with standardized procedures; establish a method for the review and approval of all proposed standardized procedures; review and recommend approval of all proposed standardized procedures covering registered nurses at the District; ensure that the CNOchief nurse executive has a system in place for identifying and designating the registered nurses who are qualified to practice under each standardized procedure, both on an initial and a continuing basis; and ensure that the names of registered nurses approved to perform functions according to each standardized procedure are on file in the office of the CNO chief nurse executive or at some other designated place; (b) oversee Advanced Practice Providers who practice at the District, as follows: (i) identify specific categories of Advanced Practice Providers that might perform services at the District and make appropriate recommendations;

257 (ii) (iii) (iv) (v) make recommendations concerning the minimum standards of practice applicable to Advanced Practice Providersallied health professional categories at the District; make recommendations concerning the supervision required for Advanced Practice Providers at the District; review applications for permission to practice and renewal of permission to practice and privileges granted to practitioners from accepted categories in accordance with applicable Medical Staff bylaws, rules/regulations and policies; and conduct investigations and review concerns related to the practice of Advanced Practice Providers, in accordance with applicable Medical Staff bylaws, rules/regulations and policies; (c) (d) 12.P.12.N. recommend policies and procedures for the granting of expanded role privileges to Registered Nurses; and review and recommend approval of standardized procedures under which Registered Nurses practice in expanded roles. JOINT CONFERENCE COMMITTEE 12.P.112.N.1 Composition: The Joint Conference Committee shall be composed of a member of the Board of Directors, the Medical Staff Officers, the CMO (ex officio), and the CEO (ex officio). The member from the Board and the Chief of Staff shall have voting privileges. Other District representatives and/or Medical Staff members may attend as determined by the chair. 12.P.212.N.2 Duties: The Joint Conference Committee shall constitute a forum for the discussion of matters of District and Medical Staff policy, practice and planning and the primary forum for interaction between the Board and the Medical Staff on such matters as may be referred by the MEC or the Board. 12.Q.12.O. PEER REVIEW COMMITTEE ( PRC ) 12.Q.112.O.1 Composition: The PRC shall be comprised of at least five members of the Active Staff, which shall include, when possible, the vice chairs of the clinical departments and which may include additional Active Staff members as necessary, selected on a basis that will ensure representation of the clinical departments. In addition, an Advanced Practice Provider recommended by the CNO and appointed by the Chief of Staff will serve as a voting member. The PI Quality and Patient Safety Medical Director and the CMO shall serve as

258 ex officio members, without vote. The PRC Cchair shall only vote to affect the outcome. The Cchair will be a member of the Active Staff and will be appointed by the Chief of Staff from committee members who have served for more than one year. The Cchair will be a voting regular member of the MEC. The committee shall elect a vice-chair who will preside at PRC meetings when the Cchair is not available, and who shall also serve as a non-voting member of the Credentials Committee. 12.Q.212.O.2 Duties: The Peer Review Committee shall: (a) (b) (c) (d) (e) (f) (g) (h) (i) 12.R.12.P. develop indicators that measure standards of care based on best practices, whether internally developed or externally imposed, in conjunction with individual departments and care groups; review aggregated results of indicators of best practice to determine trends relevant to physician performance and identify any individual outliers; review cases in which an individual patient s care has been or may have been compromised by the care provided, either by individual or aggregate (group) practitioners; identify opportunities for improvement, either for individuals or in the aggregate, and communicate the issues and need for a plan for improvement to the appropriate individuals, groups, or departments; assure that plans for improvement are developed in a timely manner and monitor progress; develop and oversee policies and procedures for outside case review; work collaboratively with the hospital s performance improvement department in collecting and refining information regarding physician performance; review screening tools, referral systems and performance indicators for relevance at least annually, in collaboration with the Medical Staff department chairs, and make recommendations to the MEC; and work collaboratively with the Credentials Committee Chair and Medical Staff department chairs to define appropriate content and format for individual physician performance feedback reports. PHARMACY AND THERAPEUTICS COMMITTEE 12.R.112.P.1 Composition: The Pharmacy and Therapeutics Committee shall be comprised of at least three representatives from the Medical Staff and a voting representative from the

259 pharmaceutical service. The COO is a nnon-voting member.s shall include the Chief Nursing Officer and the CEO. 12.R.212.P.2 Duties: The Pharmacy and Therapeutics Committee shall: (a) (b) (c) (d) (e) (f) (g) (h) (i) 12.S.12.Q. assist in the formulation of professional practices and policies regarding the continuing evaluation, appraisal, selection, procurement, storage, distribution, use, safety procedures, and all other matters relating to drugs in the District, including antibiotic usage; advise the Medical Staff and the pharmaceutical service on matters pertaining to the choice of available drugs; make recommendations concerning drugs to be stocked on the nursing unit floors and by other services; periodically develop and review a formulary or drug list for use in the District; evaluate clinical data concerning new drugs or preparations requested for use in the District; establish standards concerning the use and control of investigational drugs and of research in the use of recognized drugs; be involved in the development and monitoring of pharmacy standardized procedures; maintain a record of all activities relating to pharmacy and therapeutics functions and submit periodic reports and recommendations to the MEC concerning those activities; and review untoward drug reactions. PROFESSIONAL STAFF QUALITY COMMITTEE 12.S.112.Q.1 Composition: (a) The Professional Staff Quality Committee shall be comprised of the following voting members: the Vice Chief of Staff (who shall serves as the Chair of the Committee), the Medical Directors of the Hospitalist Service, Emergency Department, Infectious Disease, Critical Care, Surgical Services, and Health Informatics, the Credentials Committee Chair, the Peer Review Committee Chair, the PIQuality and Patient Safety Medical Director, the Director of PIQuality and Patient Safety, the Director of Risk, the Director of Pharmacy, the Director of Nursing Practice, the Director of Clinical and Nursing Servicesthe Assistant Chief Nursing Officer, and an IS representative. The

260 Committee shall also include the following ex Oofficio, non-voting members: the Chief of the Medical Staff, the Medical Staff Secretary/-Treasurer, the Immediate Past Chief of Staff, the CNO, the CMO, and the CEO, and a KDHCD Board Member. Formatted: Font: Italic Formatted: Font: Italic (b) (c) The following committee members shall participate in setting the agenda for meetings: the Vice Chief of Staff, the of PIQuality and Patient Safety Medical Director, the PIQuality and Patient Safety Director, the Immediate Past Chief of Staff, the Chief of Staff, the Secretary/-Treasurer, and the CMO. The Professional Staff Quality Committee may appoint subcommittees to help fulfill the responsibilities and duties set forth below. All duly authorized subcommittees shall report to the Professional Staff Quality Committee at a frequency designated by that Ccommittee. 12.S.212.Q.2 Duties: The Professional Staff Quality Committee shall: (a) (b) (c) recommend for approval of the MEC plans for maintaining quality patient care throughout the District. These may include mechanisms to (i) establish systems to identify potential problems in patient care or significant departures from established patterns of clinical practice; (ii) set priorities for action on problem correction; (iii) refer priority problems for assessment and corrective action to appropriate departments or committees; (iv) monitor the results of quality assessment and improvement activities throughout the District, i.e., blood utilization review; and (v) coordinate quality improvement activities that ensure that the findings, conclusions, recommendations, and actions taken to improve the organization s performance are communicated to the appropriate Medical Staff members; and submit regular confidential reports to the MEC on the quality of medical care provided and on quality review activities conducted. measure, assess, and improve the following: Formatted: Level 5, Indent: Left: 1", No bullets or numbering (i) (ii) (iii) (iv) patient safety, including processes to respond to patient safety alerts, meet patient safety goals, and reduce patient safety risks; the District s and individual practitioners performance on Joint Commission and Centers for Medicare & Medicaid Services ( CMS ) core measures; medical assessment and treatment of patients; medication usage, including review of significant adverse drug reactions, medication errors, and the use of experimental drugs and procedures; Formatted: Level 5c

261 (v) (vi) (vii) the utilization of blood and blood components, including review of significant transfusion reactions; operative and other invasive procedures, including tissue review and review of discrepancies between pre-operative and post-operative diagnoses; appropriateness of clinical practice patterns; (viii) significant departures from established patterns of clinical practice; (ix) (x) (xi) (xii) the use of developed criteria for autopsies; sentinel events, including root cause analyses and responses to unanticipated adverse events; nosocomial infections and the potential for infection; unnecessary procedures or treatment; (xiii) appropriate resource utilization; (xiv) (xv) (xvi) education of patients and families; coordination of care, treatment, and services with other practitioners and District personnel; accurate, timely, and legible completion of medical records; (xvii) the required content and quality of history and physical examinations, as well as the time frames required for completion, all of which are set forth in Appendix A to these Bylaws; (xviii) review of findings from the ongoing and focused professional practice evaluation activities that are relevant to an individual s performance; and (b)(xix) communication of findings, conclusions, recommendations, and actions to improve performance to appropriate Medical Staff members, the MEC, and the Board. Formatted: Level 5c, Indent: Left: 1.5" 12.T.12.R. TRAUMA COMMITTEE 12.T.112.R.1 Composition: The Trauma Committee shall be comprised of a general surgeon, the eemergency Ddepartment mmedical ddirector/ (or designee), an orthopedic surgeon, a pediatrician, an anesthesiologist, the ICU mmedical ddirector, the OR ddirector, the eemergency ddepartment ddirector, the ttrauma ccare sservice nnurse ccoordinator, critical care and ER registered nurses, the Chief Operating Officer and any additional members as

262 may be necessary identified by the Cchair. The Cchair of the committee shall be a member of the Active Staff. 12.T.212.R.2 Duties: The Trauma Committee shall: (a) (b) (c) (d) (e) (f) (g) (h) 12.U.12.S. facilitate revision, development, and approval of integrated trauma care policies and procedures; coordinate review of trauma charts, the care of trauma patients, and the utilization of trauma services; conduct preliminary peer review for the purpose of analyzing and evaluating the quality and appropriateness of care and treatment provided to trauma patients. The committee shall routinely collect information about important aspects of patient care provided to trauma patients, periodically assess this information, and develop objective criteria for use in evaluating patient care provided to trauma patients; provide a forum for review and evaluation of performance improvement and ongoing quality of trauma care provided within the District; plan and provide continuing medical education programs; address regulatory standards/ and requirements and facilitate compliance; provide leadership for future community trauma needs; and appoint a subcommittee of the Trauma Committee to function as the Trauma Peer Review Subcommittee with responsibility and oversight of the peer review process for trauma -related cases, providing a report on the same to the Peer Review Committee and the MEC on a regular basis. WELL-BEING COMMITTEE 12.U.112.S.1 Composition: The Well-Being Committee shall be comprised of not less than five members of the Active Staff, a majority of which, including the chair, shall be physicians. The membership of the Committee shall specifically include, when possible, one member from the Department of Psychiatry, the most recent five Immediate Past Chiefs of Staff who no longer serve on the MEC, if willing, and one voting member over the age of 70, when possible. Each member shall serve a term of two years, and the terms shall be staggered as deemed appropriate by the MEC to achieve continuity. The Chief of Staff will appoint a Past Chief of Staff to serve as chair of the committee. The chair of the Ccommittee may be appointed to serve longer than a two-year term. Insofar as possible, members of the committee shall not serve as active participants on other peer review or quality improvement committees while serving on this committee

263 12.U.212.S.2 Duties: The Well-Being Committee shall receive reports related to the health, well-being, or impairment of medical/allied health staff members credentialed practitioners and, as it deems appropriate, may evaluate such reports. With respect to matters involving individual Medical Staff members, the committee may, on a voluntary basis, provide such advice, counseling or referrals as may seem appropriate. Such activities shall be confidential; however, in the event information received by the committee clearly demonstrates that the health or known impairment of a Medical Staff member poses an unreasonable risk of harm to Districthospitalized patients, that information may be referred to the MEC for formal action. The committee shall also consider general matters related to the health and well-being of the Medical Staff and, with the approval of the MEC, develop educational programs or related activities. 12.V.12.T. CREATION OF STANDING COMMITTEES The MEC may, by resolution and without amendment of these Bylaws, establish additional committees to perform one or more staff functions, subject to the approval of the Board. In the same manner, the MEC may dissolve or rearrange committee structure, duties, or composition as needed to better accomplish Medical Staff functions, also subject to the approval of the Board. Any function required to be performed by these Bylaws thatwhich is not assigned to an individual, a standing committee, or a special committee shall be performed by the MEC. 12.W.12.U. SPECIAL COMMITTEES Special committees shall be created and their members and chairs shall be appointed by the Chief of Staff and/or the MEC. Such special committees shall confine their activities to the purpose for which they were appointed and shall report to the MEC

264 ARTICLE 13 MEETINGS 13.A. MEDICAL STAFF YEAR The Medical Staff year is July 1 to June B. MEDICAL STAFF MEETINGS 13.B.1 Regular Meetings: The Medical Staff shall meet on an as-needed basis, as determined by the Medical Staff Officers, but at least quarterly. 13.B.2 Special Meetings: Special meetings of the Medical Staff may be called by the Chief of Staff, the MEC, or by a petition signed by at least 20% of the voting staff. 13.C. DEPARTMENT AND COMMITTEE MEETINGS 13.C.1 Regular Meetings: Except as otherwise provided in these Bylaws, each department and committee shall meet as necessary to accomplish itstheir functions, at times set by the chairpresiding Officer. 13.C.2 Special Meetings: A special meeting (i.e., a meeting called for the discussion and/or vote on a specific issue or matter of concern) of any department or committee may be called by or at the request of the chairpresiding Officer, the Chief of Staff, the MEC, or by a petition signed by not less than 25% of the voting staff members of the department or committee (but in no event fewer than two members). 13.C.3 Executive Sessions: Medical Staff committees and clinical departments may conduct business in formally designated executive sessions, which shall be limited to the voting members of such committees or departments as well as necessary support staff and other invitees as necessary. 13.D. PROVISIONS COMMON TO ALL MEETINGS 13.D.1 Notice of Meetings: (a) Medical Staff members shall be provided notice of all regular meetings of the Medical Staff and regular meetings of departments and committees at least seven days in advance of the meetings. The means of notification shall be at the discretion of the Medical Staff Services Department and may be accomplished

265 through written, electronic, or telephonic means, including, but not limited to, posting and electronic scheduling. All notices shall state the date, time, and place of the meetings. (b) (c) When a special meeting of the Medical Staff, a department, or a committee (other than the MEC) is called, the required notice period shall be reduced to 48 hours (i.e., must be given at least 48 hours prior to the special meeting). The required notice period for special meetings of the MEC shall be reduced to 24 hours. In addition, posting may not be the sole mechanism used for providing notice of any special meeting. The attendance of any individual at any meeting shall constitute a waiver of that individual s objection to the notice given for the meeting. 13.D.2 Quorum and Voting: (a) For any regular or special meeting of the Medical Staff, department, or committee, those voting members present (but not fewer than two) shall constitute a quorum. The Eexceptions to this general rule is that for meetings of the MEC, Credentials Committee, Peer Review Committee, and the Graduate Medical Education Committee, the presence of at least 50% of the voting members of the committee shall constitute a quorum.are as follows: (1) for meetings of the MEC, Credentials Committee, Peer Review Committee, and the Graduate Medical Education Committee, the presence of at least 50% of the voting members of the committee shall constitute a quorum.; and Formatted: Indent: Left: 1.5", No bullets or numbering (2) for amendments to these Medical Staff Bylaws, at least 30% of those eligible to vote shall constitute a quorum. (b) (c) Recommendations and actions of the Medical Staff, departments, and committees shall be by consensus when possible. In the event it is necessary to vote on an issue, that issue will be determined by a majority vote of those voting members present. In the discretion of the chairpresiding Officer (e.g., the Chief of Staff, the department chair, or the committee chair), as an alternative to a formal meeting, the voting members of the Medical Staff, a department, or a committee may also be presented with a question by mail, facsimile, , hand-delivery, telephone, or other technology approved by the Chief of Staff, and their votes returned to the chairpresiding Officer by the method designated in the notice. Except for amendments to these Bylaws and actions by the MEC, the Credentials Committee, the Peer Review Committee, and the Graduate Medical Education Committee (as noted in (a)), a quorum for purposes of these votes shall be the number of responses returned to the chairpresiding Officer by the date indicated (but not fewer than two). The question raised shall be determined in the

266 affirmative and shall be binding if a majority of the responses returned has so indicated. (d) Meetings may be conducted by , telephone conference, or videoconference. 13.D.3 Agenda: The chairpresiding Officer for the meeting shall set the agenda for any regular or special meeting of the Medical Staff, department, or committee. 13.D.4 Rules of Order: Robert s Rules of Order shall not be binding at meetings and elections, but may be used for reference in the discretion of the chairpresiding Officer for the meeting. Rather, specific provisions of these Bylaws and Medical Staff, department, or committee custom shall prevail at all meetings. The chairpresiding Officer shall have the authority to rule definitively on all matters of procedure. 13.D.5 Minutes, Reports, and Recommendations: (a) (b) (c) Minutes of all meetings of the Medical Staff, departments, and committees shall be prepared and shall include a record of the attendance of members and the recommendations made and the votes taken on each matter. The minutes shall be deemed final upon authenticated by the Presiding Officer following approval by the relevant body. A summary of all recommendations and actions of the Medical Staff, departments, and committees shall be transmitted to the MEC. The Board shall be kept apprised of the recommendations of the Medical Staff and its clinical departments and committees. A permanent file of the minutes of all meetings shall be maintained by the Medical Staff Office. 13.D.6 Confidentiality: All Medical Staff business conducted by committees or departments is considered confidential and proprietary and should be treated as such. However, members of the Medical Staff who have access to, or are the subject of, credentialing and/or peer review information understand that this information is subject to heightened sensitivity and, as such, agree to maintain the confidentiality of this information. Credentialing and peer review documents, and information contained therein, must not be disclosed to any individual not involved in the credentialing or peer review processes, except as authorized by these Bylaws or other applicable Medical Staff policy. A breach of confidentiality with regard to any Medical Staff information may result in the imposition of disciplinary action

267 13.D.7 Attendance Requirements: (a) (b) Attendance at all meetings of the MEC, the Credentials Committee, and the Peer Review Committee is required. All members are required to attend at least 50% of all regular and special meetings of these committees per appointment term. Failure to attend the required number of meetings may result in replacement of the member. Each Active Staff member is expected to attend and participate in Medical Staff meetings and applicable department and committee meetings each year

268 ARTICLE 14 CONFLICT OF INTEREST A matrix that illustrates the conflict of interest guidelines set forth in this article is attached as an Appendix A. 14.A. General Principles: (1) All those involved in credentialing and professional practice evaluation activities must be sensitive to potential conflicts of interest in order to be fair to the individual whose qualifications are under review, to protect the individual with the potential conflict, and to protect the integrity of the review process. (2) It is also essential that peers participate in credentialing and professional practice evaluation review activities in order for these activities to be meaningful and effective. Therefore, whether and how an individual can participate must be evaluated reasonably, taking into consideration common sense and objective principles of fairness. 14.B. Immediate Family Members: No immediate family member (spouse, parent, child, sibling, or in-law) of a practitioner whose application or care is being reviewed shall participate in any aspect of the review process, except to provide information. 14.C. Contractual Relationship with the District: A contractual arrangement with the District or an affiliate shall not, in and of itself, preclude an individual from participating in credentialing and professional practice evaluation activities. Rather, participation by such individuals shall be evaluated as outlined in the paragraphs below. 14.D. Actual or Potential Conflict Situations: With respect to a practitioner whose application or care is under review, actual or potential conflict situations involving other members of the Medical Staff include, but are not limited to, the following: (1) significant financial relationships exists (e.g., members of small, single specialty group; referral relationship; partners in business venture); (2) being a direct competitor; (3) close friendship; (4) history of personal conflict; (5) personal involvement in the care of a patient thatwhich is subject to review;

269 (6) raising the concern that triggered the review; or (7) prior participation in review of the matter at a previous level. Any such individual shall be referred to as an Interested Member in the remainder of this Article for ease of reference. 14.E. Guidelines for Participation in Credentialing and Professional Practice Evaluation Activities: An Interested Member shall have the obligation to disclose any actual or potential conflict of interest. When an actual or potential conflict situation exists as outlined in the paragraph above, the following guidelines shall be used. (1) Initial Reviewers. An Interested Member may participate as an initial reviewer as long as there is a check and balance provided by subsequent review by a Medical Staff committee. This applies, but is not limited, to the following situations: (a) (b) participation in the review of applications for appointment, reappointment, and clinical privileges because of the Credentials Committee s and MEC s subsequent review of credentialing matters; and participation as a case reviewers in professional practice evaluation activities because of the Peer Review Committee s subsequent review of peer review matters. (2) Credentials Committee or Peer Review Committee Member. An Interested Member may fully participate as a member of these committees because these committees do not make any final recommendation that could adversely affect the clinical privileges of a practitioner, which is only within the authority of the MEC. However, the chairs of these committees always have the discretion to recuse an Interested Member if they determine that the Interested Member s presence would inhibit full and fair discussion of the issue or would skew the recommendation or determination of the committee. (a) (b) Ad Hoc Investigating Committee. Once a formal investigation has been initiated, additional precautions are required. Therefore, an Interested Member may not be appointed as a member of an ad hoc investigating committee, but may be interviewed and provide information to the ad hoc investigating committee if necessary for the committee to conduct a full and thorough investigation. MEC. An Interested Member will be recused and may not participate as a member of the MEC when the MEC is considering a recommendation that could adversely affect the clinical privileges of a practitioner, subject to the rules for recusal outlined below

270 (c) Board. An Interested Member will be recused and may not participate as a member of the Board when the Board is considering a recommendation that could adversely affect the clinical privileges of a practitioner, subject to the rules for recusal outlined below. 14.F. Guidelines for Participation in Development of Privileging Criteria: Recognizing that the development of privileging criteria can have a direct or indirect financial impact on particular physicians, the following guidelines apply. Any individual who has a personal interest in privileging criteria, including criteria for privileges that cross specialty lines or criteria for new procedures, may: (1) provide information and input to the Credentials Committee or an ad hoc committee charged with development of such criteria; (2) participate in the discussions or actions of the Credentials Committee or an ad hoc committee charged with development of such criteria because these committees do not make the final recommendation regarding the criteria (however, the Cchair of the Credentials Committee or ad hoc committee always has the discretion to recuse an Interested Member in a particular situation, in accordance with the rules for recusal outlined below); butand (3) participate in the discussions or actions of the MEC when it is considering its final recommendation to the Board regarding the criteria or participate in the final discussions or action of the Board related to the criteria. 14.G. Rules for Recusal: (1) When determining whether recusal in a particular situation is required, the Chief of Staff or committee chairman shall consider whether the Interested Member s presence would inhibit full and fair discussion of the issue before the committee, skew the recommendation or determination of the committee, or otherwise be unfair to the practitioner under review. (2) Any Interested Member who is recused from participating in a committee or Board meeting must leave the meeting room prior to the committee s or Board s final deliberation and determination, but may answer questions and provide input before leaving. (3) Any recusal will be documented in the committee s or Board s minutes. (4) Whenever possible, an actual or potential conflict should be brought to the attention of the Chief of Staff or committee chair, a recusal determination made, and the Interested Member informed of the recusal determination prior to the meeting

271 14.H. Other Considerations: (1) Any member of the Medical Staff who is concerned about a potential conflict of interest on the part of any other member, including but not limited to the situations noted in the paragraphs above, must call the conflict of interest to the attention of the Chief of Staff (or to the Vice Chief of Staff if the Chief of Staff is the person with the potential conflict) or the applicable committee/board chair. The member s failure to provide such noticefy will constitute a waiver of the claimed conflict. The Chief of Staff or the applicable committee/board chair has the authority to make a final determination as to how best to manage the situation, guided by this Article, including recusal of the Interested Member, if necessary. (2) No staff member has a right to compel the recusaldisqualification of another staff member based on an allegation of conflict of interest. Rather, that determination is within the discretion of the Medical Staff Leaders or Board chair, guided by this Article. (3) The fact that an individual chooses to refrain from participation, or is excused from participation in any credentialing or peer review activity, shall not be interpreted as a finding of actual conflict that inappropriately influenced the review process

272 ARTICLE 15 CONFIDENTIALITY AND PEER REVIEW PROTECTION 15.A. CONFIDENTIALITY Actions taken and recommendations made pursuant to these Bylaws shall be strictly confidential. Individuals participating in, or subject to, credentialing and professional practice evaluation activities shall make no disclosures of any such information (discussions or documentation) outside of committee meetings, except: (1) when the disclosures are to another authorized member of the Medical Staff or authorized District employee who has agreed to maintain the confidentiality of such information and are for the purpose of researching, investigating, or otherwise conducting duly authorized credentialing and professional practice evaluation activities; or (2) when the disclosures are authorized by a Medical Staff or District policy that has been approved by the MEC. Any breach of confidentiality shall be reviewed by the MEC and may result in a professional review action and/or appropriate legal action. Such breaches are unauthorized and do not waive the peer review privilege. Any member of the Medical Staff who becomes aware of a breach of confidentiality must immediately inform the CEO or the Chief of Staff (or the Vice Chief of Staff if the Chief of Staff is the person committing the claimed breach). 15.B. PEER REVIEW PROTECTION (1) All credentialing and professional practice evaluation activities pursuant to these Bylaws shall be performed by peer review committees in accordance with California law. These committees include, but are not limited to: (a) all standing and ad hoc Medical Staff and District committees that have been assigned protected peer review activities; Formatted: Level 4 Alt, Outline numbered + Level: 4 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Tab after: 1" + Indent at: 1" (b) (c) (d) (e) all clinical departments of the Medical Staff; hearing panels; the Board and any committees thatwhich engage in peer review activities, but only with regard to those protected peer review activities; and any individual acting for or on behalf of any such entity, including but not limited to department chairs and, department vice chairs, committee chairs and members, officers of the Medical Staff Officers, the CMO, and experts or consultants retained to assist in peer review activities

273 All reports, recommendations, actions, and minutes (and all drafts thereof) made, or taken, or received by peer review committees and correspondence sent by such committees are confidential and covered by the applicable provisions of California law. All peer review committees shall also be deemed to be professional review bodies as that term is defined in the Health Care Quality Improvement Act of 1986, 42 U.S.C et seq

274 ARTICLE 16 INDEMNIFICATION Provided the Covered Individual to be indemnified has endeavored in good faith to comply with all laws and regulations, the applicable Medical Staff Bylaws, Rules and Regulations, and policies of the Medical Staff, the District shall, to the extent allowable by law, indemnify, defend, and hold harmless Covered Individuals from and against losses and expenses (including attorneys fees, judgments, settlements, regulatory fines, and all other costs, direct or indirect) incurred or suffered by reason of or based upon any threatened, pending, or completed action, suit, proceeding, investigation, or other dispute relating or pertaining to any alleged act or failure to act within the scope of peer review, quality assessment, or other Medical Staff functions as described in these Bylaws, the Rules and Regulations, and related policies of the Medical Staff including, but not limited to, (1) as a member of or witness for a Medical Staff department, division, committee or hearing panel, (2) as a member of or witness for the District bboard or any District task force, group, or committee, and (3) as a person providing information to any Medical Staff or District group, committee, officer, bboard member or employee for the purpose of aiding in the evaluation of the qualifications, fitness, or character of a Medical Staff member or applicant. The Covered Individual may seek indemnification for such losses and expenses under this Bylaws provision, statutory and case law, any available liability insurance or otherwise as the Covered Individual sees fit, and concurrently or in such sequence as the Covered Individual may choose. Payment of any losses or expenses by the Covered Individual is not a condition precedent to the District s indemnification obligations hereunder. For purposes of this Article, Covered Individuals shall include the Medical Staff organization, administrative personnel, Medical Staff members, witnesses, consultants, hearing officers, arbitrators, hearing panel members, and invited participants in the Medical Staff functions described above. All issues regarding coverage, indemnification, or defense arising from this Article shall be resolved by an Ad Hoc Dispute Resolution Committee described in Section 12.GF

275 17.A. MEDICAL STAFF BYLAWS ARTICLE 17 AMENDMENTS (1) Neither the MEC, the Medical Staff, nor the Board shall unilaterally amend these Bylaws. (2) Amendments to these Bylaws may be proposed by the MEC or by a petition signed by at least 25% of the voting members of the Medical Staff. (3) All proposed amendments to these Bylaws must be reviewed by the MEC prior to a vote by the Medical Staff. The MEC shall present all proposed amendments to the voting staff by written ballot or to be returned to the Medical Staff Office by the date indicated by the MEC. Along with the proposed amendments, the MEC may, atin its discretion, provide a written report on them the amendments either favorably or unfavorably. To be adopted, (i) the amendment must be voted on by at least 20% of the voting staff, and (ii) the amendment must receive a two-thirds (66%) majority of the votes cast. Voting will be performed as set forth in Section 17.D. (4) The MEC shall have the power to adopt technical, non-substantive amendments to these Bylaws thatwhich are needed because of reorganization, renumbering, punctuation, spelling, or other errors of grammar or expression. (5) All amendments shall be effective only after approval by the Board, which approval shall not be unreasonably withheld. (6) If the Board has determined not to accept a recommendation submitted to it by the MEC or the Medical Staff, the MEC may request a conference between the officers of the Board and the officers of the Medical Staff Officers through the use of a Joint Conference Committee. Such conference shall be for the purpose of further communicating the Board s rationale for its contemplated action and permitting the officers of the Medical Staff Officers to discuss the rationale for the recommendation. Such a conference will be scheduled by the CEO within two weeks after receipt of a request. Following the Joint Conference Committee review process, the Board shall make a decision on the recommendation within 60 days. If the Board declines to adopt such a recommendation, it shall state the reasons for that determination in writing, which shall be provided to the MEC or Medical Staff, as applicable. 17.B. OTHER MEDICAL STAFF DOCUMENTS (1) In addition to the Medical Staff Bylaws, there shall be policies, procedures, and Rules and Regulations that shall be applicable to all members of the Medical Staff and other individuals who have been granted clinical privileges or a scope of practice. All Medical Staff policies, procedures, and Rules and Regulations shall

276 be considered an integral part of the Medical Staff Bylaws, but will be amended in accordance with this section. (2) An amendment to the Medical Staff Rules and Regulations shall be made in the same manner as the Medical Staff Bylaws as set forth in Section 17.A. (3) All other policies of the Medical Staff may be adopted and amended by a majority vote of the MEC. No prior notice is required. (4) Adoption of, and changes to, the Medical Staff Rules and Regulations, and other Medical Staff policies will become effective only when approved by the Board. (5) The present Medical Staff Rules and Regulations are hereby readopted and placed into effect insofar as they are consistent with these Bylaws, until such time as they are amended in accordance with the terms of these Bylaws. To the extent any existingpresent Rule or Regulation is inconsistent with these Bylaws, it is of no force or effect. 17.C. CONFLICT MANAGEMENT PROCESS (1) When there is a conflict between the Medical Staff and the MEC with regard to: (a) proposed amendments to the Medical Staff Bylaws or Rules and Regulations; Formatted: Outline numbered + Level: 4 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Tab after: 1" + Indent at: 1" (b) (c) a new policy proposed or adopted by the MEC; or proposed amendments to an existing policy that is under the authority of the MEC, a special meeting of the Medical Staff to discuss the conflict may be called by a petition signed by not less than 25% of the voting members of the Medical Staff. The agenda for that meeting will be limited to attempting to resolve the differences that exist with respect to the amendment(s) or policy at issue. A petition to initiate the conflict management process shall designate two Active Medical Staff members to serve as representatives of the petitioners, describe the nature of the conflict, and state the reasons why the conflict management process should be utilized to address it. (2) With respect to each particular conflict, the MEC shall determine and specify a process that the MEC deems most appropriate to the issues and circumstances. At a minimum, the conflict management process shall do all of the following: (a) (b) Provide a reasonably timely, efficient and meaningful opportunity for the parties to express their views; Require good-faith participation by representatives of the parties; and Formatted: Indent: Left: 1" Formatted: Outline numbered + Level: 4 + Numbering Style: 1, 2, 3, + Start at: 1 + Alignment: Left + Aligned at: 0.5" + Tab after: 1" + Indent at: 1" Formatted: Level 4c Alt, Indent: Left: 1", Outline numbered + Level: 4 + Numbering Style: a, b, c, + Start at: 1 + Alignment: Left + Aligned at: 1.5" + Tab after: 2" + Indent at: 2", Tab stops: Not at Formatted: Level 4c Alt, Tab stops: Not at 1.5" + 2"

277 (c) Provide for a written decision or recommendation by the MEC on the issues within a reasonable time, including an explanation of the MEC's rationale for its decision or recommendation. (6)(3) At the MEC's discretion, the process for management of a conflict between the MEC and Medical Staff members may include the involvement of a third party to facilitate or mediate the conflict management efforts. (7)(4) This conflict management process shall be a necessary prerequisite to any proposal to the Board by Medical Staff members for adoption or amendment of a Bylaw, Rules provision or policy not supported by the MEC, including, but not limited to, a proposed Bylaws amendment intended to remove from the MEC some authority that has been delegated to it by the Medical Staff. If the differences cannot be resolved, the matter shall be referred to an Ad Hoc Dispute Resolution Committee for further review and disposition. Formatted: Font: 12 pt Formatted: Font: 12 pt Formatted: Font: 12 pt Formatted: Font: 12 pt Formatted: Font: 12 pt Formatted: Font: 12 pt Formatted: Font: 12 pt (8)(5) This conflict management section is limited to the matters noted above. It is not to be used to address any other issue, including, but not limited to, professional review actions concerning individual members of the Medical Staff. (9)(6) Nothing in this section is intended to prevent individual Medical Staff members from communicating positions or concerns related to the adoption of, or amendments to, the Medical Staff Rules and Regulations or other Medical Staff policies directly to the Board. Communication from Medical Staff members to the Board will be directed through the CEO, who will forward the request for communication to the Chair of the Board. The CEO will also provide notification to the MEC by informing the Chief of Staff of all such exchanges. The Chair of the Board will determine the manner and method of the Board s response to the Medical Staff member(s). 17.D. VOTING PROCEDURE FOR AMENDMENTS (1) Ballots will be sent to all Active Medical Staff via . Notifications will then be sent to all Active Staff via text message to inform them a ballot was ed. (2) The Medical Staff Services Office will send ballots and text notifications 3 times, with at least 72 hours elapsing between s. (3) The voting will be considered final 72 hours after the third notifications are sent

278 ARTICLE 18 ADOPTION These Medical Staff Bylaws are adopted and made effective upon approval of the Board, superseding and replacing any and all previous Medical Staff Bylaws, Rules and Regulations, policies, manuals, or District policies pertaining to the subject matter thereof. Adopted by the Medical Staff:, 2018 Approved by the Board:,

279 APPENDIX A MEDICAL STAFF CATEGORIES SUMMARY Active Courtesy Consulting Community Affiliate Honorary/ Administrative Basic Requirements Number of patient contacts/2-year > 24 > 6 & < 24 NA N N Rights Admit Y > 6 & < 24 Y N N Exercise clinical privileges Y Y Y N N May attend meetings Y Y Y Y Y Voting privileges Y P P P P Hold office Y N, unless waiver N, unless waiver N, unless waiver N, unless waiver Responsibilities Serve on committees Y Y Y Y Y Emergency call coverage Y FUC N FUC N Meeting requirements Y N N N N Dues Y Y Y Y N Comply w/ guidelines Y Y Y Y N Y = Yes N = No P = Partial (with respect to voting, only when appointed to a committee) FUC = Follow-up care

280 APPENDIX AB HISTORY AND PHYSICAL EXAMINATIONS A. General Documentation Requirements 1. A complete medical history and physical examination ("H&P") must be performed and documented in the patient s medical record within 24 hours after admission, observation, or prior to surgery or an invasive procedure requiring anesthesia services by an individual who has been granted privileges by the District to perform histories and physicals. 2. The scope of the H&Pmedical history and physical examination will include, as pertinent: date of service; patient identification (i.e., name, gender, age); chief complaint; history of present illness; review of systems; personal medical history, including medications and allergies; family medical history; social history, including any abuse or neglect; physical examination, to include pertinent findings in those organ systems relevant to the presenting illness and to co-existing diagnoses; data reviewed; assessments, including problem list; impression, plan of treatment; if applicable, signs of abuse, neglect, addiction, or emotional/behavioral disorder, which will be specifically documented in the physical examination, and any need for restraint or seclusion, which will be documented in the plan of treatment; mental health hospital patients require each cranial nerve, I XII, to be individually assessed; and

281 medical necessity certification for inpatient admissions to include: (i) estimated time patient will need to be hospitalized; (ii) inpatient admission is reasonable and medically necessary; and (iii) reason for inpatient admission. 3. In the case of a pediatric patient, the H&Phistory and physical examination report must also include: (i) developmental age; (ii) length or height; (iii) weight; (iv) head circumference (if appropriate); and (v) immunization status. B. H&Ps Performed Prior to Admission, Observation, or Surgery/Invasive Procedure 1. Any H&Phistory and physical performed more than 30 days prior to an admission or registration does not meet the requirements of this provisionis invalid. 2. If an H&P medical history and physical examination has been completed within the 30-day period prior to admission or registration, a durable, legible copy of this report may be used in the patient s medical record. However, in these circumstances, the patient must also be evaluated within 24 hours after the time of admission, observation, or prior to surgery/invasive procedure, whichever comes first, and an update recorded in the medical record by an individual who has been granted clinical privileges by the District to perform histories and physicals. 3. The update of the H&P history and physical examination shall be based upon an examination of the patient and must reflect (i) any changes in the patient s condition since the date of the original history and physical that might be significant for the planned course of treatment or (ii) state that there have been no changes in the patient s condition. C. Cancellations, Delays, and Emergency Situations 1. When the H&Phistory and physical examination is not recorded in the medical record before a surgical or other invasive procedure (including, but not limited to, procedures performed in the operative suites, endoscopy, colonoscopy, bronchoscopy, cardiac catheterizations, radiological procedures with sedation, and procedures performed in the Emergency Room), the operation or procedure will be canceled or delayed until an appropriate H&Phistory and physical examination is recorded in the medical record, unless the attending physician states in writing that an emergency situation exists. 2. In an emergency situation, when there is no time to record either a complete or an abbreviated H&Phistory and physical, the attending physician will record an admission or progress note immediately prior to the procedure. The admission or progress note will document, at a minimum, an assessment of the patient s heart rate, respiratory rate, and blood pressure. Immediately following the emergency procedure, the attending physician is then required to complete and document a complete H&Phistory and physical examination. D. Ambulatory and Same Day Procedure Documentation Requirements

282 For ambulatory or same day procedures, a Pre-operative History and Physical Form, approved by the Documentation Standards Committee, may be utilized. These forms shall document, at a minimum, the patient s chief complaint or reason for the procedure, relevant history of the present illness or injury, current clinical condition, general appearance, vital signs, and an assessment of the heart and lungs. E. Prenatal Records The current obstetrical record will include a complete prenatal record. The prenatal record may be a legible copy of the admitting physician s office record transferred to the District before admission. An interval admission note must be written that includes pertinent additions to the history and any subsequent changes in the physical findings. F. Skilled Nursing Facility The attending physician shall perform a patient evaluation, including a written report of a physical examination, within five days prior to admission or within 72 hours following admission. The initial history and physical must be completed by the attending physician. G. Long Term Care/Subacute The attending physician shall perform an initial evaluation and prepare a written report of physical examination of the patient within 72 hours of admission to the long-term care unit and within 48 hours of admission to the subacute unit

283 Potential Conflicts Provide Information APPENDIX C CONFLICT OF INTEREST GUIDELINES Individual Reviewer Application/ Case Levels of Participation Committee Member Credentials Peer Review MEC Ad Hoc Investigating Hearing Panel Family member Y N R R R N N R Contractual relationship with related Y Y Y Y Y Y Y Y foundation Significant financial Y Y Y Y R N N R relationship Direct competitor Y Y Y Y R N N R History of conflict Y Y Y Y R N N R Close friends Y Y Y Y R N N R Personally involved in care of patient Reviewed at prior level Raised the concern Y Y Y Y R N N R Y Y Y Y R N N R Y Y Y Y R N N R Board Y Y green Y ) means the Interested Member may serve in the indicated role, no extra precautions are necessary. yellow Y ) means that the Interested Member may generally serve in the indicated role. It is legally-permissible for such Interested Members to serve in these roles because of the check and balance provided by the multiple levels of review, and the fact that the Peer Review Committee and Credentials Committee do not have disciplinary authority. In addition, the Chair of the Credentials Committee or Peer Review Committee always has the authority and discretion to recuse a member in a particular situation if the Chair determines that the Interested Member s presence would inhibit the full and fair discussion of the issue before the committee, skew the recommendation or determination of the committee, or otherwise be unfair to the practitioner under review

284 Allowing Interested Members to participate in the credentialing or professional practice evaluation process underscores the importance of establishing (i) objective threshold criteria for appointment and clinical privileges, (ii) objective criteria to review cases against in PPE activities (adopted protocols, etc.), and (iii) objective review and evaluation forms to be used by reviewers. N R red N ) means the individual may not serve in the indicated role. (red R ) means the individual must be recused in accordance with the rules for recusal. Rules for Recusal Interested Member must leave the meeting room prior to the committee s or Board s final deliberation and determination, but may answer question and provide input before leaving. Recusal shall be specifically documented in the minutes. Whenever possible, the actual or potential conflict should be raised and resolved prior to meeting by committee or Board chair and the Interested Member informed of the recusal determination in advance. No Medical Staff member has the RIGHT to demand recusal that determination is within discretion of the Medical Staff Leaders. Voluntarily choosing to refrain from participating in a particular situation is not a finding or an admission of an actual conflict or any improper influence on the process

285 APPENDIX BD CATEGORIES OF APPROVED CATEGORIES OF ADVANCED PRACTICE PROVIDERS Those individuals currently practicing as Category I practitioners at the District are as follows: Formatted: Line spacing: single Moonlighting Residents Those individuals currently practicing as Category II practitioners at the District are as follows: Certified Nurse Midwife (CNM) Formatted: Font: Not Bold Certified Registered Nurse Anesthetist (CRNA) Nurse Practitioner (NP) Physician Assistant (PA) Those individuals currently practicing as Category III practitioners at the District are as follows: Pharmacist Formatted: Font: Not Bold

286 2017 MERP Annual Review Summary The purpose of the annual review of the Medication Error Reduction Plan (MERP) is to determine the effectiveness of the plan. Kaweah Delta Health Care District MERP goals are established and reviewed annually in accordance with Health & Safety (H&S) Code MERP goals are designed to eliminate or substantially reduce errors in the procedures and systems including, but not necessarily limited to, prescribing, prescription order communications, product labeling, packaging and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use. Internal and external data and information were utilized to identify weakness in the systems and procedures. From these identified weaknesses, MERP goals and objectives are established. The MERP is modified as warranted to guide improvements in areas where weakness or deficiencies are noted, based on internal/external medication error information. Four methods for assessing medication safety are identified in the literature (Massetti, et al., 2011) Incident report review Direct observation Chart review Trigger tool review The effectiveness of MERP goals may be assessed using any or all of these methods; the final determination of effectiveness is a consensus opinion of the Medication Safety Committee. Five levels of determination of effectiveness have been established for MERP Goals: 1. Effective in reducing system / process weakness 2. Partially effective in reducing system / process weakness 3. Potentially effective in reducing system / process weakness. 4. Not effective in reducing system / process weakness. 5. Unable to assess effectiveness in reducing system / process weakness Meyer-Massetti, C., Cheng, C. M., Schwappach, D. B., Paulsen, L., Ide, B., Meier, C. R., & Guglielmo, B. (2011). Systematic review of medication safety assessment methods. American Journal of Health-System Pharmacy, 68(3), doi: /ajhp Color KEY Gray Pink Green Previously Closed Goal Carry Over Goal Recommend Goal Closure 1

287 2017 MERP Goal Annual Review of Effectiveness Summary MERP Goals/Strategies Effectiveness of Goals Prescribing (1) (Carry Over) Prescription Order Communication (1) (Carry Over) Improve prescribing of proton pump inhibitors to reduce risk of adverse drug reactions Unable to assess effectiveness in reducing system/process weakness Carry over goal from 2016 MERP. Proton pump inhibitors (PPI) are a frequently prescribed class of medications to reduce stomach acid. However, there are a number of ways in which these drugs are overprescribed, including longer duration of use than indicated, continuation from one setting to another when not indicated (e.g., ICU to med-surg), and initiating without a clear indication. Despite their widespread use and easy availability in the community setting through over-the-counter purchases, PPIs carry a number of risks to patients. PPI restrictions and use reduction are topics of interest in both ASHP and SIDP due to the potential for patient harm. Some of the more prominent potential complications stemming from PPI use are: Clostridium difficile infection, Community-acquired pneumonia, Ischemic stroke, Fractures (e.g. hip), Vitamin malabsorption (e.g. B12). Workgroup established January 2017 Baseline data collection completed, order sets with PPI inclusion identified, and a proposed list of required indications developed New electronic health record implementation pending (go live delayed from November 2017 to 5/1/18), rule builds and other enhancements will be evaluated for implementation Effectiveness assessment methodology Evaluate inclusion and pre-selection of PPIs on commonly used order sets Develop approved set of indications for PPI use and require inclusion on all orders Audit inappropriate continuation of PPIs during transitions of care Specify criteria for pharmacy per protocol discontinuation of PPIs and substitution with an H2-receptor antagonist (H2RA) Determine cost savings from reduced PPI use Decrease the use of stated, estimated, or historical weights Partially effective in reducing system / process weakness ISMP Targeted Medication Safety Best Practice 3 was revised to address the source of patient weights. The District implemented and closed 2 MERP goals in 2015 related to documenting accurate weights utilizing the metric scale. To build upon this safe practice, and address the ISMP Best Practice for , this goal will address how often stated weights, healthcare provider estimated weights, or documented weights from a previous encounter are utilized. Relying on these weights can cause inaccurate dosing of medications (both under- and overdosing). Estimated, stated, and historical weights observed to occur in the emergency department (ED) District-wide, metric scale availability noted as a barrier Audit of acute care units revealed discrepancies for weights documented in the ED compared to acute care units. Effectiveness assessment methodology Evaluation occurred over 1 year (Q Q4 2017) Availability of ED gurneys with integral metric scales increased by 150% (12 to 30) Patients discharged from the ED with a recorded metric weight increased from 54% to 82% Patient discharged from the ED with a stated weight was reduced from 6% to 3% New EMR implementation May 1 st, 2018 offers additional safeguards to ensure accurate, timely, and metric only weights are documented. Evaluation post-go live is needed to ensure this MERP goal is fully achieved. 2

288 Product Labeling (1) (Carry Over) Administration (1) (Recommended for CLOSURE) Monitoring (1) (Carry Over) Standardize auxiliary label placement for intravenous infusions Unable to assess effectiveness in reducing system/process weakness The pharmacy department uses auxiliary stickers on various infusions to distinguish high alert characteristics or other important information that needs to be communicated to nursing staff prior to administration. The Pharmacy Quality Assurance Review Team reviewed consistency and quality of auxiliary label placement and determined additional guidance and system support of this process is needed. Near miss event reports have also been noted. Targeted infusions identified and baseline data collected; location of labels not conduscive to workflow Intervention via education of standard operating procedure and technology standardization via DoseEdge pending Pharmacy Quality Assurance Review Team overseeing project Effectiveness assessment methodology Audit DoseEdge for appropriate label placement (percentage correct) Improve the independent double check process Effective in reducing system/process weakness Carry over goal from Independent double checks (IDC) are a common strategy to reduce risk of error prior to drug administration. When an IDC is completed correctly, they can detect up to 95% of errors. One major issue is the failure to conduct an IDC in a way that is truly independent. ECRI has identified failure to conduct IDC independently as a Top 10 Patient Safety Concern and ISMP has also published recommendations to both limit and promote a true IDC for select medications. The District has experienced medication error where the IDC process failed. July 2016: Workgroup pending at this time. The proposed goal will ensure a full evaluation of use and quality of the IDC process for select medications. Weight based heparin infusions, PCA and continuous opioid infusions were identified as highrisk processes requiring improvement in conduct of IDC. September 2016: workgroup identified January 2017: IDC Training and skills validation has been incorporated into the curriculum of the mandatory high-risk infusion workshop for clinical nurses to begin mid-february. A new set of guidelines is in development with the intent of standardization of the IDC process and provision of a checklist tool per process (heparin infusion, PCA, epidural, etc.). Workshops completed in March 2017 with 584 nurses attending. Each RN was required to demonstrate initiation and titration of six infusion scenarios including six opportunities to demonstrate independent double checks (IDC). Effectiveness assessment methodology Clinical nurses completed initial IDC training and demonstrated competence. Ongoing competence is ensured by requiring new clinical nursing staff to complete IDC, this process (High Risk/Low Volume Skills training in the RN Residency Program was implemented January 2018 IDC skills validation are incorporated into annual unit-based skills fairs to ensure ongoing competence. Improve error detection, reporting, and use of information to improve Partially effective in reducing system / process weakness medication safety Kaweah Delta (KD) has experienced fewer adverse drug event (ADE) reports over time. Error-reporting systems, such as Midas, are an essential component of the medication safety program to identify potential risks, actual errors, causes of errors, and prevention strategies. A strategy for increased reporting is needed. IHI global trigger tool assessment was implemented this year to increase detection of harm events organizationally Health Services Advisory Group (HSAG) data provided by the Patient Safety department improved detection of adverse drug event date for anticoagulants, agents for diabetes, and opioids. 3

289 Use (1) (Recommended for CLOSURE) Use (2) (Carry Over) Medication Safety Coordinator began regularly attending morning huddle in the department of pharmacy to highlight recent error experiences and lessons learned Patient safety newsletter articles published by the medication safety team Effectiveness assessment methodology IHI GTT review is detecting approximately 40 events per 100 admissions during CY The results of GTT review will be incorporated into an interprofessional GME quality improvement project. An increase of 18.2% in the volume of MIDAS event reports is observed when CY 2017 is compared to CY Kaweah Delta Medical Center is participating in an joint HSAG/CDC study that will examine rates of anticoagulant-related harm in the community, results will be available Fall Evaluate perioperative medication safety Effective in reducing system/process weakness Carry over goal from The literature on perioperative (preoperative, intraoperative and immediate postoperative) medication error types and rates is sparse and consists largely of self-reported data, which undercount true errors. Because self-reports of perioperative medication errors at Kaweah Delta in calendar year 2015 number only three, there is minimal information regarding process improvement opportunities. A project proposal was designed and approved by the Research Oversight Committee and has been vetted by stakeholders in the operating room. A gap analysis of med safety best practices recommended by Association of Perioperative Registered Nurses (AORN) was completed via interviews and direct observations of procedures beginning October A PGY1 Pharmacy Practice Resident has selected this project as part their residency requirements and is helping lead efforts for this goal. Surgery observations completed December 2016; surgeon preference cards, staff interviews and policy review completed January Operating room staff meeting planned to discuss identified areas of improvement. At that time, OR leadership will determine priorities and actions moving forward. Gaps identified include: development of policy/procedures, standardization of surgeon preference cards, and ongoing education for staff. Findings will be presented at the May OR Staff meeting, at which time, the department will determine actionable items moving forward which will be reported to the Committee as applicable for the District s MERP goal. Effectiveness assessment methodology A new Perioperative Medication Safety policy (SS 4001) has been developed. A process has been proposed that would ensure the Pharmacy Department has opportunity to review new medication requests for surgeon s preference cards Medication labeling education and annual skills validation has been incorporated into the annual perioperative skills fair for RN and Technician staff Training and annual skills validation on beyond use date procedures has been incorporated into the annual perioperative skills fair for RN and Technician staff Monthly medication labeling audits have been performed in CY 2018 with 96.5% policy compliance Ensure all appropriate antidotes, reversal agents, and rescue agents are Partially effective in reducing system / process weakness readily available This goal is proposed to address ISMP Targeted Medication Safety Best Practice 9. The goal of the Best Practice is to ensure hospitals have appropriate antidote, reversal, and rescue agents available for drugs that have a high potential for adverse reactions and for those that might need quick reversal in the event of an overdose. Although the District has much in place, this goal will ensure a full evaluation is completed and communicated organizationally. A comprehensive list of agents and elements recommended by ISMP for each was developed Full gap analysis completed, pending final approval from the medication safety committee Prioritization of efforts, particularly those surrounding system support, are pending new EMR implementation. 4

290 Effectiveness assessment methodology Defined outcome of interest was to define a list of antidotes, reversal agents, and rescue agents that should be administered immediately in emergency situations to prevent patient harm. Defined list created and will be managed to meet ISMP standards by the Medication Safety Quality Focus Team. 5

291 Policy Manuals AP38 Appendix D Policy Submission Summary Manual Name: Medical Staff Support Staff Name: April McKee Routed to: Department Director Medical Director (if applicable) Medical Staff Department (if applicable) Patient Care Policy (if applicable) Pharmacy & Therapeutics (if applicable) Interdisciplinary Practice Council (if applicable) Credentials Committee (if applicable) Executive Team (if applicable) Medical Executive Committee (if applicable) Board of Directors Date: Approved By: (Name/Committee Date) MS 25 6/12 MS 25 & MS 45 6/13 Policy/Procedure Title # Status (New, Revised, Reviewed, Deleted) Name and Phone # of person who wrote the new policy or revised an existing policy Focused Professional Practice MS 45 New Teresa Boyce x2365 Evaluation Code of Conduct for Medical MS 47 New Teresa Boyce x2365 Staff & Advanced Practice Providers Practitioner Health Policy MS 49 New April McKee x2344 Medical Staff Well Being MS 02 Revised Teresa Boyce x2365 Committee Current Title: Reporting Final Decisions or Recommended Actions (Per Cal. Bus. Prof. Section effective January 1, 2011) New Title: Reporting Guidelines for (CA Business Professional Code) MS 33 Revised Teresa Boyce x2365 Rescinded/Lapsed Membership MS 25 Revised Teresa Boyce x2365 and/or Privileges Documenting Current Clinical MS 29 Reviewed Teresa Boyce x2365 Competence (Co-Manage/Co- Admit) Disruptive Medical/Advanced MS 11 Delete Practice Provider Staff Member Policy Reporting & Investigating MS 12 Delete Medical Staff Behavior Complaints Proctoring Policy MS 30 Delete

292 Subcategories of Department Manuals not selected. Policy Number: MS 45 Date Created: 08/02/2017 Document Owner: April McKee (Medical Staff Date Approved: Not Approved Yet Coordinator) Approvers: Board of Directors (Administration), Credentials Committee, Medical Executive Committee, Cindy Moccio (Board Clerk/Exec Assist-CEO), Debbie Roeben (Credentialing Coordinator), Teresa Boyce (Director of Medical Staff Svcs) Focused Professional Practice Evaluation Guidelines for Initial Proctoring Printed copies are for reference only. Please refer to the electronic copy for the latest version. Scope: 1. Newly appointed Physicians and Advanced Practice Providers 2. Practitioners who request additional clinical privileges Policy: The Medical Staff is responsible for overseeing the quality of care provided by Physicians and Advanced Practice Providers (hitherto referred to as practitioners). In order to ensure competency, all new practitioners will be required to participate in Focused Professional Practice Evaluation (FPPE) which may include proctoring, as specified by their Departments. Proctoring is an objective evaluation of a physician's clinical competence by a proctor who represents, and is responsible to the medical staff. Prospective, retrospective and concurrent proctoring and/or chart review may be used to confirm clinical competence according to each department s guidelines. PROCEDURE: I. New Staff Member Initial Appointment Responsibilities A practitioners FPPE begins when privileges are granted by the Board, either for new applicants or current members requesting new/additional privileges. 1. Proctors will be assigned by the Department Chair. The involvement of two or more proctors in the proctoring process is encouraged. 2. The new practitioner will review privileges granted and proctoring requirements as delineated on their delineation of privileges (DOP) form. 3. The new practitioner will accept the responsibility to schedule his/her cases at a time when an eligible proctor has agreed to be available The new practitioner must be proctored for the minimum number of procedures indicated on the DOP. when the practitioner demonstrates competency to the satisfaction of the proctor. 5. The practitioner must request an extension if he/she is unable to complete proctoring within the timeframe allowed. II. Temporary Physicians & Advanced Practice Providers Proctoring Guidelines

293 1. Physicians who are on site for a specific patient or to proctor another physician are not subject to the proctoring requirements of this policy. 2. Locum Tenens covering for a specific practitioner are not subject to proctoring requirements as established in this policy. 3. Long term temporary practitioners (more than 30 days) will be subject to complete proctoring requirements as established in this policy. The proctoring will be based on activity from their first patient contactand procedures performed. 2 III. IV. Proctor Responsibilities 1. A proctor will complete and sign a confidential proctoring form for each case proctored and return this form to the new staff member to compile for submission to the MSO. 2. The proctor s role is to observe and record the performance of the practitioner being proctored. The proctor is not mandated to intervene when he/she observes what could be construed as deficient performance on the part of the practitioner being proctored. 3. In an emergency situation, the proctor may intervene; even though he/she has no legal obligation to do so, and in such a circumstance, the proctor is acting in good faith and should be qualified as a Good Samaritan within the Good Samaritan laws of the State of California. 4. The activities of the proctor constitute an integral part of the peer review system of the Medical Staff, and as such, any and all information and records regarding the proctorship shall be subject to all confidentiality requirements within the bylaws and proctors are subject to all immunities accorded Medical Staff peer review activities and any applicable regulations, statutes or legal decisions. Department Responsibilities 1. The Department Chair will assigned a proctor(s) 2. Members of the Department will participate in proctoring when assigned by the Department Chair. 3. The Department Chair may consider an extension or automatic expiration of privileges for practitioners who have failed to complete proctoring within the assigned time frame. This recommendation will be forwarded to the Credentials Committee to approve the extension or allow the privileges to automatically expire, per the Medical Staff Bylaws. 4. The Department Chair will evaluate proctoring results and make a recommendation to the Credentials Committee. V. Options 1. KDHCD may accept up to 80% of proctoring from other institutions to supplement actual observation on the premises if the following conditions are present: a. Preapproval of the Department Chair and Credentials Chair. b. The range and level of privileges requested are similar at both institutions.

294 c. Proctor reports, or a summary of proctored cases (volume/procedures), have been signed and dated within the last 15 months. 3 VI. VII. Medical Staff Office (MSO) Responsibilities 1. The MSO will provide each new staff member at initial appointment with blank proctoring forms, a copy of clinical privileges granted, and proctoring requirements. This information will be sent to the practitioner by and with the Governing Board letter. 2. The MSO will send two courtesy reminders via . A final notification will be sent via certified mail 30 days prior to the deadline informing practitioners of expiration date. 3. MSO will notify Department Chair when a practitioner fails to complete proctoring within 90 days or at the end of a granted extension period. Department Chair will recommend to Credentials Committee extension of time frame or automatic relinquishment. 4. At the recommendation of the Credentials Committee the practitioner s privileges will be automatically relinquished, or an extension will be granted. If privileges are automatically relinquished, per Medical Staff Credentialing Policy 3.B., the practitioner may not reapply for one (1) year. MSO will resign practitioner from data bases and send out notification. 5. The MSO will submit a proctoring summary to the Credentials Committee. The summary will identify the successful completion of the proctoring requirements and any outstanding privileges that require an extension of time for completion of proctoring. Completion of proctoring 1. Successful Completion Proctoring shall be deemed successfully completed when the practitioner satisfactorily completes the required number of proctored cases within the time frame established and the practitioners performance in the cases meet the standard of care of the Medical Center. 2. Failure to Complete Necessary Volume Refer to Medical Staff Credentials Policy 3.B. (4). 3. Failure to Complete Proctoring Satisfactorily Refer to Medical Staff Credentials Policy 3.B. (5). Resources Medical Staff Credentials Policy 3.B. MS 44 Ongoing Professional Practice Evaluation (OPPE) / Focused Professional Practice Evaluation (FPPE) "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

295 Subcategories of Department Manuals not selected. Policy Number: MS 47 Date Created: 03/27/2018 Document Owner: April McKee (Medical Staff Date Approved: Not Approved Yet Coordinator) Approvers: Board of Directors (Administration), Medical Executive Committee, Cindy Moccio (Board Clerk/Exec Assist-CEO), Teresa Boyce (Director of Medical Staff Svcs) Code of Conduct For Medical Staff & Advanced Practice Providers Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: The purpose of this policy is to encourage behavior that promotes a culture of safety, quality and respect. A high standard of professional behavior, ethics and integrity are expected of individual members of the Medical Staff and Advanced Practice (APP) Staff at Kaweah Delta. The Code of Conduct is a statement of the ideals and guidelines for professional behavior of the Medical Staff/APP in all dealings with patients, their families, other health professionals, employees, students, vendors, government agencies, and others they may encounter. Policy: Medical Staff/APP have a responsibility for the welfare of their patients, along with a responsibility to maintain their own professional and personal well-being. Each member is expected to treat all fellow colleagues, hospital staff, students, patients and others with courtesy and respect. When a practitioner is found to have fallen short of these expectations, the Medical Staff supports tiered, non-confrontational intervention strategies focused on restoring trust, placing accountability on, and rehabilitating the offending Medical Staff/APP. However, the safeguarding of patient care and safety is paramount, and the Medical Staff will enforce this policy with disciplinary measures whenever necessary. I. DEFINITIONS A. Appropriate behavior includes any reasonable conduct to advocate for patients, to recommend improvements in patient care, to participate in the operations, leadership or activities of the organized Medical Staff, or to engage in professional practice including practice that may be in competition with the hospital. Appropriate behavior is not subject to discipline under the bylaws. B. Inappropriate behavior means conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated

296 Code of Conduct For Medical Staff & Advanced Practice Providers 2 inappropriate behavior can become a form of harassment and thereby become disruptive, and subject to treatment as disruptive behavior. C. Disruptive behavior means any abusive conduct including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised. D. Harassment means conduct toward others based on but not limited to their race, religious creed, color, national origin, physical or mental disability, marital status, sex, age, sexual orientation, or veteran status; which has the purpose or direct effect of unreasonably interfering with a person s work performance or which creates an offensive, intimidating or otherwise hostile work environment. E. Sexual harassment means unwelcome sexual advances, requests for sexual favors, or verbal or physical activity through which submission to sexual advances is made an explicit or implicit condition of employment or future employment-related decisions; unwelcome conduct of a sexual nature which has the purpose or effect of unreasonably interfering with a person s work performance or which creates an offensive intimidating or otherwise hostile work environment. F. Practitioner means physicians or advanced practice providers that have been granted membership and/or privileges at Kaweah Delta by the Board of Directors. II. TYPES OF CONDUCT A. Appropriate Behavior. Examples of appropriate behavior include, but are not limited to the following: Criticism communicated in a reasonable manner and offered in good faith with the aim of improving patient care and safety; Encouraging clear communication; Expressions of concern about a patient s care and safety; Expressions of dissatisfaction with policies through appropriate grievance channels or other civil non-personal means of communication; Use of cooperative approaches to problem resolution; Constructive criticism conveyed in a respectful and professional manner Professional comments to any professional, managerial, supervisory, or administrative staff of members of the board of Directors about patient care or safety provided by others; Active participation in medical staff and hospital meetings B. Inappropriate Behavior

297 Code of Conduct For Medical Staff & Advanced Practice Providers 3 Inappropriate behavior by Medical Staff members is strongly discouraged. Examples of inappropriate behavior include, but are not limited to the following: Belittling or berating statements; Name calling Use of profanity or disrespectful language; Inappropriate comments written in the medical record; Blatant failure to respond to patient care needs or staff requests; Personal sarcasm or cynicism; Lack of cooperation without good cause; Refusal to return phone calls, pages, or other messages concerning patient care; Condescending language; and degrading or demeaning comments regarding patients and their families; nurses, physicians, hospital personnel and/or the hospital C. Disruptive Behavior Disruptive behavior by Medical Staff members is prohibited. Examples of disruptive behavior include, but are not limited to the following: Physically threatening language directed an anyone in the hospital including physicians, nurses, other Medical Staff members or any hospital employee, administrator, or member of the Board of Directors; Physical contact with another individual that is threatening or intimidating; Throwing instruments, charts or other things; Threats of violence or retribution; Sexual harassment; and Other forms of harassment including, but not limited to, persistent inappropriate behavior and repeated threats of litigation; Repetitive inappropriate comments or disruptions in meetings D. Interventions Interventions should initially be non-adversarial in nature with the focus on restoring trust, placing accountability on and rehabilitating the offending practitioner and protecting patient care and safety. III. PROCEDURE A. Delegation by Chief of Staff At the discretion of the Chief of Staff (or Vice Chief if the Chief of Staff is the subject of the complaint), the duties here assigned to the Chief of Staff can be delegated to a designee. Designees may be the Chief Medical Officer, other Medical Staff Officers, or Department Chairs. B. Initiation of Complaints Complaints about a member of the Medical Staff regarding allegedly inappropriate or disruptive behavior are encouraged to be entered into the

298 Code of Conduct For Medical Staff & Advanced Practice Providers 4 event reporting system or to contact the Peer Review Coordinator (PRC). Information should include the following: 1. Date, time and location of the behavior; 2. A factual description of the behavior 3. The circumstances which precipitated the incident; 4. The name and medical record number of any patient or other persons who were involved in or witnessed the incident; 5. The consequences, if any, of the inappropriate or disruptive behavior as it relates to patient care of safety, hospital personnel or operations; and 6. Any action taken to intervene in or remedy the incident, including names of those intervening. The complainant will be provided a written acknowledgement of the complaint. C. Processing Behavioral Event Reports The process whereby the event report is processed is as follows (see attached flow chart): 1. Incident report is submitted through MIDAS. Reports involving physicians are immediately routed to the Medical Staff PRC and Chief Medical Officer (CMO). (VP of HR is also notified on all Hostile Work Environment or Harassment incidents). 2. The PRC does an initial screening and reports result of inquiry to CMO. 3. Minor incidents are tracked and trended. 4. Significant incidents are sent to PRC for detailed Case Review. Results are reported to CMO and Chief of Staff (COS). (If incident is considered Hostile Work Environment of Harassment, VP of HR is also informed). The following action may be taken: a. Prompt Collegial Intervention by COS and/or CMO b. Forward to Department Chair for Collegial Intervention c. Forward to Behavior Committee (which consists of COS, VCOS, PCOS, Secretary Treasurer and CMO as an ex-officio member) i. Letter will be sent to practitioner containing a synopsis of the event, asking for practitioner s view of the event with a response expected within 30 days ii. Incident and response letter discussed at subsequent Behavior Committee iii. Action may include: 1. Dismiss as unfounded or if unable to authenticate; 2. Track and Trend; 3. 1:1 conversation with practitioner and COS or other officer; 4. Request for additional information; 5. Educational letter to physician iv. Three (3) incidents in a rolling 12 months require action

299 Code of Conduct For Medical Staff & Advanced Practice Providers 5 1. Behavior Committee meets with and advises practitioner that recurring behavior must cease or corrective action will be initiated. This final warning shall be sent to the offending medical staff member in writing. d. Track and Trend e. Forward to MEC for further action per bylaws; Options are: i. FPPE developed by Department Chair ii. Referral to Well Being Committee iii. Summary Suspension: If a single incident of disruptive behavior or repeated incidents of disruptive behavior constitute an imminent danger to the health of an individual or individuals, the offending practitioner may be summarily suspended, per the Medical Staff Bylaws. The medical staff member shall have all of the due process rights set forth in the medical staff bylaws. References: Kaweah Delta Medical Staff Bylaws "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

300 Code of Conduct For Medical Staff & Advanced Practice Providers 6

301 Subcategories of Department Manuals not selected. Policy Number: MS 49 Date Created: 03/27/2018 Document Owner: April McKee (Medical Staff Date Approved: Not Approved Yet Coordinator) Approvers: Board of Directors (Administration), Medical Executive Committee, Cindy Moccio (Board Clerk/Exec Assist-CEO), Teresa Boyce (Director of Medical Staff Svcs) Practitioner Health Policy Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: In order to provide safe, high quality care at Kaweah Delta Health Care District (KDHCD) facilities, all Medical Staff and Advanced Practice Providers (Practitioners) granted privileges and/or membership by the KDHCD Board of Directors are required to adhere to the health requirements listed below. Procedure: I. Tuberculosis Screening A. Medical Staff and Advanced Practice Providers must submit evidence of a tuberculosis screening test during the initial application process and annually thereafter to the Medical Staff Services Department. Acceptable documentation: 1. PPD Skin Test that includes date administered, date read, lot # expiration date, and results of test. PPD Skin Tests can be administered by Employee Health, free of charge. The practitioner is responsible for providing the Medical Staff Services Department with the results after the test is read. 2. Quantiferon Gold-TB Blood Test 3. Positive reactors will complete the TB Affidavit form and attach a copy of their most recent chest x-ray report. A new chest x-ray is only required upon the development of TB symptoms. B. Any Medical Staff or Advanced Practice Provider exposed to a patient with TB will be contacted by the Employee Health Department for a baseline TB Test ten (10) weeks after the exposure. II. Influenza Prevention and Immunization A. Medical Staff and Advanced Practice Providers must comply with annual influenza vaccinations. Employee Health will offer the seasonal influenza vaccination free of charge to Medical Staff Members and Advanced Practice Providers. Practitioners applying for initial privileges during

302 Practitioner Health Policy 2 influenza season will be required to submit proof of vaccination with their application. Employee Health will not provide influenza vaccinations for applicants. B. All Vaccinated Health Care Professionals will be provided and wear a designation on their badge, indicating they have received a current influenza vaccination. C. The scheduled annual influenza timeframe begins November 1 and ends March 31 st unless otherwise determined by the Infection Prevention Team and/or Public Health Officer. D. In Limited Circumstances, a seasonal vaccination exemption will be permitted for either medical contraindication or religious/philosophical beliefs. 1. Documentation of influenza vaccination declination must be submitted to the Medical Staff Services Department Annually. 2. If Medical Staff or Advanced Practice Provider declines the influenza vaccination they will be required to wear a mask during the defined influenza timeframe. III. Well Being Committee A. The Medical Staff has established a Well Being Committee to provide support for providers dealing with behavioral, health, aging, and/or substance abuse issues. (See Well Being Committee Policy for details). B. Financial Assistance The Medical Staff Organization will provide up to $5,000 life-time financial assistance for fit-for-duty evaluations for a medical staff member, as required/requested by MEC or the medical staff well-being committee. References: Medical Staff Bylaws "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

303 Medical Staff Services Policy Number: MS 02 Date Created: 02/01/2007 Document Owner: April McKee (Medical Staff Date Approved: Not Approved Yet Coordinator) Approvers: Board of Directors (Administration), Medical Executive Committee, Well-Being Committee MEDICAL STAFF WELL-BEING COMMITTEE Printed copies are for reference only. Please refer to the electronic copy for the latest version. PURPOSE: In order to maintain and improve the quality of care and assist staff members in the maintenance of appropriate standards of personal performance, the medical staff Well-Being Committee is responsible to take note of and to evaluate issues related to the health, behavior, well being or impairment of medical staff/allied health members. DEFINITIONS: 1. Impaired practitioner: one who is unable to practice medicine with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process or loss of motor skill, or abuse or excessive use of drugs, including alcohol. 2. Recognition of impairment of practitioners: a. Irritability: mood swings; negative attitude; argumentative; inappropriate anger; overreaction of criticism; altercations with staff, peers and patients; personality change b. Inaccessibility: frequent tardiness; frequent absence; MIA missing in action (frequent trips to bathroom, parking lot); prolonged lunch breaks; unavailable when on call; frequent beeper failure; frequent illness c. Cognitive impairment: lack of concentration; confusion; forgetfulness; difficulty thinking/speaking d. Physical impairment (resulting in the inability to provide optimal patient care): loss of motor skills; problems with balance; poor coordination and clumsiness e. Mental impairment: disruption in thinking, feeling, moods, and ability to relate to others f. Incidentals: disheveled appearance; tremors; green tongue from mints; bruises; needle tracks; heaving drinking at staff or social functions; off-duty intoxication; runny nose; raspy voice; alcohol on breath; red, yellow or black and blue eyes; dilated or constricted pupils; staff, patient or peer complaints; slurred speech; black outs; subject of hospital gossip (marital problems, DUI, financial problems, party reputation, etc.) Formatted: Indent: Left: 0.4", No bullets or numbering 3.2. Inappropriate behavior: physical or verbal activity or any event that demeans a person, is disrespectful, causes unnecessary or unreasonable stress, or

304 MEDICAL STAFF WELL-BEING COMMITTEE 2 creates work disruption. Such behavior may include but are not limited to displaying disruptive attitudes, hollering yelling or swearing, bullying belittling or intimidating; harassment, including sexual harassment 4.3. Sexual Harassment: unwelcome verbal or physical conduct of a sexual nature which may include verbal harassment (such as epithets, derogatory comments or slurs), physical harassment (such as unwelcome touching, assault, or interference with movement or work), and visual harassment (such as the display of derogatory cartoons, drawings, or posters) RESPONSIBILITIES: The role of the Well-Being Committee is advisory in nature, and not a substitute for a personal physician or a disciplinary body. The Committee s focus should be the needs of the physician in question. It will report only to MEC and to the physician in question. REFERRALS TO THE COMMITTEE: 1. Practitioners who develop a physical/mental impairment are required to self report to the chief of staff/designee. The practitioner agrees to notify the chief of staff/designee immediately in writing upon learning that he/she has developed substance abuse, mental or physical illness, or sustained any injury which could have an effect on the exercise of his/her clinical privileges. 2. Any person, practitioner or employee, suspecting a practitioner of being impaired must initiate a report to the Well-Being Committee. The individual making the report does not have to have proof of the impairment, but must state the facts leading to the suspicions, including dates, times, locations. The report will be forwarded to the chief of staff, via the medical staff office A charge of, or arrest for, driving while intoxicated/under the influence will automatically trigger a referral to the Well Being Committee. Formatted: List Paragraph, No bullets or numbering, Tab stops: Not at -1" Formatted: Font: (Default) Arial 3.4. Recurrent inappropriate behaviors that are not amenable to informal counseling and are documented in occurrence reports or confirmed by documented interviews by medical staff leaders (MEC) or medical staff officers. The Committee: 1. Will be the identified point within the District where information and concerns about the health and behavior of an individual medical/allied health member can be delivered for consideration and evaluation. 2. May receive and assess reports related to the health, behavior, well-being or impairment of medical/allied health staff members; seek corroboration and additional information. 3. The referring source will be advised that follow-up action was taken.

305 MEDICAL STAFF WELL-BEING COMMITTEE 3 4. Provide advice, recommendations and assistance to the medical/allied health staff in question; provide recommendations for treatment and/or education; provide assistance in obtaining what is recommended. 5. Monitor medical/allied health staff for compliance with the terms of a monitoring agreement. 6. Assist medical/allied health staff with reinstatement issues. 7. Educate the members of the medical/allied health staff and other organization staff about physician health, behavior, well-being and impairment; about appropriate responses to different levels and kinds of distress and impairment; about treatment, recovery and monitoring; about the responsibilities of the medical staff in response to concerns about a medical/allied health member s health; and about appropriate resources for prevention, treatment, rehabilitation, monitoring and reinstatement. 8. When the medical staff receives a notification that a physician has entered the Medical Board of California s Diversion Program (or similar program), this communication should trigger the development of a monitoring agreement between the Well-Being Committee and the physician in diversion. a. Once practitioner has completed a program, the Well-Being Committee will establish a post-monitoring agreement whereby the practitioner agrees to provide an attestation at the time of reappointment. Attestation will address continued compliance regarding their particular issue. 9. All contacts with the committee shall be confidential to the degree protected by law. In the event information received by the committee clearly demonstrates that the health or known impairment of a medical/allied health member poses an unreasonable risk of harm to patients or others in the hospital, that information shall be conveyed to those individuals or committees within the medical staff responsible for assuring that appropriate follow-up action is taken. COMPOSITION: A minimum of ffive (5) active members of the medical staff shall be appointed by the chief of staff, a majority of which, including the chair, shall be physicians. The membership shall include a psychiatrist and up to 5 immediate Past Chiefs of Staff who no longer serve on MEC>a Except for initial appointments, each shall serve a term of two (2) years, and the terms shall be staggered. Insofar as possible, members of the committee shall not serve as active participants on other peer review or quality improvement committees while serving on this committee. Individuals who are not members of the medical staff may be appointed when such appointment will materially increase the effectiveness of the work of the committee. Involvement of the following qualified physicians is desirable:

306 MEDICAL STAFF WELL-BEING COMMITTEE 4 1. Physician recovering from alcoholism and/or other chemical dependence; 2. Psychiatrist or physician with mental health and/or addiction medicine training RECORD KEEPING Only those records should be kept which are appropriate to the charges given to the committee by the medical staff.

307 Medical Staff Services Policy Number: MS 33 Date Created: 06/01/2011 Document Owner: April McKee (Medical Staff Date Approved: Not Approved Yet Coordinator) Approvers: Board of Directors (Administration), Medical Executive Committee Reporting of Certain Final Decisions or Recommended Actions(Per Cal. Bus. Prof. Section effective January 1, 2011) Reporting Guidelines for (CA Business Professional Code) Printed copies are for reference only. Please refer to the electronic copy for the latest version. I. Policy In addition to reporting disciplinary actions under BP Section 805, certain final decisions or recommendations of the Medical Executive Committee, following formal investigation of practitioners, must be reported to the applicable licensing board - regardless of whether a hearing is held. Practitioners. This policy applies to physicians, dentists, podiatrists and psychologists, licensed midwifes and physician assistants. Formal Investigation refers to a formal disciplinary investigation performed by or under the direction of the Medical Executive Committee, pursuant to the corrective action provisions of the bylaws or rules, in which the practitioner receives notice of the reasons for the proposed action or recommendation and has a reasonable opportunity to respond. This policy does not apply to investigations or reviews conducted by clinical departments, officers, or other committees which are not part of the Medical Executive Committee s formal disciplinary process. Decisions or final recommendations covered by this policy must satisfy each of the following four elements: 1. Final decisions or recommended actions to deny, terminate or restrict (for a cumulative total of 30 days within a 12 month period) the clinical privileges of a practitioner; 2. Made by the Medical Executive Committee; 3. Following a formal investigation of the practitioner; 4. Based on the Medical Executive Committee s written determination that any of the following acts may have occurred: a. Incompetence, or gross or repeated deviation from the standard of care involving death or serious bodily injury to one or more patients, to the extent or in such manner as to be dangerous or injurious to

308 Reporting of Certain Final Decisions or Recommended Actions(Per Cal. Bus. Prof. Section effective January 1, 2011) 2 any person or to the public even if no summary suspension is required; b. The use of or prescribing for or administering to himself or herself, any controlled substance, or the use of any dangerous drug, or of alcoholic beverages, to the extent or in such manner as to be dangerous on injurious to the practitioner, any other person, or the public, or to the extent that such use impairs the ability of the licentiate to practice safely; c. Repeated acts of clearly excessive prescribing, furnishing, or administering of controlled substances or repeated acts of prescribing, dispensing or furnishing of controlled substances without a good faith effort prior examination of the patient and medical reason therefore this does not apply to a prescribing, furnishing or administering controlled substances for intractable pain consistent with lawful prescribing; d. Sexual misconduct with one or more patients during a course of treatment or examination. II. Procedure 1. Following a formal investigation Tthe Medical Executive Committee shall vote to certify in writing to the Chief of Staff and CEO thatapprove a final action or recommendation (i.e. termination, summary suspension or restriction of privileged) against a practitioner of due to actions contained in I.4 of covered by this Policy has been made.. 2. The Medical Staff Services ManagerDirector/designee shall promptly complete a facility report form required by the applicable licensing board. 3. The report form shall be signed by the Chief of Staff/designee and by the CEO/designee. 4. The report shall be transmitted within 15 days of the Medical Executive Committee s certification. 5. The Medical Staff Services managerdirector/designee shall send the practitioner a copy of the report along with notice of the practitioner s right to submit a response by electronic or other means. 6. Applicable Medical Staff officers and support staff shall proceed to implement the decision or final recommendation in accordance with the bylaws, rules and policies of the Medical Staff. 7. Applicable Medical Staff officers and support staff shall assure that any additional reporting required by Section 805 or NPDB is timely made. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

309 Reporting of Certain Final Decisions or Recommended Actions(Per Cal. Bus. Prof. Section effective January 1, 2011) 3

310 Medical Staff Services Policy Number: MS 25 Date Created: 11/01/2001 Document Owner: April McKee (Medical Staff Date Approved: Not Approved Yet Coordinator) Approvers: Board of Directors (Administration), Credentials Committee, Interdisciplinary Practice Committee, Medical Executive Committee RESCINDED OR LAPSED MEMBERSHIP AND/OR PRIVILEGES Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: It shall be the policy of the medical staff to consider an individual s request to rescind their resignation and/or reestablish medical/allied health staff membership and/or privileges if the: Resignation of or voluntary lapse in membership and/or privileges occurred within the previous 12 months. Individual resigned or voluntarily allowed their membership and/or privileges to lapse while in good standing. Individual not currently the subject of discipline or investigation by a licensing authority, governmental or regulatory body or other health care entity. PROCEDURE: The individual shall have the burden of proof in providing or complying with each of the following: A completed reappointment application accompanied by other documents required for reappraisal purposes, as defined in the medical staff bylaws. A signed statement regarding interval activity from date of resignation to present. A check in the amount of the applicationpayment of Medical Staff fees, as appropriate. Appearance at a professional interview, should it be determined necessary. The Department Chair will review and recommend reinstatement through the end of the practitioner s original term of appointment. Approval process will follow the process defined in the Medical Staff Bylaws. Formatted: List Paragraph, No bullets or numbering Formatted: List Paragraph, No bullets or numbering

311 RESCINDED OR LAPSED MEMBERSHIP AND/OR PRIVILEGES 2 If the relinquishment and/or resignation was due to an administrative error, the Department Chair may recommend temporary privileges until the reinstatement is approved through the process defined in the Medical Staff Bylaws. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

312 Adult Hospitalist Medicine Privileges in Adult Hospitalist Medicine Name: Please Print ADULT HOSPITALIST MEDICINE INITIAL CRITERIA Education/Training: M.D. or D.O.; AND Successful completion of an ACGME or AOA-accredited residency in (internal medicine, family medicine, critical care medicine) AND Successful completion of board certification or active participation in the examination process (with achievement of certification within 5 years) leading to board certification in the appropriate specialty by the ABMS or AOA Boards; Certification: ACLS Current Experience: Documentation of 80 cases required in the past two years; OR successful completion of a hospital affiliated accredited residency, special clinical fellowship, or research within the past 12 months. Renewal Criteria: Maintenance of certification or active participation in the examination process (with achievement of certification within 5 years) leading to board certification in the appropriate specialty by the ABMS or AOA Boards AND Documentation of care for 48 inpatients in the last 2 years. FPPE: Minimum of 5 diverse admissions. CORE PRIVILEGES Request Procedure Approve Core Privileges include: Evaluate, diagnose, treat, perform history and physical exam, and provide nonsurgical treatment of general medical problems, including consultation for adult patients admitted or in need of care to treat general medical problems. Admitting Privileges (must request Active or Courtesy staff status) ADVANCED PRIVILEGES (Must meet Initial Criteria) Request Procedure Additional Criteria Renewal Criteria FPPE Approve Endotracheal Tube placement Documentation of 10 procedures in the last 2 years Holter Monitor Interpretation Documentation of 10 procedures in the last 2 years Treadmill exercise testing (supervision & interpretation) Documentation of 10 procedures in the last 2 years Venous Central Line Placement Documentation of 5 procedures in the last 2 years Arterial Line Placement Documentation of 5 procedures in the last 2 years Uncomplicated Ventilator Management Documentation of 5 procedures in the last 2 years and completion of an airway management course. Documentation of 8 procedures in the last 2 years Documentation of 10 procedures in the last 2 years Documentation of 10 procedures in the last 2 years Documentation of 5 procedures in the last 2 years Documentation of 5 procedures in the last 2 years Documentation of 5 procedures in the last 2 A minimum of 5 3 concurrent None A minimum of 2 concurrent A minimum of 3 concurrent A minimum of 3 concurrent None1 concurrent ADVANCED ADDITIONAL PRIVILEGES (Must meet the Initial Criteria) Request Procedure Additional Criteria Renewal Criteria FPPE Approve Outpatient Services at a Kaweah Delta Health Care District Clinic. Please identify: Dinuba Exeter Lindsay Woodlake Family Medicine Clinic Chronic Disease Management Center Procedural Sedation Initial criteria AND Contract for services with Kaweah Delta Health Care District or KDHCD ACGME Family Medicine Program Successful completion of KDHCD sedation exam Maintain initial criteria Successful completion of KDHCD sedation exam None if currently active in the hospital; otherwise, 2 chart reviews None Adult Hospitalist Medicine 1 Approved Draft revision

313 Adult Hospitalist Medicine Acknowledgment of Practitioner: I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise and I understand that (a) In exercising any clinical privileges granted, I am constrained by any Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation. (b) Emergency Privileges In case of an emergency, any member of the medical staff, to the degree permitted by his/her license and regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient from serious harm. Name: Print Signature: Applicant Date Department of Critical Care, Pulmonology and Adult Hospitalist Medicine Chairperson's Signature Date Adult Hospitalist Medicine 2 Approved Draft revision

314 Advanced Practice Provider - Emergency Medicine/Urgent/Prompt Care Provider Name: Date: Please Print Advanced Practice Provider Emergency Medicine & Urgent/Prompt Care Location: Kaweah Delta Medical Center Urgent Care-Court St Urgent Care - North Prompt Care _ Ben Maddox _ Sequoia ADVANCED PRACTICE PROVIDER EMERGENCY MEDICINE & URGENT/PROMPT CARE Initial Criteria Physician Assistant: Completion of an ARC-PA approved program; Current certification by the NCCPA (Obtain certification within one year of completion of PA program); Current licensure to practice as a PA by the California board of medicine; OR Nurse Practitioner: Completion of a master s/post-masters or doctorate degree in an nursing program accredited by the Commission of Collegiate of Nursing Education (CCNE) or National League for Nursing Accrediting Commission (NLNAC) with emphasis on the NPs specialty area; current certification by the ANCC or AANP (Obtain certification within one year of completion of Masters/Doctorate program) Certification: Current, full schedule DEA license; AND Urgent/Prompt Care: BLS OR ACLS ; Emergency Department: ACLS; PALS & ATLS (Must obtain within 12 months of hire) Current Clinical Experience: Documentation of patient care for 100 patients in the past two years OR completion of completion of NP/PA training program within the last 12 months. Renewal Criteria: Documentation of patient care for 100 patients in the past 24 months AND maintenance of current certification by NCCPA, ANCC, or AANP; AND full schedule DEA license; AND Urgent/Prompt Care: BLS OR ACLS; Emergency Department: ACLS; PALS & ATLS FPPE: A minimum of 10 5 cases by Direct Observation and/or retrospective Chart Review at the supervising physicians discretion (proctor may require additional review) Request CORE PRIVILEGES Includes care for patients of all ages and procedures on the following list and such other procedures that are extensions of the same techniques and skills: Perform H&Ps/ OR Medical Screening Exam (MSE); Prescribe & Administer medications per formulary of designated certifying board Perform other emergency treatment per protocol Write Discharge Instructions Apply, remove, and change dressings and bandages; Perform debridement and general care for superficial wounds and minor superficial surgical procedures Counsel/ instruct patients, families, & caregivers Direct care per Emergency Room protocol Order and initial interpretation of diagnostic testing and therapeutic modalities per Emergency Room protocol Implement palliative care and end-of-life care through evaluation, modification, and documentation according to the patient s response to therapy, changes in condition, and to therapeutic interventions Implement therapeutic intervention for specific conditions per Emergency Room protocol Remove arterial catheters, central venous catheters, chest tubes; Insert and remove nasogastric tube; provide tracheostomy care Perform field infiltrations of anesthetic solutions; incision and drainage of superficial abscesses; Short-term and indwelling urinary bladder catheterization; venous punctures for blood sampling, cultures, and IV catheterization; superficial surgical procedures Removal of drains, sutures, staples, & packing Apply/remove cast; diagnosis/treatment and strapping of sprains; splinting and reduction of simple fractures and dislocations; Application of traction; general wound care; removal of foreign body; incision and drainage; Simple laceration repair (not requiring plastics intervention); nasal packing; excision of simple skin lesion; removal of impacted cerumen; insertion/removal of drains or packing; nail trephination & removal; excision of thrombosed hemorrhoids; Debridement of wounds and burns; nail trephination; Ultrasound guided paracentesis; Tonometry / Wood s & Slit Lamp exam of the eye Itraosseaus Line insertion with EZ-10 efast examination Approve Advanced Practice Provider Emergency Medicine/Urgent/Prompt Care 1 Approved: Draft revision

315 Advanced Practice Provider - Emergency Medicine/Urgent/Prompt Care Provider Name: Date: Please Print Additional Core for Emergency Medicine Privileges: Direct care per Emergency Room protocol efast examination Implement palliative care and end-of-life care through evaluation, modification, and documentation according to the patient s response to therapy, changes in condition, and to therapeutic interventions Insert and remove nasogastric tube; provide tracheostomy care Itraosseaus Line insertion with EZ-10 Perform other emergency treatment per protocol Remove arterial catheters EMERGENCY MEDICINE ADVANCED PRIVILEGES Request Procedure Criteria Renewal Criteria FPPE Requirements Lumbar Puncture 3 procedures in the last 2 3 procedures in the last 2 concurrent years 2 years Thoracentesis 5 procedures in the last 2 5 procedures in the last Minimum of 1 2 years 2 years concurrent Insertion of Chest Tubes 5 procedures in the last 2 years Endotracheal extubation and intubation 5 10 procedures in the last 2 years Insertion and removal of central venous access or 5 procedures in the last 2 dialysis catheters years Arthrocentesis & Joint aspiration 2 procedures in the last 2 years Ultrasound guided paracentesis; 5 procedures in the last 2 years 5 procedures in the last 2 years 5 8 procedures in the last 2 years 5 procedures in the last 2 years 2 procedures in the last 2 years 5 procedures in the last 2 years Minimum of 13 concurrent Minimum of 1 3 concurrent Minimum of 1 2 concurrent any site 1 concurrent 5 concurrent Approve Formatted: Font: Bold Formatted: Font: (Default) Times New Roman, 9 pt Formatted: Normal, Indent: Left: -0.01", No bullets or numbering, Adjust space between Latin and Asian text, Adjust space between Asian text and numbers Acknowledgment of Practitioner: I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise and; I understand that: (a) (b) In exercising any clinical privileges granted, I am constrained by any Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation. Emergency Privileges In case of an emergency, any member of the medical staff, to the degree permitted by his/her license and regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient from serious harm. Advanced Practice Provider Signature Date Supervising Physician Signature Date Department of Emergency Medicine Chair Signature Date Advanced Practice Provider Emergency Medicine/Urgent/Prompt Care 2 Approved: Draft revision

316 CARDIOTHORACIC SURGERY Privileges in Cardiothoracic Surgery Name: Please Print CARDIOTHORACIC SURGERY Education & Training: MD or DO; AND successful completion of a general surgery residency training program approved by the Accreditation Council for Graduate Medical Education (ACGME), by the American Osteopathic Association (AOA) or by the Royal College of Physicians & Surgeons of Canada if board certified by an ABMS board or actively pursuing board certification by an ABMS board; AND successful completion of a fellowship in general thoracic and cardiovascular surgery approved by the Accreditation Council for Graduate Medical Education (ACGME) or by the American Osteopathic Association (AOA); AND current board certification by the American Board of Surgery or the American Osteopathic Board of Surgery and board certification in thoracic surgery by the American Board of Thoracic Surgery, or active participation in the examination process leading to board certification in cardiovascular medicine by one of these boards, with certification obtained within five (5) years from the date of completion of training. Current Clinical Competence: Documentation of the performance of at least 100 cardiothoracic procedures in the past 2 years or successful completion of a residency or clinical fellowship in the past 12 months Renewal Criteria: Maintenance of Board Certification and documentation of 100 procedures reflective of the privileges requested. FPPE: Core: Direct observation of a minimum of five (5) diverse procedures; TAVR: Direct observation of the first 3 cases Request CORE PRIVILEGES Approve CORE PRIVILEGES INCLUDE: Medical H&P; evaluate, diagnose, provide consultation and treat patients over the age of one year presenting with illnesses, injuries and disorders of the thoracic cavity and related structures, including the chest wall. These privileges include operations on:abdominal and peripheral blood vessels; aortic dissection; cricothyroidotomy and tracheostomy; blood vessels of head, neck and base of brain; esophagus (intrathoracic); cardiac valve repair or replacement; heart, pericardium and great vessels; cardiopulmonary bypass; lung chest wall, pleura, diaphragm and mediastinum; repair of congenital/acquired anomalies; coronary artery bypass. The core privileges in this specialty include the procedures on the following procedure list and such other procedures that are extensions of the same techniques and skills: Ablative surgery for Wolff-Parkinson-White syndrome All procedures upon the heart for the management of acquired/congenital cardiac disease, including surgery upon the pericardium, coronary arteries, the valves, and other internal structures of the heart and for acquired septal defects and ventricular aneurysms Bronchoscopy Central Venous Access Procedures Correction or repair of all anomalies or injuries of great vessels and branches thereof, including aorta, pulmonary artery, pulmonary veins, and vena cava Endarterectomy of pulmonary artery Endomyocardial biopsy Endoscopic procedures and instrumentation involving the esophagus and tracheobronchial tree Hemodialysis Access Procedures Management of congenital septal and valvular defects Maze Medianstinoscopy Operations for myocardial revascularization Minimally invasive direct coronary artery bypass (MIDCAB) Transmyocardial Laser Revascularization Admitting Privileges (must request Active or Courtesy staff status) Pacemaker or AICD implantation and management, transvenous and transthoracic Palliative vascular procedures (not requiring cardiopulmonary bypass) for congenital cardiac disease Pericardiocentesis, pericardial drainage procedures, pericardiectomy Pulmonary embolectomy Surgery for mechanical devices to support the heart Surgery of patent ductus arteriosus and coarctation of the aorta Surgery of the aortic arch and branches; descending thoracic aorta for aneurysm/trauma Surgery of the thoracoabdominal aorta for aneurysm Surgery of tumors of the heart and pericardium Vascular access procedures for use of life support systems, such as extra corporeal oxygenation and cardiac support Vascular operations exclusive of thorax (e.g., caval interruption, embolectomy, endarterectomy, repair of excision of aneurysm, vascular graft, or prosthesis) VATS (video assisted thoracic surgery) If residency/fellowship trained prior to 1995, must demonstrate successsful completion of an approved and recognized course and provide documentation of competence in performing this procedure Cardiothoracic Surgery 1 Approved

317 CARDIOTHORACIC SURGERY ADVANCED PROCEDURES Request Procedure Initial Criteria Renewal Criteria Approve Transcutaneous Cardiac Valve Implantation and/or Repair (TAVR) Board certified or board eligible for certification in Cardiothoracic Surgery AND Documentation of training by letter from Director of Training Program OR completion of a FDA Approved certification course AND Documentation of 100 career Aortic Valve Replacements (AVR) including 10 highrisk patients OR 25 AVRS in one year; OR 50 AVRs in the last two years which include at least 20 AVRS performed in the last year. 10 procedures in the last two years as primary physician or first assistant. Procedural Sedation Outpatient Services at a Kaweah Delta Health Care District Outpatient Clinic. Please identify: Dinuba Exeter Lindsay Woodlake Family Medicine Clinic Chronic Disease Management Center Pass KDHCD Sedation/Analgesia (Procedural Sedation) Exam Executed contract with Kaweah Delta Health Care District or KDHCD ACGME Family Medicine Program Pass KDHCD Sedation/Analgesia (Procedural Sedation) Exam Maintain initial criteria Acknowledgment of Practitioner: I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise and I understand that (a) (b) In exercising any clinical privileges granted, I am constrained by any Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation. Emergency Privileges In case of an emergency, any member of the medical staff, to the degree permitted by his/her license and regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient from serious harm. Signature: Applicant Department of Cardiovascular Services Chair Date Date Cardiothoracic Surgery 2 Approved

318 Cardiovascular Medicine Privileges in Cardiovascular Medicine Name: Please Print CARDIOVASCULAR DISEASE PRIVILEGES Education & Training: M.D. or D.O. and Successful completion of an ACGME or AOA-accredited fellowship in cardiovascular disease. AND Current certification or active participation in the examination process leading to certification within 5 years in Cardiovascular Disease by the American Board of Internal Medicine or the American Osteopathic Board of Internal Medicine (unless waived under Medical Staff Bylaws prior to 2016) Current Clinical Competence: Documentation of having cared for a minimum of 100 cardiology patients within the past 2 years of a broad cross-section of procedures corresponding to the privileges being requested. Renewal Criteria: Minimum of 10 cases required in the past two years FPPE Requirement: Minimum of 5 chart reviews Request Cardiology Medicine Core Privileges Approve Evaluate, diagnose, consult, treat, perform history and physical exam, and provide treatment of adolescent and adult patients presenting with diseases of the heart, lungs, and blood vessels and management of complex cardiac conditions. Cardiologists may provide care to patients in the intensive care setting in conformance with unit policies, and may assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges include the following procedures list and such other procedures that are extensions of the same techniques and skills: Ambulatory electrocardiology monitor interpretation; Cardioversion, electrical and elective; EKG interpretation; Imaging studies and interpretation including chest radiograph, tilt testing, ECG and ECG recordings; Infusion and management of Gp IIb/IIIa, thrombolytic, and antithrombolytic agents; Insertion and management of central venous catheters, pulmonary artery catheters, and arterial lines; Noninvasive hemodynamic monitoring; Pericardiocentesis; Stress echocardiography (exercise and pharmacologic stress); Tilt table testing; Transcutaneous external pacemaker placement; Transthoracic 2-D echocardiography, Doppler and color flow; Temporary trans-venous pacemaker placement Admitting Privileges (must request Active or Courtesy staff status) Cardiac Assist Devices (i.e., Impella), insertion and management Cardiac Angiography: Includes abdominal aorta; coronary angiogram; left ventricu-ology (including vein and arterial grafts and LIMA) Carotid angiography * - includes: Common Carotid, Vertebral aa (diagnostic only) Internal Carotid (diagnostic only) Prerequisite: Peripheral Angiography Mgmt of uncomplicated mechanical ventilator for up to 48 Cardiovascular Disease Advanced Privileges Request Procedure Initial Criteria Renewal Criteria FPPE Requirement Approve Documentation of training OR A minimum of 3 Direct observation of Completion of 5 procedures using procedures in the last 2 the first device in the last 2 years years. 2 cases Permanent Pacemaker/ Implantable Cardiovertor Defibrillator (ICD) Placement and removal Peripheral Angiography - Includes: Subclavian, Axillary, Brachial (not by axillary approach) common external iliac; femoropoliteal; Infrapopliteal; Renals Prerequisite: Fluoroscopy Documentation of training and a minimum of 50 procedures in the last two years. Completion of Cardiovascular Disease fellowship in the last 12 months OR 30 diagnostic carotid angiograms (at least 15 as primary) in the last 2 years 5 ventilator cases within the previous 2 years or completion of an airway management course A minimum of 15 procedures as primary operator in the last 2 years. Completion of Cardiovascular Disease fellowship in the last 12 months OR Documentation of 100 diagnostic angiograms (at least 50 as primary) in the last 2 years. A minimum of 50 procedures in the last 2 years. 25 Diagnostic carotid angiograms in the last 2 years 5 ventilator cases in the last 2 years or completion of airway management course A minimum of 10 Pacemaker and/or AICD procedures in the last 2 years 25 Diagnostic angiograms in the last 2 years Direct observation of the first 2 cases Direct observation of the first 3 cases Direct observation of the first case Direct observation of the first 2 cases Direct observation of the first 3 cases Cardiovascular Medicine Approved:

319 Cardiovascular Medicine Percutaneous Intra-aortic balloon placement and monitoring Trans-Esophageal Echocardiography (TEE) Completion of Cardiovascular Disease fellowship in the last 12 months OR Certificate of training AND Completion of 5 procedures using device in the last 2 years Training in residency in the last 12 months; Documentation of 50 category 1 CME hrs in the last 12 months OR Documentation of having passed the ASE exam AND case list of 20 procedures performed during the past 24 months A minimum of 3 procedures in the last 2 years. 10 cases in the last 2 years Direct observation of the first 2 cases Direct Observation of the first 3 cases and 5 over-reads INTERVENTIONAL CARDIOLOGY PRIVILEGES Initial Criteria Education & Training: MD or DO; Completion of an ACGME or AOA accredited training program in interventional cardiology or equivalent practice experience if training occurred prior to 2003 & hold a subspecialty certification in interventional cardiology by the ABIM or AOBIM; AND Certificate of training for newly developed cardiac assist devices. Current Competence: 150 percutaneous intervention procedures in the last 2 years or successful completion of an ACGME or AOA residency or clinical fellowship within the past 12 months. Renewal Criteria: Maintenance of Board Certification and 150 percutaneous intervention procedures in the last 2 years FPPE Requirement: Retrospective chart review of 5 diverse admissions. Request Interventional Cardiology Core Privileges Approve Evaluate, provide an H&P, treat and provide consultation to adolescent and adult patients by use of specialized imaging and other diagnostic techniques to evaluate blood flow and pressure in the coronary arteries and chambers of the heart, as well as technical procedures, including the following procedure list and such other procedures that are extensions of the same techniques and skills: Cardiac Assist Devices, insertion and management Endomyocardial biopsy Femoral, brachial, or radial axillary cannulation for diagnostic angiography or percutaneous coronary intervention Interpretation of coronary arteriograms, ventriculography, and hemodynamics Intracoronary foreign body retrieval Intracoronary infusion of pharmacological agents, including thrombolytics Intracoronary mechanical thrombectomy Intracoronary stents Intravascular ultrasound of coronaries Management of mechanical complications of percutaneous intervention Performance of balloon angioplasty, stents and other commonly used interventional devices Percutaneous transluminal septal myocardial ablation Use of intracoronary Doppler and flow wire Use of vasoactive agents for pericardial and microvascular spasm Admitting Privileges (must request Active or Courtesy staff status) Interventional Cardiology Advanced Privileges Request Procedure Initial Criteria Renewal Criteria FPPE Approve Peripheral Vascular Interventions (peripheral balloon, stent placement and arthrectomy). Includes:Abdominal Aorta; Use of approved atherectomy device; Femoropopliteal Subclavian, Axillary, Brachial (not by axillary approach) Infrapopliteal Renals Completion of Interventional Cardiology fellowship in the last 12 months OR, if trained before 1995, must have performed at least 50 peripheral balloon angioplasties (25 as primary operator within the last 2 years. 25 balloon angioplasties and/ or stent placements in the last 2 years Direct observation of the first 3 cases (at least 2 at KDHCD) Prerequisite: Peripheral Angiography Percutaneous PFO/ASD Closure Completion of Interventional Cardiology fellowship in the last 12 months and/or 10 procedures in the last 2 years 20 procedures in the last 2 years. Direct observation of the first 2 cases Balloon Valvuloplasty Completion of Interventional Cardiology Fellowship in the last 12 months OR Documentation of training AND at least 5 cases in the last two years. 2 procedures in the last two years. Direct observation of the first 2 cases Cardiovascular Medicine Approved:

320 Cardiovascular Medicine Transcatheter embolization or occlusion (PFO) includes: Atrial septal defect/patent foramen ovale Ventricular septal defect Patent ductus arteriosis Left atrial appendage Completion of Interventional Cardiology Fellowship in the last 12 months OR Documentation of training and at least 2 procedures within the past two years for each procedure 3 procedures in the last two years. Direct observation of the first 2 cases Carotid Interventions (Includes: carotid stenting and angiography) Completion of Interventional Cardiology fellowship in the last 12 months OR documentation of 30 Cervico-cerebral angiograms (15 as primary) & 25 carotid stent procedures (13 as primary) & completion of FDA training program in device used in carotid artery stenting procedures. 10 procedures in the last two years. Direct observation of the first 3 cases Transcutaneous Cardiac Valve Implantation and/or Repair (TAVR) Board certified or board eligible for certification in Interventional Cardiology AND Documentation of training by letter from Director of Training Program OR completion of a FDA Approved certification course AND Documentation of 100 career structural heart procedures OR 30 left-sided structural procedures per year of which 60% should be balloon aortic valvuloplasty (BAV)/TAVR. 10 procedures in the last two years as primary physician or first assistant. Direct observation of the first 3 cases CLINICAL CARDIAC ELECTROPHYSIOLOGY PRIVILEGES Initial Training Criteria: Completion of an ACGME or AOA accredited training program in CCEP OR EQUIVALENT PRACTICE EXPERIENCE /Training if training occurred prior to 1998, and/or current subspecialty certification or active participation in the examination process leading to certification within 5 years in CCEP by the ABIM or completion of a CAQ in CCEP by the AOBIM. Current Clinical Competence: Documentation of a minimum of 100 procedures in the last 2 years. Renewal Criteria: Maintenance of subspecialty certification or active participation in the examination process leading to certification withing 5 years in CCEP by the ABIM or completion of a CAQ in CCEP by the AOBIM AND A minimum of 50 procedures in the last two years. FPPE: Direct observation of 1 device implantation and 1 EP/ablation And 5 retrospective chart reviews Request Clinical Cardiac Electrophysiology Core Privileges Approve Core privileges include evaluate, provide H&P, treat, and provide consultation to acute and chronically ill adolescent and adult patients with heart rhythm disorders, including the performance of invasive diagnostic and therapeutic cardiac electrophysiology procedures; including the following procedures and other procedures that are extensions of the same techniques and skills: Atrial appendage occlusion device implantation Intracardiac echo Transseptal catheterization Implantation and removal of defibrillators and pacemakers Venous angioplasty Interpretation of activation sequence mapping recordings, Therapeutic catheter ablation procedures, including: Supraventricular tachycardia; Atrial Fibrillation requiring transseptal puncture; Ventricular Tachycardia) Electrophysiologic studies +- ablation for SVT including endocardial electrogram recording Imaging studies including chest radiograph, tilt testing, ECGs and ECG recordings (all) Admitting Privileges (must request Active or Courtesy staff status) Clinical Cardiac Electrophysiology Advanced Privileges Request Procedure Initial Criteria Renewal Criteria FPPE Approve Implantation of Bi-ventricular devices that A minimum of 15 procedures as include a CS lead primary operator in the last 2 years. ADDITIONAL PRIVILEGES A minimum of 10 BiV cases in the last 2 years Direct observation of the first case Request Procedure Initial Criteria Renewal Criteria FPPE Approve Outpatient Services at a Kaweah Delta Health Care District Rural Health or 1206(d) Clinic. Privileges include pre/post surgical care and Executed contract with Kaweah Delta Health Care District or KDHCD ACGME Family Medicine Maintain initial criteria None Cardiovascular Medicine Approved:

321 Cardiovascular Medicine disease management. Please identify location: Dinuba Exeter Lindsay Woodlake Family Medicine Clinic Chronic Disease Management Center Sequoia Cardiology Clinic Admit, treat, or provide follow-up care for inpatients ages 14 years or younger. (excluding patients 6 months or ASA > 3) Program Board Certification in Pediatric Medicine or Pediatric Cardiology Minimum of 20 cases required in the past two years 3 Chart Reviews Administration of Procedural Sedation Fluoroscopy and/or supervision of a technologist using fluoroscopy equipment Successful completion of KDHCD sedation exam Fluoroscopy Supervisor and Operator Permit or a Radiology Supervisor & Operator Permit Successful completion of KDHCD sedation exam Maintenance of Supervisor & Operator Permit None None Acknowledgment of Practitioner: I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise and; I understand that: (a) (b) In exercising any clinical privileges granted, I am constrained by any Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation. Emergency Privileges In case of an emergency, any member of the medical staff, to the degree permitted by his/her license and regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient from serious harm. Name: Print Applicant Signature Department of Cardiovascular Services Chair Signature Date Date Date Cardiovascular Medicine Approved:

322 Critical Care, Pulmonary & Sleep Medicine Privileges in Critical Care, Pulmonary & Sleep Medicine Name: Please Print CRITICAL CARE CORE PRIVILEGES Education & Training: M.D. or D.O. and Successful completion of an ACGME or AOA accredited program in the relevant medical specialty AND Successful completion of an accredited fellowship in critical care medicine and/or current subspecialty certification or active participation in the examination process (with achievement of certification within 5 years) leading to subspecialty certification in critical care medicine by the ABMS or AOA Boards Current Clinical Competence: Documentation of provision of inpatient care to at least fifty (50) patients in the CCU over the past 24 months. OR *CA licensed physicians involved in their 2 nd or 3 rd year Critical Care Fellowship Program Renewal Criteria: Minimum 60 cases required in the past two years including documentation of 5 therapeutic Bronchoscopies AND Maintain current certification or active participation in the examination process leading to certification in Critical Care Medicine by the ABMS or AOA Board. FPPE Requirement: Minimum of 10 of the following cases reviewed concurrently or retrospectively, To include: 5 diverse admissions And 2 therapuetic Bronchoscopies Request Procedure Approve Privileges include: Privileges to evaluate, diagnose, perform history and physical exam, provide treatment or consultation to patients 14 years of age and older, with multiple organ dysfunction and in need of critical care AND Airway management, including intubation Arterial puncture and cannulation Cardiopulmonary resuscitation Cardioversion and defibrillation Central venous and pulmonary artery catheter insertion Flexible bronchoscopy (Thera Bal Only) Lumbar puncture Needle and tube thoracostomy Paracentesis Pericardiocentesis, emergency Thoracentesis Tracheostomy/cricothyroidotomy, emergency Transthoracic Echocardiography Admitting Privileges (Must request and maintain inpatient contact volume for Courtesy or Active Staff Status) PULMONARY CORE PRIVILEGES Education & Training: M.D. or D.O. and Successful completion of an ACGME or AOA-accredited fellowship in pulmonary medicine. AND ACLS Certification unless boarded in Critical Care AND Current certification or active participation in the examination process leading to certification (with achievement of certification within 5 years) in Pulmonary Disease OR Critical Care by the American Board of Internal Medicine or the American Osteopathic Board of Internal Medicine. OR *CA licensed physicians involved in their 2 nd or 3 rd year Pulmonary Fellowship Program Renewal Criteria: Minimum 100 cases required in the past two years AND Maintenance of certification or active participation in the examination process leading to certification in Pulmonary Disease OR Critical Care by the American Board of Internal Medicine or the American Osteopathic Board of Internal Medicine AND ACLS Certification unless boarded in Critical Care. FPPE Requirements: Minimum of 5 diverse admissions concurrently or retrospectively (Critical Care Core can be counted) Request Procedure Approve Core Privileges include: Admit, evaluate, diagnose, consult, perform history and physical exam, and provide treatment and consultation to patients with disorders chest or thorax AND Airway Management, including intubation Arterial puncture and cannulation Central venous and pulmonary artery catheter insertion Inhalation challenge studies Pulmonary function testing interpretation Thoracentesis and related procedures Admitting Privileges (Must request and maintain inpatient contact volume for Courtesy or Active Staff Status) ADVANCED PRIVILEGES (Must meet the criteria for Pulmonary Core Privileges) Request Procedure Initial Criteria Renewal Criteria FPPE Approve Flexible bronchoscopy with Transbronchial biopsies Flexible bronchoscopy with Endobronchial biopsies Documentation of 5 procedures in the last 2 years. Documentation of 5 procedures in the last 2 years. 5 procedures in the last two years. 5 procedures in the last two years. Minimum of 3 cases reviewed concurrently Minimum of 3 cases reviewed concurrently Critical Care, Pulmonary & Sleep Medicine 1 Approved revised 4/23/18

323 Critical Care, Pulmonary & Sleep Medicine SLEEP MEDICINE CORE PRIVILEGES Education & Training: M.D. or D.O. and Successful completion of an ACGME or AOA-accredited fellowship in sleep medicine, AND ACLS Certification unless boarded in Critical Care AND/OR Current sub-specialty certification or active participation in the examination process leading to certification with achievement of certification within 5 years) in Sleep Medicine by the by the relevant ABMS board or completion of a CAQ by the relevant AOA board. Current certification by the AASM is acceptable for applicants who became certified prior to Renewal Criteria: Minimum of 100 cases required in the past two years AND Maintenance of certification or active participation in the process leading to certification in Sleep Medicine OR completion of a CAQ by the relevant AOA board. Current certification by the AASM is acceptable for applicants who became certified prior to 2007 AND Documentation of 10 Cat I or II CME hours in sleep medicine. FPPE Requirements: Minimum of 3 cases reviewed concurrently or retrospectively Request Procedure Approve Core Privileges include: Admit, evaluate, diagnose, consult, perform history and physical exam, and provide treatment to patients presenting with conditions or sleep disorders AND Actigraphy Home/ambulatory testing Maintenance of wakefulness testing Monitoring with interpretation of EKGs, electroencephalograms, electro-oculographs, electromyographs, flow, oxygen saturation, leg movements, thoracic and abdominal movement, and CPAP/BI-PAP tritration Multiple sleep latency testing Oximetry Polysomnography (including sleep stage scoreing) Sleep log interpretation Admitting Privileges (Must request and maintain inpatient contact volume for Courtesy or Active Staff Status) ADDITIONAL PRIVILEGES (Must also meet the Criteria Above) Request Procedure Initial Criteria Renewal Criteria FPPE Approve Administration of Moderate Sedation Percutaneous tracheostomy Fluoroscopy Privileges Successful completion of KDHCD sedation exam Documentation of training and 10 procedures in the last 2 years Current California Fluoroscopy Certificate Successful completion of KDHCD sedation exam Minimum of 5 cases required in past 2 years None 5 direct observation None Acknowledgment of Practitioner: I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise and I understand that (a) In exercising any clinical privileges granted, I am constrained by any Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation. (b) Emergency Privileges In case of an emergency, any member of the medical staff, to the degree permitted by his/her license and regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient from serious harm. Signature: Applicant Date Signature: Department of Critical Care, Pulmonology, Adult Hospitalist Medicine Chairman Date Critical Care, Pulmonary & Sleep Medicine 2 Approved revised 4/23/18

324 VASCULAR SURGERY Privileges in Vascular Surgery Name: Please Print VASCULAR SURGERY Education & Training: MD or DO; AND Successful completion of a general surgery residency training program approved by the Accreditation Council for Graduate Medical Education (ACGME), by the American Osteopathic Association (AOA) or by the Royal College of Physicians & Surgeons of Canada if board certified by an ABMS board or actively pursuing board certification by an American Board/American Osteopathic Board within 5 years; AND successful completion of an accredited vascular surgery fellowship ; AND current board certification or actively pursuing certification by the American Board/American Osteopathic Board of Vascular Surgery within 5 years. Current Clinical Competence: Documentation of the performance of at least 100 vascular procedures in the past 2 years, the majority being reconstructive; (excluding cardiac surgery) or successful completion of a residency or clinical fellowship in the past 12 months Renewal Criteria: Maintenance of Board Certification and documentation of 70 procedures reflective of the privileges requested. FPPE: Direct observation of a minimum of five (5) diverse procedures Request CORE PRIVILEGES Approve VASCULAR SURGERY CORE PRIVILEGES INCLUDE : Medical H&P; work up, diagnosis, ordering and prescribing medication, ordering diagnostic tests, as well as surgical and non-surgical treatment of patients of all ages presenting with diseases/disorders of the arterial, venous, and lymphatic circulatory systems, excluding the heart and intracranial vessels. Vascular surgery procedures include but are not limited to: Abdominal aortic aneuryamectomy Amputations, upper extremity, lower extremity; Aneurysmectomy Angio-access for dialysis, chemotherapy Central vascular access, permanent: fistula, graft, shunt Embolectomy (non-dialysis access related); arterial, graft, venous Endartectomy - Carotid; Peripheral Endovascular percutaneous interventions/repairs Intraoperative angiography Peripheral arterial bypass grafts - Obstructive bypass Peripheral venous procedures (includes varicose veins) Portal systemic venous shunts Skin Grafts Sympathectomy (Cervical, Thoracic, Lumber) Admitting Privileges (must request Active or Courtesy staff status) ADVANCED PROCEDURES FPPE: Direct observation of the first 3 cases of each privilege granted. Request Procedure Initial Criteria Renewal Criteria Approve Peripheral Angiography - Includes: Subclavian, Axillary, Brachial (not by axillary approach) Renals Prerequisite: Fluoroscopy Carotid angiography * - includes: Common Carotid, Vertebral aa (diagnostic only) Internal Carotid (diagnostic only) Prerequisite: Peripheral Angiography Peripheral Vascular Interventions (peripheral balloon, stent placement and arthrectomy). Includes: Abdominal Aorta; Use of approved atherectomy devices; Femoropopliteal Subclavian, Axillary, Brachial (not by axillary approach) Infrapopliteal Renals Prerequisite: Peripheral Angiography Documentation of 100 diagnostic angiograms (at least 50 as primary) in the last 2 years. 30 diagnostic carotid angiograms (at least 15 as primary) in the last 2 years Meets initial training criteria OR, if trained before 1995, must have performed at least 50 peripheral balloon angioplasties (25 as primary operator within the last 2 years. 25 Diagnostic angiograms in the last 2 years 25 Diagnostic carotid angiograms in the last 2 years 25 balloon angioplasties and/ or stent placements in the last 2 years Carotid Interventions (Includes: carotid stenting and angiography) Meets initial training criteria OR documentation of 30 Cervico-cerebral angiograms (15 as primary) & 25 carotid stent procedures (13 as primary) 10 procedures in the last two years. Vascular Surgery 1 Approved:

325 VASCULAR SURGERY ADVANCED PROCEDURES FPPE: Direct observation of the first 3 cases of each privilege granted., except Hypoerbaric which requires the first 2 cases observed and charts reviewed. Request Procedure Initial Criteria Renewal Criteria Approve Laparoscopic placement of peritoneal dialysis catheter Peripheral Catheter Directed Thrombolysis Prerequisite: Peripheral vascular intervention privileges. Completion of General Surgery Residency OR Fellowship in Vascular Surgery AND documentation of 10 procedures in the last 2 years Documentation of at least 10 procedures in the previous 2 years 5 procedures in the last 2 years To maintain privileges: must have performed 5 peripheral catheter directed thrombolysis procedures within previous 2 years Use of surgical laser Wound Care: Surgical debridement of wounds, transcutaneous oximetry interpretation, complicated wound management, local and regional anesthesia, wound biopsy and preparation of wound bed and application of skin substitute AND 20 procedures in the last 2 years Training in residency OR completion of an approved eight-hour minimum CME course that included training in laser principles & a letter of reference from preceptor experienced & credentialed in laser privileges AND a minimum of 24 laser procedures in the last 2 years. Meets initial criteria for core and documentation of a minimum of 20 procedures in the last two years. A minimum of 24 laser procedures in the last 2 years Documentation of 5 procedures in the last 2 years. Hyperbarics Oxygen Therapy Document completion of a training program in hyperbaric oxygen therapy (HBOT) of a minimum of 40 hours, approved by the Undersea and Hyperbaric Medical Society (UHMS) or the American College of Hyperbaric Medicine (ACHM) AND 20 proceduresdives in the last 2 years. within the previous 24 month period. ADDITIONAL PROCEDURES Documentation of 5 20 procedures dives in the last 2 years. FPPE: None Request Procedure Initial Criteria Renewal Criteria Approve Fluoroscopy Current CA Fluoroscopy Supervisor and Operator Permit or a Radiology Supervisor and Operator Permit Maintenance of CA Fluoroscopy Certification Procedural Sedation Outpatient Services at a Kaweah Delta Health Care District Outpatient Clinic. Please identify: Dinuba Exeter Lindsay Woodlake Family Medicine Clinic Chronic Disease Management Center Wound Care Center Pass KDHCD Sedation/Analgesia (Procedural Sedation) Exam Executed contract with Kaweah Delta Health Care District or KDHCD ACGME Family Medicine Program Pass KDHCD Sedation/Analgesia (Procedural Sedation) Exam Maintain initial criteria Formatted: Space After: 0 pt, Line spacing: single, Don't adjust space between Latin and Asian text, Don't adjust space between Asian text and numbers Formatted: Space After: 0 pt, Line spacing: single Formatted: Space After: 0 pt, Line spacing: single, Don't adjust space between Latin and Asian text, Don't adjust space between Asian text and numbers Acknowledgment of Practitioner: I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise and I understand that (a) In exercising any clinical privileges granted, I am constrained by any Hospital and Medical Staff policies and rules applicable generally and any applicable to the particular situation. (b) Emergency Privileges In case of an emergency, any member of the medical staff, to the degree permitted by his/her license and regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient from serious harm. Signature: Applicant Date Vascular Surgery 2 Approved:

326 VASCULAR SURGERY Department of Cardiovascular Services Chair Date Vascular Surgery 3 Approved:

327 Kaweah Delta Health Care District HUMAN RESOURCES COMMITTEE MISSION AND PURPOSE: The Human Resources Committee of the Board serves to ensure furtherance of the Kaweah Delta goal of providing an Ideal Work Environment for our employees and volunteers. Members provide support and guidance with regard to Human Resources strategies and programs for recruitment and retention. SPECIFIC RESPONSIBILITIES: Review of annual HR Report of Recruitment and Retention, as well as updates on Employee Engagement initiatives and the biannual survey and follow up action planning process. In addition, the Committee reviews additional information on specific strategies on total rewards (compensation and benefits), workforce analysis and staffing with associated analytics, organizational development programs, wellness, and compliance with regulatory agencies. The Committee assists with furthering the development of the Human Resources function over time. MEETING FREQUENCY: The Committee will meet every other month or as is practically necessary. Adopted by the Human Resources Committee on June 19, 2018 and approved by the Board of Directors on, Human Resources Committee Mission & Purpose June 19, 2018 Page 1 of 1

328 Kaweah Delta Health Care District GOVERNANCE AND LEGISLATIVE AFFAIRS COMMITTEE MISSION AND PURPOSE: This committee will review committee structure, committee membership, calendar, bylaws, plan the Board self-evaluation, committee charters, monitor & resolve Board conflict of interest, district boundaries, Board education, building & maintaining medical staff relations, plan medical staff retreat. To develop and maintain collegial relationships with local, state, and nationally elected officials with a goal of working harmoniously to further the Healthcare District s mission of providing high-quality, customer-oriented, and financially strong healthcare services. SPECIFIC RESPONSIBILITIES: Committee activities will include; reviewing Board committee structure calendar bylaws planning the Board self-evaluation monitor conflict of interest establishing the legislative program scope & direction for the district annually review appropriation request to be submitted by the District effectively communicating and maintaining collegial relationships with local, state, and nationally elected officials. Adopted by the Governance and Legislative Affairs Committee June 19, 2018.

329 Annual Budget Review

330 Comparison of FY 2019 Budget to FY 2018 Projected Actual (000 s) FY18 Projected Actual FY 19 Budget Variance % Change Operating Revenue Net patient service revenue $565,906 $604,844 38, % Supplemental Gov't Programs 42,356 43, % Prime Program 18,009 11,964 (6,045) (33.6%) Premium revenue 31,952 35,931 3, % Management services revenue 28,875 29, % Other Revenue 20,402 18,417 (1,985) (9.7%) Other operating revenue 141, ,880 (2,714) (1.9%) Total Operating Revenue 707, ,724 36, % Operating Expenses Salaries and wages 266, ,822 20, % Contract Labor 7,435 3,713 (3,722) (50.1%) Employee benefits 69,334 72,755 3, % Total Personnel Expenses 342, ,290 20, % Medical and other supplies 110, ,979 2, % Medical and other fees 78,073 86,365 8, % Purchased services 38,309 35,601 (2,708) (7.1%) Repairs and maintenance 24,555 25, % Utilities 5,717 5, % Rents and leases 6,136 6, % Depreciation and amortization 26,770 33,808 7, % Interest Expense 4,637 6,007 1, % Other Expenses 17,736 17,332 (404) (2.3%) Management Services Expenses 28,375 28, % Total Operating Expenses 683, ,025 38, % Operating Margin $23,677 $21,699 ($1,978) (8.4%) Nonoperating Revenue 2,700 5,153 2, % Excess Margin $26,377 $26,852 $ % Operating Margin % 3.3% 2.9% Excess Margin % 3.7% 3.6%

331 Revenue Generating/Cost Reducing Initiatives Throughput Initiatives Utilization Focus with new Cerner applications Underpayment focus with new Cerner applications Payroll elimination of double time and reduction in overtime Payroll reduction of unnecessary hours, premium and differential pay through relaunching of departmental benchmarks with regular budget accountability reviews with departments Improve supply inventory controls through development of applications and a more stringent procurement process Continued expansion of service lines

332 Ratios: Revenue Categories as a % of Total Operating Revenue % of Total Operating Revenue FY 18 Projected Actual FY 19 Budget % Change Net Patient Service Revenue 80.0% 81.3% 1.7% Supplemental Gov't Programs 6.0% 5.8% (2.8%) Prime Program 2.5% 1.6% (36.8%) Premium Revenue 4.5% 4.8% 7.0% Management Services Revenue 4.1% 3.9% (3.6%) Other Revenue 2.9% 2.5% (14.1%) Other Operating Revenue 20.3% 18.7% (8.1%) Total Operating Revenue 707, , %

333 Efficiency: Expenses as a % of Total Operating Revenue FY 18 Projected Actual FY 19 Budget % Change Total Operating Revenue (000 s) 707, , % Ratios: Operating Expenses /Operating Revenue Salaries and wages 37.6% 38.6% 2.5% Contract Labor 1.1% 0.5% (52.5%) Employee benefits 9.8% 9.8% (0.2%) Total Employment Expenses 48.5% 48.8% 0.8% Medical and other supplies 15.6% 15.2% (2.8%) Medical and other fees(phys fees) 11.0% 11.6% 5.2% Purchased services 5.4% 4.8% (11.6%) Repairs and maintenance 3.5% 3.4% (1.1%) Utilities 0.8% 0.8% (2.2%) Rents and leases 0.9% 0.9% 0.9% Depreciation and amortization 3.8% 4.5% 20.1% Interest Expense 0.7% 0.8% 23.2% Other Expenses 2.5% 2.3% (7.0%) Management Services Expenses 4.0% 3.9% (3.6%) Total Operating Expenses 96.7% 97.1% 0.4% Operating Margin 3.3% 2.9% (12.8%) Nonoperating Revenue 0.4% 0.7% 81.6% Excess Margin 3.7% 3.6% (3.2%)

334 Inpatient Volumes FY 18 Actuals FY 19 Budget Change % Change % Occupancy Average Daily Census % Patient Days: Medical Center 102, , % 74.3% Acute I/P Psych 17,166 17, % 75.6% Sub-Acute 11,316 11, % 97.0% Rehab 6,825 7, % 43.3% TCS-Ortho 4,515 4,439 (76) (1.7%) 76.0% TCS 5,991 6, % 82.0% NICU 4,400 4, % 86.9% Nursery 6,923 6, % Total Patient Days 159, ,132 2, %

335 Other Volume Assumptions FY 18 Actuals FY 19 Budget Change % Change Adjusted Patient Days 304, ,811 9, % Equivalent Outpatient Volume 145, ,679 7, % Cardiac Surgeries % Rural Health Clinic Visits 129, ,065 9, % Home Health Visits 30,207 31,350 1, % Non-Cardiac Inpatient Surgeries 3,864 3, % MRIs and CT Scans 53,590 54, % Outpatient Surgeries 5,765 5, % Chronic Dialysis Treatments 21,951 22, % Laboratory Procedures 1,649,628 1,672,494 22, % Diagnostic Radiology Procedures 101, ,782 1, % Cardiac Catheterizations 13,154 13, % Emergency Department Visits 90,828 92,058 1, % Deliveries 4,800 4, % Urgent Care Visits (UC/SPCs) 91,949 81,343 (10,606) -11.5%

336 Reimbursement Net Patient Revenue (000 s) FY 18 Projected Actual FY 19 Budget Variance % Change Net Patient Service Revenue (000 s) $565,906 $604,844 38, % Patient Volume/Service Increase $23,928 Commercial Insurance Rate Increase $4,102 Medicare Rate Increase $3,405 Medi-Cal Managed Care Rate Increase $2,156 Reduction in Underpayments $2,740 Clinical Documentation Improvement $1,500 Patient Acuity Increase - Expanded Service Lines $858 Increase in Medicare Reimbursement for residents $89 All other $160 $38,938

337 Other Operating Revenue (000 s) FY 18 Projected Actual FY 19 Budget Variance % Change Other Operating Revenue $141,594 $138,880 $(2,714) (1.9%) Quality Assurance Fee Payment, Medi-Cal MC Rate Range & FFS IGT Payment $26,727 $26,727 $0 Supplemental Medi-Cal DSH payment relating to GME $10,403 $16,573 $6,170 Supplemental Prior Years Adj of Medi-Cal supplemental $5,266 $0 ($5,266) Supplemental Prime Grant Payments $18,089 $11,964 ($6,045) Prime Humana MA Revenue $3,978 Premium Rev. Sequoia Regional Cancer Center - Management Revenue $393 Mgmt Rev. Health Related Investment Income ($765) Other Grant Revenue Decrease ($481) Other Other Operating Revenue ($738) Other ($2,714)

338 Personnel Expenses FY 18 Projected Actual FY 19 Budget Variance % Change Total Personnel Expense $342,957 $363,290 $20, % Manhours Increase (offset by $1.6 M reduction for decreased utilization/throughput) $12,717 Average Hourly Wage Increase (offset by budgeted elimination of double time $2.7M) $7,917 Contract Labor Decrease ($3,722) Payroll Tax Increase from increase in Payroll $ $1,448 Employee Health Benefits Cost Increase $627 Workers Compensation Cost Increase $3,635 Defined Benefit Plan Expense Decrease ($3,394) 401 (k) Employer Contribution Increase $946 Other $159 $20,333

339 Other Operating Expense FY 18 Projected Actual FY 19 Budget Variance % Change Total Other Operating Expense $340,866 $358,735 $17, % Physician Fee Increase $9,421 Depreciation Increase $7,186 Pharmaceuticals Increase $2,746 Interest Expense Increase $1,370 Cerner Training - Purchase Service Decrease ($413) Initiative to Reduce LOS, Supply Consumption and Pricing ($1,260) Professional Liability Insurance Decrease ($1,354) Other $173 $17,869

340 Physician Fee Expense FY 18 Projected Actual FY 19 Budget Variance % Change Total Physician Fee Expense $72,885 $82,306 $9, % Kaweah Delta Medical Foundation $3,192 Kaweah Delta Neurosciences Center $2,332 Kaweah Delta Sequoia Cardiology Center $1,166 Kaweah Delta Hospitalist programs $749 OB Laborist program $999 Kaweah Delta Rural Health Clinics $787 All other $196 $9,421

341 Capital Budget Strategic Projects and Infrastructure $7,217,000 ISS Capital 2,272,000 Patient Monitoring Equipment 1,367,000 Available for all other Capital Requests 5,144,000 Recurring Capital $16,000,000 Enterprise Capital 820,000 General Contingency Capital 340,000 FY 2019 Capital Budget $17,160,000

342 Surplus Cash Flows (000 s) Excess Margin $26,852 Additional Sources (Uses) of Cash: Capital Expenditures: Annual Recurring (16,000) Enterprise Capital (820) General Capital Contingency Fund (340) Depreciation/Amortization (Non-Cash Item) 33,808 Capitalized Interest Payments (1,796) Capitalized Employment Expense (1,393) Additional DB Plan Funding (3,307) Debt Service Payments (Principal) (7,602) Total Additional Net Sources (Uses) of Cash 2,550 Projected Surplus Cash Flow (Deficit) $29,402

343 General Fund Cash Reserves (000 s) Projected Balance at July 1, 2018 $274,685 Cash Flow from Operations 29,402 Balance at June 30, 2019 $304,087

344 Credit Highlights (000 s) Ratio/Statistic Moody s A (1) Operating Income $24,227 $18,842 $15,521 $23,678 $21,699 Net Income $50,134 $23,650 $17,588 $26,378 $26,852 Unrestricted Cash $528,632 $258,946 $281,003 $291,742 $321,144 Total Debt $320,778 $244,194 $238,387 $227,963 $220,360 Operating Margin 3.2% 3.1% 2.4% 3.3% 2.9% Excess Margin 6.1% 3.8% 2.7% 3.7% 3.6% Debt Service Coverage 5.00x 3.74x 2.88x 3.56x 4.24x Debt to Capitalization 33.9% 36.6% 35.3% 33.0% 31.1% Days Cash on Hand (1) Represents 2016 median ratios for all non-profit hospitals rated A by Moody s Investor Services (hospitals rated A1, A2 or A3).

345

346 Kaweah Delta Health Care District Budget Questions?

347 Additional Supporting Information

348 Reimbursement Assumptions Medicare (41.6% of GPR): 3.4% I/P payment increase ($2.9m FY impact): 2.8% market basket increase 0.8% productivity adjustment decrease 0.75% ACA update reduction 0.50% increase required by legislation 1.65% increase proposed changes to uncompensated care and other items No general contingency reserve for RAC, MAC and other Medicare payer denials, cut-backs, etc.

349 Reimbursement Assumptions Other Medicare Reimbursement: 1.4% increase in outpatient ($327k increase) 0.9% increase for rehab 1.0% increase for psychiatric 2.4% increase for skilled nursing and subacute 0.4% decrease for home health 1.4% increase for RHCs (all other total $119k increase)

350 Reimbursement Assumptions Other Medicare Reimbursement: $750,000 of increased reimbursement through continued enhancement of CDI program $14.9 million budgeted for direct and indirect medical education payments ($88,000 increase over FY 2018) $35.9 million of Humana Medicare Advantage capitation revenue (12.5% increase over 2018)

351 Reimbursement Assumptions Medi-Cal (31.9% of GPR): No change in reimbursement for acute inpatient, acute rehab, skilled nursing, subacute, psychiatric, home health, outpatient and rural health clinics $7.3 million of FFS IGT revenue (AB113) $12.0 million of Provider Fee payments $16.6 million in DSH funds (including GME) $750,000 of increased reimbursement through continued enhancement of CDI program

352 Reimbursement Assumptions Medi-Cal Managed Care Reimbursement: 1.9% negotiated increase for all inpatient and outpatient services ($2.2 million impact) $7.4 million of Medi-Cal Managed Care program (SB90) IGT grant payments

353 Reimbursement Assumptions Commercial Insurance (23.5% of GPR): 2.6% increase in negotiated rates ($4.1 million impact) Assumes no further enrollment of uninsured into Medi- Cal or Covered California during FY19 Uninsured (3.0% of GPR) Overall increase in net revenue per adjusted patient day of 4.0% (including premium revenue)

354 Budget Highlights 2.9% operating margin ($21.7m) 3.6% excess margin ($26.9m) $29.4 million increase in total cash reserves $744m total operating revenue $722m total operating expenses ($2.0m/day) 2.3% increase in cost per APD ($2,294) 40.7% compensation ratio (excluding benefits) 15.8% supply costs ratio

355 Utilization Assumptions Patient days projected to increase 1.5% from FY 2018 (ADC of 444): Adult Medical/Surgical/OB 279 (0.8%) Pediatrics/NICU/Nursery 36 (4.3%) Rehabilitation 20 (4.3%) Subacute & TCS 61 (2.4%) Acute Psychiatric 48 (1.2%)

356 Budget Highlights $11.4 million contribution to DB plan $1.9 million contribution to malpractice fund Repayment of external debt ($15.7m) $16.0 million recurring capital expenditures budget (50% of depreciation expense) 4.33 debt service coverage ratio 4.24 max. debt service coverage ratio (1.75) 163 days cash on hand (90 days)

357 Operating Budget Highlights No retail charge increase 6.6% increase in net patient revenue 29.5% reimbursement rate (70.5% DFR) $95.6 million in nonpatient revenue $359.6 million labor compensation budget (49.8% of total operating expenses) $722.0 million operating expense budget $21.7 million operating margin (2.9%)

358 Compensation & Benefits Assumptions 7.2% increase in payroll & benefits 2.8% increase in AHW (2.5% annual average since 2015) 2.45% average PFP increase (range 0-4%) 4.1% increase in FTEs (4,240); 0.9% increase in labor hours per adjusted patient day 2.3% increase in employee health benefits 213.6% increase in workers compensation 12.3% decrease in employee retirement expense 40.7% compensation ratio (40.3% for FY 2018)

359 Overall Cost Assumptions 2.3% increase in cost per adjusted patient day (compared to 5.0% increase in FY 2018) $3.7 million decrease in contract labor- 50% Reduction in supply costs as % of net operating revenue from 16.3% to 15.8% $52.1 million of hospital-based physician expense $1,999,000 of physician recruitment expense $16.0 million capital expenditures budget (50% of depreciation expense) Kaweah Delta Medical Foundation budgeted loss of $58M

360 PRIME Revenue PRIME Funds Available DY 11 DY 12 DY 13 DY 14 DY 15 DMPH Total $ 200,000,000 $ 200,000,000 $ 200,000,000 $ 180,000,000 $ 153,000,000 Kaweah Factor 15.8% 15.8% 15.8% 15.8% 15.8% TOTAL $ 31,580,000 $ 31,580,000 $ 31,580,000 $ 28,422,000 $ 24,158,700 Total Available IGT-Revenue $ 15,790,000 $ 15,790,000 $ 15,790,000 $ 14,211,000 $ 12,079,350 $ 73,660,350 PRIME Funding and Budget Projections FY16 FY17 FY18 FY19 FY20 FY21 Budgeted $ - $ 16,000,000 $ 18,009,111 $ 11,963,810 $ 11,542,105 $ 5,303,129 $ 3,947,500 $ 11,842,500 $ 9,474,000 $ 6,071,444 $ 6,238,976 $ 5,303,129 Received $ 1,887,097 $ 3,459,754 $ 5,892,366 $ 5,303,129 $ 1,887,097 $ 5,075,357 Total PRIME Funding Gross $ 3,947,500 $ 15,616,694 $ 18,009,111 $ 11,963,810 $ 11,542,105 $ 5,303,129 $ 66,382,349

361 Adult Med/Surg/OB Average Daily Census (ADC) Occupancy ICU % CVICU % 3W - ICCU % 2N - Cardiac % 2S Med/Surg - OF % 3E Broderick % 3N - Med/Surg % 3S - Oncology % 4N - Renal % 4S - Ortho % 4 Tower % Obstetrics % Total Med/Surg/OB %

362 Other Services ADC Occupancy Pediatrics % ICN % Nursery Acute Rehab % Acute Psych %

363 KAWEAH DELTA HEALTH CARE DISTRICT EXECUTIVE SUMMARY When reflecting on the District s goals, it s clear that the first three outstanding health outcomes, excellent service to our patients and customers, and an ideal work environment for our staff and physicians are made possible by the fourth: maintain financial strength to ensure the delivery of outstanding health care services. The stated objectives for this important fourth goal are: Develop and effectively implement financial plans that meet service and facility requirements for outstanding patient care Maintain sufficient profitability and liquidity to consistently sustain operations and provide costeffective access to capital markets After several months of considerable effort by the District s leadership team, the resulting annual budget meets these objectives but underscores the need for Kaweah Delta to become increasingly-more efficient and cost effective if it is to succeed in an environment of continually-lower reimbursement rates and rising regional competition. While this annual budget exceeds the minimum level of performance required by our creditors and provides the financial resources necessary to carry out our mission and goals, it will only be accomplished if we are successful in our planned efforts to reduce our acute inpatient length of stay; our consumption of supplies; and our performance of unnecessary clinical tests and treatments; improve our labor productivity; and successfully implement all seven of our health care delivery system improvement initiatives under the new Public Hospital Redesign and Incentives in Medi-Cal (PRIME) Program. In terms of overall profitability, the District s consolidated excess margin is projected at $26.9 million, or 3.6%, which is higher than the $26.4 million (3.7%) estimated for Of the $26.9 million excess margin, $5.2 million, or 19%, is derived from investment earnings. The District s operating margin (excluding investment earnings) is projected at 2.9% which represents a decrease from the estimated operating margin of 3.3%. The annual budget continues the District s fiscally-responsible practice of full payment of annual principal and interest on external debt, a contribution to the general and professional liability self-insurance trust fund equal to the amount recommended by the District s actuarial firm, and full compliance with all external debt covenants. In addition, in an effort to achieve full funding of the District s defined benefit pension plan liability within a targeted timeframe, this budget also reflects an $11.4 million contribution to the pension trust fund. The District s annual budget reflects an operating expense budget of $722 million, an increase of $38.2 million, or 5.6%, over the prior year. After considering the effects of increases in patient service volumes, the District s cost per adjusted patient day (the same measurement used for benchmarking purposes) is projected to increase by 2.3%, from $2,242 for to $2,294 for Over the past four years the District s cost per adjusted patient day has increased by a cumulative 22.5% from $1,872 in 2015 to $2,294 for fiscal year Over this same four-year period, the District s average hourly wage rate has increased annually on average 2.5% from $29.91 in 2015 to $32.85 for fiscal year Similar to certain years past where much of the District s expense increases have been concentrated in payroll and benefits, the budget reflects an increase of $24.1 million, or 7.2%, in total payroll and benefits, comprising 63% of the increase in total operating expenses. This increase is the result of a 4.1% increase in full-time equivalent employees from last year, a 2.8% increase in average hourly wage and $1.6 million in pay-range compression adjustments. Nonlabor expenses are expected to increase $14.1 million, or 4.1%, from The primary areas showing material increases are pharmaceutical supplies, depreciation and physician fees, reflective of the District s continuing effort to develop and enhance the presence of the Kaweah Delta Medical Foundation, as well as hospitalist programs, co-management service-line models and other integration initiatives designed to improve the overall quality, efficiency and patient experience associated with specific services. After considering the effects of increases in patient service volumes, nonlabor costs expressed as an amount per adjusted patient day are projected to increase by 0.9%.

364 The District s capital expenditures budget reflects a total outlay of $16.0 million for recurring capital assets and completion of strategically-important projects and infrastructure improvements, which represents a $2.0 million increase from the capital expenditures budget for fiscal year Total capital expenditures represent 50% of depreciation expense reflecting the District s continued commitment to replenish aging assets and maintain an Average Age of Plant ratio consistent with that of other A -rated hospitals (14.0 years at April 30, 2018 versus Moody s benchmark of 11.4 years). Of the $16.0 million capital budget, $7.2 million has been committed to complete strategically-important projects and upgrade aging infrastructure, $1.4 million committed to replacement of patient monitoring equipment and $2.3 million to information systems. The remaining $5.1 million of available capital funds will be used to meet recurring capital needs as identified by management. The District s management team will use its discretion in determining the expenditures most critical to patient care and the District s strategic interests. In addition to the $16.0 million capital expenditures budget, management has separately budgeted $820,000 for enterprise capital, funds allocated for specific investment in District service lines that operate in a uniquely-competitive environment, such as the Lifestyle Center and the District s rural health clinics, and to provide funding for pursuit of other business opportunities that may arise during the coming year. Furthermore, management has also provided for a general capital contingency fund of $340,000 to respond to unforeseen capital equipment needs or enhancement of operating systems. Combined, the District s capital expenditures budget plan for approximates $17.2 million. Operating Budget Analysis After several months of preparation, analysis, and revision, the resulting annual budget reflects the generation of net cash flows equal to $60.7 million (excess margin plus amortization and depreciation) which will be expended to acquire capital equipment and make principal debt service payments. After making these expenditures, the anticipated cash flows will provide for a $29.4 million increase in the District s surplus funds. Budgeted excess margin (net income) for the District of $26,852,000 represents a $474,000, or 1.8%, increase from , comprised of a $1,979,000, or 8.4%, decrease in operating margin and a $2,453,000, or 90.9%, increase in investment income. The projected excess margin of 3.6% is below the 6.1% median benchmark performance achieved by hospitals awarded an A rating by the Moody s bond rating agency for The District s projected 2.9% operating margin is lower than the median ratio of 3.2%, generally regarded by rating agencies as a more-important reflection of a hospital s financial performance. Patient Utilization Inpatient utilization for reflects an average daily patient census of 444, representing a 1.5% increase from the estimated average daily patient census for This increase is the combined effect of a 1.3% increase in acute patient days and a 2.4% increase in nonacute days. The patient days total of 162,132 for reflects general population growth in the District s primary service area and the presence of new physicians, tempered by the industry trend of increasingly moving patient care from inpatient to outpatient settings and the District s ongoing initiative to improve patient throughput and reduce its average length of stay. The acute medical/surgical patient days total of 101,939 (comprised of ICU and the primary medical/surgical units on the main campus) represents an increase of 0.8% from and an overall average occupancy rate of 75.5%. The remaining acute patient days total of 37,839 for the pediatrics, ICN, nursery, rehabilitation and acute psychiatry areas represents an increase of 2.9% outpatient activity expressed in equivalent inpatient days is projected to increase 5.2% from due primarily to increased patient activity in Imaging, Laboratory, Emergency/Urgent Care, Infusion Services, Rural Health Clinics, Sleep Center, Kaweah Delta Neurosciences Center, Chronic Disease Management Center, Kaweah Delta Medical Foundation and the Kaweah Delta Sequoia Cardiology Center.

365 Gross Patient Service Revenue Gross patient service revenue for will increase by 3.8% due primarily to increased patient care volumes. The budget does not reflect an increase to retail charges. The primary areas of gross patient service revenue increase are Routine Nursing, Emergency/Urgent Care services, Infusion Services, Kaweah Delta Neurosciences Center, Kaweah Delta Sequoia Cardiology Center and the Kaweah Delta Medical Foundation. Numerous other ancillary service areas are projecting modest increases in volume and gross patient revenue. Deductions from Revenue Budgeted deductions from revenue (DFR) for represent 70.5% of gross patient service revenue, an improvement from the 71.3% DFR rate experienced in DFR include contractual allowances for the Medicare and Medi-Cal programs, discounts negotiated directly with employers and other third-party payers, and provisions for bad debts and charity care. DFR for , as a percent of gross patient revenue, improves from levels primarily from the beneficial effects of slightlyincreased Medicare, Medi-Cal managed care and commercially-insured managed care reimbursement rates, improved Medicare reimbursement related to the District s ongoing clinical documentation improvement initiative, expected payment increases from Medi-Cal supplemental payment programs and receipt of direct and indirect medical education payments. Projecting DFR continues to be one of the most difficult components of the annual budget process, complicated by implementation of new payment systems by governmental payers, employers potential shift from one health plan to another, and most importantly, the requirement to project potential and likely changes in Medicare and Medi-Cal reimbursement rates far in advance of the passage of Federal and State budgets for the coming year. It is important to note that this budget reflects the increases and decreases currently residing in existing laws and regulations applicable to our fiscal year as well as the Centers for Medicare & Medicaid Services (CMS) proposed rule for Federal fiscal year With respect to Medicare, our largest payer, representing 41.6% of the District s gross patient revenue, the budgeted Medicare DFR percentage of 73.8% reflects reimbursement rate increases and decreases in a number of District programs including inpatient and outpatient general and rehabilitative acute services, home health, skilled nursing and rural health clinic services. These projected rate increases and decreases reflect a combination of both proposed and approved changes as published by CMS in various Federal Registers. With respect to general acute inpatient services reimbursed under the DRGbased Prospective Payment System, it is estimated that Kaweah Delta will experience an overall increase of 3.4% beginning October 1, 2018, the start of Federal fiscal year This reflects an overall marketbasket update of 2.8%, reduced by a cumulative 1.0% for numerous reductions mandated by the ACA and ATRA. This rate increase, together with other proposed payment policies and proposed changes in uncompensated care payments is estimated to increase Medicare IPPS payments by 3.4%. The budget also reflects a 1.4% increase in outpatient reimbursement rates, a 0.9% increase in acute rehabilitation rates, a 2.4% increase in skilled nursing and subacute rates, a 1.0% increase in acute psychiatric reimbursement rates, a 0.4% decrease in home health reimbursement rates, and a 1.4% increase in rural health clinic reimbursement rates. Lastly, the Medicare DFR rate also reflects approximately $750,000 in additional reimbursement resulting from our continuing efforts to improve clinical documentation and a minimal increase in additional direct and indirect medical education payments associated with the increase of additional physician resident FTEs. Medi-Cal, including Medi-Cal managed care, representing 31.9% of gross patient revenue, is expected to be reimbursed at an average rate of 31.4% of gross billed charges with 68.6% written-off to DFR. This DFR rate recognizes the reimbursement of services furnished to Medi-Cal managed care enrollees at negotiated rates and fee-for-service (FFS) reimbursement rates paid for most inpatients and outpatients in aid categories not eligible for the managed care program. With respect to patients covered under the Medi-Cal managed care program, the District is anticipating overall reimbursement rate increases of approximately 1.9% based on scheduled rate increases already included in multi-year contracts. The budget also includes $7.4 million of Medi-Cal Managed Care program Inter-Governmental Transfer (IGT) payments. With respect to patients covered under the State s FFS program, this budget reflects no change in reimbursement for acute medical/surgical, acute rehabilitation, skilled nursing, subacute, psychiatric, home health, and outpatient services, $7.3 million in FFS IGT revenue, $16.6 million in disproportionate share payments (with additional funding for graduate medical education), and $12.0

366 million in Provider Fee payments. Lastly, the Medi-Cal DFR rate also reflects approximately $750,000 in additional reimbursement resulting from efforts to improve clinical documentation relating to the Medi-Cal population. With respect to the remaining nongovernment category of patients representing 26.5% of gross patient revenues, the budget assumes we will collect an average of 32.2% of every dollar billed. The budget assumes that 88.6% of this nongovernment payer category will be covered by some form of commercial insurance (excluding Medicare and Medi-Cal managed care) where the District has agreed to accept reimbursement at a fixed price per patient day, per case or per procedure. Reimbursement rates for this nongovernment payer category are expected to increase an average of 2.6%, reflective of scheduled rate increases negotiated in prior years with many of the District s major managed care payers. Other Operating Revenue Other operating revenue for of $95,580,000 represents a $3,659,000, or 3.7%, decrease from Other operating revenue includes revenue generated from cafeteria food sales, operation of the Lifestyle Center and Kaweah Kids Center, the District s appropriation of general County taxes, revenue generated by the medical oncology component of Sequoia Regional Cancer Center (a joint venture with Sequoia Oncology Medical Associates and Adventist Health), and income received from the District s joint venture ownership in Quail Park Retirement Village, LLC; Laurel Court at Quail Park, LLC; Sequoia Surgery Center, LLC; and Cypress Company, LLC. Additionally, other operating revenue includes $12.0 million in Federal funding made available to district hospitals (non-designated public hospitals) under the 5-year Medicaid waiver (the PRIME healthcare delivery system improvement program previously referenced) and approximately $35.9 million in capitation payments to be received from Humana under their fully-capitated Medicare Advantage plan. Operating Expenses Operating expenses for of $722,025,000 represent a $38,202,000, or 5.6%, increase from This increase is the combined effect of a $24,055,000, or 7.2%, increase in employment costs and a $14,147,000, or 4.1%, increase in nonlabor expenses. The salaries budget reflects an average 2.45% pay-for-performance increase for District employees for and provides for $1,600,000 in funding for pay-range compression adjustments. Total paid manhours are projected to increase by 4.1%. Labor productivity, as measured by the number of full-time equivalents (FTEs) per adjusted occupied bed, is projected to be 4.92 in , a slight decrease (less productive) from the productivity levels experienced in and 5.0% lower than four years ago. Overall cost-efficiency, as measured by expense per adjusted patient day, is projected to increase 2.3% in , and is 22.5% higher than four years ago. Employee benefits for of $72,755,000 represents a $3,421,000, or 4.9%, increase from due primarily to increased workers compensation costs ($3,635,000) and increased social security costs ($1,448,000) offset by reduced employee retirement plan expense ($2,394,000). Employee retirement plan expense is expected to decrease as the District is no longer amortizing the deferred cost of the impact of mortality table changes. Benefits as a percentage of salaries for are 25.4% compared to 26.0% for Other direct expenses for of $362,448,000 represent a $14,147,000, or 4.1%, increase from This results primarily from a $7,186,000, or 28.9%, increase in depreciation expense, a $9,421,000, or 12.9%, increase in physician fees and a $2,746,000, or 9.3%, increase in pharmaceutical supplies. The depreciation expense increase results from the routine addition of new capital assets and the expected capitalization of major projects, including the Cerner information system. The physician fees increase results primarily from increased costs related to Kaweah Delta Sequoia Cardiology Center ($1,166,000), Kaweah Delta Neurosciences Center ($2,332,000), the Kaweah Delta Medical Foundation ($3,192,000), hospitalists programs ($749,000) and Rural Health Clinics physician payments ($787,000) and a new OB laborist program ($999,000) costs related to physician recruitment are $1,999,000. Various efficiency measures are projected to reduce the District s overall ratio of supplies expense to total operating revenue from 16.3% for to 15.8% for

367 Summary While the annual budget reflects the maintenance of financial strength prescribed by the District s goals, it also reflects the challenging environment in which it operates. However, our community s expectation of us to deliver high-quality clinical outcomes and outstanding patient satisfaction, while providing an ideal work environment for our employees and physicians, remains constant. Continued achievement of these expectations will require very-disciplined use of the limited resources available to us. We believe this annual budget is reflective of this discipline.

368 KAWEAH DELTA HEALTH CARE DISTRICT ANNUAL BUDGET Net patient service revenue Budget Estimated Budget Medicare $208,081,000 $231,725,000 $239,809,000 Medi-Cal 185,242, ,612, ,663,000 Other 197,808, ,925, ,672, ,131, ,262, ,144,000 Other operating revenue Nonpatient food sales 2,939,000 2,829,000 2,873,000 Lifestyle Center 3,740,000 3,665,000 3,663,000 Kaweah Kids Center 856, , ,000 Employee Assistance Care Network 171, , ,000 County taxes 1,154,000 1,255,000 1,309,000 Management services 29,243,000 28,875,000 29,268,000 Premium revenue 31,952,000 31,952,000 35,931,000 Other 23,071,000 29,623,000 21,481,000 93,126,000 99,239,000 95,580,000 Net operating revenue 684,257, ,501, ,724,000 Operating expenses Payroll: Directors/Managers/Supervisors 27,415,000 28,829,000 31,127,000 Technical/Instructors 75,993,000 75,076,000 83,906,000 RN 91,435,000 94,893,000 93,671,000 LVN 5,001,000 4,663,000 5,833,000 Aide/Orderly 18,476,000 21,252,000 22,703,000 Clerical 21,546,000 22,400,000 24,368,000 Environmental 10,466,000 11,121,000 12,057,000 Other 12,522,000 7,954,000 13,157,000 Employee benefits: 262,854, ,188, ,822,000 Social Security 19,114,000 18,686,000 20,134,000 State unemployment insurance 323, , ,000 Medical, dental and vision 24,532,000 26,749,000 27,376,000 Life insurance 328, , ,000 Workers' compensation 5,616,000 1,702,000 5,337,000 Employee retirement plans 17,919,000 19,423,000 17,029,000 Accrued vacation 3,117,000 1,657,000 1,785,000 Tuition/scholarships 300, , ,000 Other benefits 46, , ,000 71,295,000 69,334,000 72,755,000 Total payroll and benefits 334,149, ,522, ,577,000

369 KAWEAH DELTA HEALTH CARE DISTRICT ANNUAL BUDGET Budget Estimated Budget Other direct expenses: Physician fees 73,679,000 72,885,000 82,306,000 Therapist fees 605,000 1,241, ,000 Consulting fees 4,094,000 2,770,000 2,478,000 Legal fees 1,259,000 1,202,000 1,242,000 Audit fees 171, , ,000 Nurse registry 2,301,000 5,268,000 2,449,000 Contract staff 474, , ,000 Other professional fees 936,000 1,056, ,000 Prosthesis 18,811,000 21,491,000 22,938,000 Medical/surgical supplies 31,441,000 39,712,000 37,888,000 Oxygen 509, , ,000 IV solutions 699, , ,000 Pharmaceutical supplies 30,615,000 29,497,000 32,243,000 Radioactive material 821, , ,000 Radiology film 7,000 7,000 3,000 Cost of goods sold 5,380,000 6,429,000 6,485,000 Food 2,661,000 2,484,000 2,523,000 Linen 287, , ,000 Maintenance supplies 1,368,000 1,511,000 1,515,000 Office supplies 1,911,000 1,922,000 2,031,000 Uniforms 96, ,000 99,000 Minor medical equipment 744, , ,000 Other minor equipment 3,184,000 3,909,000 3,791,000 Books 134, , ,000 Medical purchased services 19,696,000 22,063,000 22,924,000 Repairs and maintenance 23,583,000 24,555,000 25,517,000 Collection services 2,500,000 3,158,000 1,792,000 Other purchased services 10,776,000 13,088,000 10,885,000 Amortization 2,057,000 1,912,000 1,764,000 Depreciation - building 5,987,000 6,007,000 5,987,000 Depreciation - leasehold improvements 94, , ,000 Depreciation - equipment/building impr 23,648,000 18,744,000 25,951,000 Rent 5,513,000 6,136,000 6,511,000 Electricity 3,014,000 3,009,000 3,094,000 Gas 1,904,000 1,975,000 2,034,000 Water and sewer 691, , ,000 Professional liability insurance 1,701,000 3,470,000 2,116,000 Other insurance 835, , ,000 Licenses and taxes 788, , ,000 Telephone 1,509,000 1,544,000 1,563,000 Dues and subscriptions 1,132,000 1,154,000 1,225,000 Education 1,174, ,000 1,219,000 Travel 1,794,000 1,637,000 1,508,000 Recruiting 2,091,000 1,173,000 1,738,000 Other direct expenses 4,894,000 6,259,000 6,306,000 Interest 5,772,000 4,637,000 6,007,000 Management services 28,703,000 28,375,000 28,740, ,043, ,301, ,448,000 Total operating expenses 666,192, ,823, ,025,000

370 KAWEAH DELTA HEALTH CARE DISTRICT ANNUAL BUDGET Budget Estimated Budget Operating margin 18,065,000 23,678,000 21,699,000 Investment income 4,383,000 2,700,000 5,153,000 Excess margin 22,448,000 26,378,000 26,852,000 Additional sources (uses) of cash Capital expenditures Annual recurring (14,000,000) (14,000,000) (16,000,000) Enterprise capital (820,000) (820,000) (820,000) General capital contingency fund (340,000) (340,000) (340,000) Debt service payments (6,926,000) (7,028,000) (7,602,000) Capitalized interest payments (3,289,000) (3,801,000) (1,796,000) Capitalized employment expenses (1,999,000) (4,544,000) (1,393,000) Unfunded DB Plan amortization 1,237,000 87,000 (3,307,000) Non-cash expenses Amortization 2,057,000 1,912,000 1,764,000 Depreciation 29,729,000 24,858,000 32,044,000 Increase in total surplus funds $28,097,000 $22,702,000 $29,402,000 Operating margin 2.6% 3.3% 2.9% Excess margin 3.3% 3.7% 3.6% Deductions from revenue percentage 70.5% 71.3% 70.5% Compensation ratio 40.6% 40.3% 40.7% Debt service coverage ratio: Annual Maximum annual Supplies as percent of net operating revenue 15.1% 16.3% 15.8%

371 KAWEAH DELTA HEALTH CARE DISTRICT FINANCIAL AND STATISTICAL COMPARATIVE ANALYSIS Estimated Budgeted Total FTEs Total 3,369 3,785 3,983 4,072 4,240 Net of excluded services * 3,098 3,513 3,731 3,832 3,999 FTEs per adjusted occupied bed ** Total Net of excluded services * Average hourly wage $29.91 $29.47 $29.75 $31.94 $32.85 Adjusted patient days 262, , , , ,811 Adjusted discharges 49,873 53,806 58,063 60,697 62,977 Total operating expenses (millions) $ $ $ $ $ Expense per adjusted patient day ** $1,873 $2,038 $2,135 $2,242 $2,294 Increase (decrease) from prior year: Dollars $43 $165 $97 $107 $52 Percent 2.3% 8.8% 4.8% 5.0% 2.3%

372 KAWEAH DELTA HEALTH CARE DISTRICT FINANCIAL AND STATISTICAL COMPARATIVE ANALYSIS Estimated Budgeted Expense per adjusted discharge ** $9,866 $10,800 $10,846 $11,266 $11,465 Increase (decrease) from prior year: Dollars $116 $934 $46 $420 $199 Percent 1.2% 9.5% 0.4% 3.9% 1.8% Average length of stay Acute Only Without Rehab and Acute Psych Inpatient/outpatient revenue mix Inpatient 55.2% 53.6% 51.9% 52.4% 51.5% Outpatient 44.8% 46.4% 48.1% 47.6% 48.5% 100.0% 100.0% 100.0% 100.0% 100.0% Financial classification of revenue Medicare 43.5% 43.6% 41.8% 41.6% 41.6% Medi-Cal 31.6% 30.7% 31.3% 31.7% 31.9% Other 24.9% 25.7% 26.9% 26.7% 26.5% 100.0% 100.0% 100.0% 100.0% 100.0% * Excluded services are Home Health, Private Homecare, Chronic Dialysis, Lifestyle Center and Kaweah Kids Center. ** Incorporates outpatient activity

373 KAWEAH DELTA HEALTH CARE DISTRICT CENSUS AND PATIENT DAYS SUMMARY Budget Estimated Budget Average Average Average Patient Daily Patient Daily Patient Daily Available Occupancy Days Census Days Census Days Census Beds Rate ICU 5, , , % CVICU 2, , , % CVICU-ICCU 2, , , % 2N-Cardiac Services 10, , , % 3W-ICCU 9, , , % 4T-Medical Telemetry 6, , , % 2S-Medical/Surgical 2, , , % 3E-Broderick Pavilion 2, , , % 3N-Medical/Surgical 12, , , % 3S-Oncology 11, , , % 4N-Renal 10, , , % 4S-Orthopedics 11, , , % 1E-Medical/Surgical , Other Overflow Units Pediatrics 1, , , % Antepartum Obstetrics 9, , , % NICU 5, , , % Rehabilitation 7, , , % Short-Stay Rehabilitation 4, , , % Transitional Care Services 6, , , % Subacute 11, , , % Acute Psychiatric 17, , , % 150, , , % Nursery 7, , , , , ,

374 KAWEAH DELTA HEALTH CARE DISTRICT KEY STATISTICS SUMMARY Budget Estimated Budget Emergency visits 90,629 90,828 92,058 Urgent Care/Sequoia Prompt Care visits 102,171 91,949 81,343 Home Health visits 30,200 30,207 31,350 Rural Health Clinic visits 113, , ,065 KD Home Infusion Pharmacy days of treatment 128, , ,090 Deliveries 4,800 4,800 4,800 Cardiac surgeries Other inpatient surgeries 3,567 3,864 3,939 Outpatient surgeries 5,630 5,765 5,852 Laboratory procedures 1,555,137 1,649,628 1,672,494 Cardiac Cath Lab procedures 12,566 13,154 13,347 Diagnostic Radiology procedures 80,917 88,857 90,165 Diagnostic Radiology procedures (KDIC) 12,346 12,428 12,617 Breast Center procedures 21,478 23,496 23,496 MRI procedures 4,456 4,900 4,972 MRI procedures (KDIC) 3,872 3,511 3,564 CAT Scan procedures 32,971 41,147 41,674 CAT Scan procedures (KDIC) 4,099 4,032 4,283 Respiratory Therapy procedures 405, , ,100 Acute Dialysis treatments 5,095 5,727 6,606 Chronic Dialysis treatments (Visalia) 23,307 21,951 22,280 Other meals (Cafeteria) 1,148,583 1,102,852 1,119,395 Patient meals (Dietary) 798, , ,699 Total meals 1,946,867 1,928,936 1,955,094 Kaweah Kids Center child care days 17,879 18,310 18,585 Lifestyle Center member months 131, , ,303

375 KAWEAH DELTA HEALTH CARE DISTRICT CAPITAL BUDGET Capital Spending Plan Facilities Infrastructure $250,000 $250,000 $250,000 Existing Facilities Renovation 500, ,000 Kaweah Care District Refurbish 200, , ,000 Misc Moves/Furnishings 100, , ,000 Misc IT Installations 250, , ,000 Small Projects Contingency 100, , ,000 Laboratory Remodel 110,000 1,190,000 SSB 5th Floor GME Offices and Lounge 170,000 Inpatient Pharmacy USP 800 Remodel 200,000 Rehabilitation Hospital Rehabilitation Ph 5 150, ,000 Radiology Equip Replacement Construction-CHC 50,000 Checker's/Doc's project (contingent) 300,000 Fire Alarm System-Mineral King 2E 100,000 Building Automation system replacement-south Campus 250,000 AHU #4 replacment (ASC entrance) 55,000 MKW East wing elevator refurbish 375,000 KDMH smokes (I-3) 137,000 4 Center AH rebuild 75,000 Chiller upgrades 350,000 IT West Roof Replacement 300,000 Cogen Assessment 55,000 Cogen Rebuild (Upgrade) 2,000,000 Urgent Care HVAC 40,000 South Campus Roof 1,600,000 Total capital spending plan $7,217,000 $2,690,000 $1,400,000 Information Systems SAN Storage $398, , ,392 Data Center Infrastructure 67,438 34, ,000 Network Equipment 86, ,000 75,000 Network Firewalls 15,176 EMS Antenna 31,334 Network Wiring 327, , ,000 Fiber Optic Cable Replacement 103,500 Server Infrastructure 48, ,000 Ambulatory Revenue Management Software 200,749 Professional Fee Computer Assisted Coding 119,103 Time & Attendance System upgrade 29,800 33,300 ED Patient Elopement/Staff Duress Sys Expansion 42,500 15,000 Ambulatory Rx Controls and Tracking 111,000 PACS Upgrade 37,500 42,000 New Intranet Website 193,000 75,000 Legacy EMR Archiving 150, , ,000 Trauma Registry System Replacement 33,000 Electronic Prescribing of Controlled Substances 100,250 Hardware/Software Adds/Repl/Upgrades 225, , ,000 Total information systems $2,272,459 $1,353,717 $1,612,692 Patient Monitoring-Nihon Kohden $1,367,400 2,958,500 78,500 Management discretionary $5,143,141 $10,856,859 $7,002,217 $3,091,192 TOTAL CAPITAL EXPENDITURES $16,000,000 $7,002,217 $3,091,192

376 KDHCD Risk Profile June 25, 2018 Evelyn McEntire Director of Risk Management

377 Risk Management Goals 1. Promote a safety culture as a proactive risk reduction strategy. 2. Reduce frequency and severity of harm (patient and non-patient). Zero incidents of never events 3. Reduce frequency and severity of claims.

378 Risk Management Profile Accomplishments Goals Proactive risk assessments conducted in the following areas: Emergency Department Mental Health Hospital KD Medical Center ligature risks in patient care areas Nursing Handoff communication gaps Antithrombotic medications Development of Workplace Violence Committee Goal: To promote a safe work environment for employees, contractors and vendors Goal: To report organizational workplace violence incidents which meet Cal/OSHA reporting requirements Continue to mitigate potential risks and hazards by conducting at least two proactive risk assessments: Nursing Handoff Communication Gap Analysis continued and development of action plan OB areas TBD Increase the Committee s role in mitigating potential risks and hazards of violence in the workplace: Track and trend all reports of workplace violence Analyze data to determine and reduce contributing factors Evaluate and implement workplace violence reduction initiatives Implementation of KD*Hub, a universal medical record system Continue to provide seamless communication of patient care through the use of a universal medical record system

379 Risk Management Profile Accomplishments Goals Exploration of Just Culture enhancement throughout KDHCD Current Planning Committee Structure: VP HR, Human Resources, Organizational Development, Quality & Patient Safety, Risk Management Engage in Just Culture enhancement at KDHCD Strengthen safety culture for patients and staff Increase event reporting Increase employee satisfaction Increase accountability among staff and leaders Provide educ/training/tools to leaders and front-line staff to foster a culture of speaking up Conduct prospective identification of potential risks and hazards: Telesitters FMEA Telemetry use FMEA Therapeutic Wound Packing FMEA Continue prospective identification of potential risks and hazards via FMEAs Information Technology TBD

380 Accomplishments Goals Conduct retrospective assessments and improvements of potential risks and hazards via: RCAs and focused reviews Medical record reviews Serious and sentinel event reporting Grievances internal and external Accreditation survey findings Completed Plans for Improvement: No Blood Products Abuse Reporting Therapeutic Wound Packing Risk Management Profile CNA/Sitter Education Inpatient Restroom Ligature Risk Reduction Continue to conduct retrospective assessments, analyze trends, and develop/implement action plans for improvement Safe Use of OR Patient Tables TBD

381 Risk Management Profile Accomplishments Goals Utilize the event reporting system to identify trends and high risk events reported by frontline staff and leaders Built data reports to organize and disseminate event reporting data to leaders Worked directly with departmental leaders to mitigate risks identified via the event reporting system Lab orders and specimen processing Blood product waste Mislabeled labs Enhance the event reporting system via the Midas Steering Committee Make the entry of event reports more user friendly Prioritize severity events (red, orange, yellow) More timely follow-up to event reports by leaders Utilize maximum features with Midas Further increase accessibility of event reporting data to leaders

382 District Bylaws Article I The District and Its Mission Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Kaweah Delta Health Care District is a community venture, operating under the authority granted through the California Health and Safety Code as a health care district. The purpose of the District is to provide quality health care within defined areas of expertise. It is the intent of the District that no person shall be denied emergency admission or emergency treatment based upon ability to pay. It is further the intent of the District that no person shall be denied admission or treatment based upon race, color, national origin, ethnic, economic, religious or age status or on the basis of sexual preference. The medical welfare of the community and its particular health needs will be fulfilled to the capacity of the District's financial limitations. Kaweah Delta Health Care District operates under the authority of California Code for a health care district. {California Health & Safety Code Division 23 Hospital Districts Sections } As such, Kaweah Delta Health Care District is publicly owned and operates as a non-profit entity. As permitted by law, the District may, by resolution of the Board, conduct any election by all-mailed ballots pursuant to Division 4 (commencing with Section 4,000) of the California Elections Code. The Mission of Kaweah Delta Health Care District is; To provide high quality, customer-oriented, and financially strong healthcare services that meet the needs of those we serve. The Vision of Kaweah Delta Health Care District is; Delivering Excellence. Together, Kaweah Delta and its Medical Staff will be recognized for consistently delivering a broad range of exceptional health care services, superior clinical quality, and exemplary customer service. The Values of Kaweah Delta Health Care District are: VISION INTEGRITY CARE ACCOUNTABILITY RESPECT EXCELLENCE We plan for and act to produce an ever-improving future. We are completely honest, candid, and transparent in our dealings. Our patients, their families, and the community must be at the center of all we do. We are completely responsible to our patients, the community, and our colleagues for producing the best results possible. We collaborate effectively with others and are socially and interpersonally skilled. We accept nothing less than our very best effort and through continual learning we are committed to achieve superior performance. March 27, 2017June 25, 2018 Page 1 of 2122

383 Section 7 Section 8 Section 1 Section 2 Section 3 Section 4 The mission, vision, and goals of the District support the safety and quality of care, treatment, and service {Joint Commission Standard LD } The Code of Conduct of Kaweah Delta Health Care District is a commitment to ethical and legal business practices, integrity, accountability and excellence. The Code is a founding document of the Compliance Program, developed to express Kaweah Delta s understanding and obligation to comply with all applicable laws and regulations {Joint Commission Standard LD }. Article II The Governing Body The Governing Body of the Kaweah Delta Health Care District is a Board of Directors constituted by the five (5) publicly elected directors, who are elected by zone, each for four (4) year terms, with two (2) being elected on staggered terms and three (3) being elected two (2) years later on staggered terms. {Health and Safety Code 32100} The election of the directors is to conform with the applicable California Code. {Government Code 1780} This publicly elected Governing Body is responsible for the safety and quality of care, treatment, and services, establishes policy, promotes performance improvement, and provides for organizational management and planning {Joint Commission Standard LD.1.10}. The Governing Body, in accordance with applicable California Code, adopts the Bylaws of the District. The principal office of the District is located at Kaweah Delta Health Care District, Kaweah Delta Medical Center - Acequia Wing, Executive Offices, 400 West Mineral King Avenue, Visalia, CA Correspondence to the Board should be addressed to the Board of Directors at this address. The District also maintains a Web site at All noticed meeting agendas and supporting materials for Board meetings and Board committee meetings can be obtained at The duties and the responsibilities of the Governing Body are: PRIMARY RESPONSIBILITY - This Board s primary responsibility is to develop and follow the organization s mission statement, which leads to the development of specific policies in the four key areas of: A. Quality Performance B. Financial Performance C. Planning Performance D. Management Performance The Board accomplishes the above by adopting specific outcome targets to measure the organization s performance. To accomplish this, the Board must: 1) Establish policy guidelines and criteria for implementation of the mission. The Board also reviews the mission statements of any March 27, 2017June 25, 2018 Page 2 of 2122

384 subsidiary units to ensure that they are consistent with the overall mission. 2) Evaluate proposals brought to the Board to ensure that they are consistent with the mission statement. Monitor programs and activities of the hospital and subsidiaries to ensure mission consistency. 3) Periodically review, discuss, and if necessary, amend the mission statement to ensure its relevance. A. QUALITY PERFORMANCE RESPONSIBILITIES - This Board has the final moral, legal, and regulatory responsibility for everything that goes on in the organization, including the quality of services provided by all individuals who perform their duties in the organization s facilities or under Board sponsorship. To exercise this quality oversight responsibility, the Board must: 1) Understand and accept responsibility for the actions of all physicians, nurses, and other individuals who perform their duties in the organization s facilities. 2) Review and carefully discuss quality reports that provide comparative statistical data about services, and set measurable policy targets to ensure continual improvement in quality performance. 3) Carefully review recommendations of the Medical Staff regarding new physicians who wish to practice in the organization and be familiar with the termination and fair hearing policies. 4) Reappoint individuals to the Medical Staff using comparative outcome data to evaluate how they have performed since their last appointment. 5) Appoint physicians to governing body committees and seek physician participation in the governance process to assist the Board in its patient quality-assessment responsibilities. 6) Fully understand the Board s responsibilities and relationships with the Medical Staff and maintain effective mechanisms for communicating with them. 7) Regularly receive and discuss malpractice data reflecting the organization s experience and the experience of individual physicians who have been appointed to the Medical Staff. 8) Adopt a Performance Improvement Plan and Risk Management Plan for the District and provide for resources and support systems to ensure that the plans can be carried out. 9) Regularly receive and discuss data about the Medical Staff to assure that future staffing will be adequate in terms of ages, numbers, specialties, and other demographic characteristics. 10) Ensure that management reviews and assesses the attitudes and opinions of those who work in the organization to identify strengths, weaknesses, and opportunities for improvement. March 27, 2017June 25, 2018 Page 3 of 2122

385 11) Monitor programs and services to ensure that they comply with policies and standards relating to quality. 12) Take corrective action when appropriate and necessary to improve quality performance. B. FINANCIAL PERFORMANCE RESPONSIBILITIES - This Board has the ultimate responsibility for the financial soundness of the organization. To accomplish this the Board must: 1) Annually review and approve the overall financial plans, budgets {Joint Commission Standard LD }, and policies for implementation of those plans and budgets on a short and long term basis. The plan must include and identify in detail the objective of, and the anticipated sources of financing for each anticipated capital expenditure: 2) Approve an annual audited financial statement prepared by a major accounting firm and presented directly to the Board of Directors. 3) Approve any specific expenditure in excess of $75,000, which is not included in the annual budget 4) Approve financial policies, plans, programs, and standards to ensure preservation and enhancement of the organization s assets and resources. 5) Monitor actual performance against budget projections and review and adopt ethical financial policies and guidelines. 6) Review major capital plans proposed for the organization and its subsidiaries. 7) Approve all contracts, whether directly, or by authority delegated to a committee or to the Chief Executive Officer or his designee(s) C. PLANNING PERFORMANCE RESPONSIBILITIES - The Board has the final responsibility for determining the future directions that the organization will take to meet the community s health needs. To fulfill this responsibility, the Board must: 1) Review and approve a comprehensive strategic plan and supportive policy statements. 2) Develop long term capital expenditure plans as a part of its long range strategic planning. 3) Determine whether or not the strategic plan is consistent with the mission statement. 4) Assess the extent to which plans meet the strategic goals and objectives that have been previously approved. 5) Periodically review, discuss, and amend the strategic plan to ensure its relevance for the community. 6) Regularly review progress towards meeting goals in the plan to assess the degree to which the organization is meeting its mission. March 27, 2017June 25, 2018 Page 4 of 2122

386 7) Annually meet with the leaders of the Medical Staff to review and analyze the health care services provided by the District and to discuss long range planning for the District. D. MANAGEMENT PERFORMANCE RESPONSIBILITES - The Board is the final authority regarding oversight of management performance by our Chief Executive Officer, Compliance and Privacy Officer, and Director of Internal Audit and support staff. To exercise this authority, the Board must: 1) Oversee the recruitment, employment, and regular evaluations of the performance of the Chief Executive Officer, the Compliance and Privacy Officer, and the Director of Internal Audit. 2) Evaluate the performance of the CEO annually using goals and objectives agreed upon with the CEO at the beginning of the evaluation cycle. Provide input to and have final approval of the annual evaluations of the Compliance and Privacy Officer, and the Director of Internal Audit. 3) Communicate regularly with the CEO, the Compliance and Privacy Officer and the Director of Internal Audit regarding goals, expectations, and concerns. 4) Periodically survey CEO, Compliance and Privacy Officer, and Director of Internal Audit employment arrangements at comparable organizations to assure the reasonableness and competitiveness of our compensation package. 5) Periodically review management succession plans to ensure leadership continuity. 6) Ensure the establishment of specific performance policies which provide the CEO, the Compliance and Privacy Officer, and the Director of Internal Audit with a clear understanding of what the Board expects, and ensure the update of these policies based on changing conditions. E. The Board is also responsible for managing its own governance affairs in an efficient and successful way. To fulfill this responsibility, the Board must: 1) Evaluate Board performance annually. Members of the governing body are elected by the public and, accordingly, are judged on their individual performance by the electorate. 2) Maintain written conflict-of-interest policies that include guidelines for the resolution of existing or apparent conflicts of interest. {Board of Directors policy BOD.05 Conflict of Interest} 3) Participate both as a Board and individually in orientation programs and continuing education programs both within the organization and externally. As such, the District shall reimburse reasonable expenses for both in-state and out-of-state travel for such educational purposes {Board Of Directors policy BOD.06 Board Reimbursement for Travel and Service Clubs} {Health and Safety Code 32103} March 27, 2017June 25, 2018 Page 5 of 2122

387 Section 5 4) Periodically review Board structure to assess appropriateness of size, diversity, committees, tenure, and turnover of officers and chairpersons. 5) Assure that each Board member understands and agrees to maintain confidentiality with regard to information discussed by the Board and its committees. 6) Assure that each Board member understands and agrees to adhere to the Brown Act ensuring that Board actions be taken openly, as required, and that deliberations be conducted openly, as required. 7) Adopt, amend, and if necessary repeal the articles and bylaws of the organization. 8) Maintain an up-to-date Board policy manual, which includes specific policies covering oversight responsibilities in the area of quality performance, financial performance, strategic planning performance, and management performance. 9) Review the District s Mission, Vision & Values statements every two years. The Board of Directors of the Kaweah Delta Health Care District shall hold regular meetings at a meeting place on the premises of the Kaweah Delta Health Care District on the fourth Monday of each month, as determined by the Board of Directors each month. {Health and Safety Code 32104} The Board of Directors of the Kaweah Delta Health Care District may hold a special meeting of the Board of Directors as called by the President of the Board or in his/her absence the Secretary/TreasurerVice President. In the absence of both officers of the Board a special meeting may be called by a majority of the members of the Board. A special meeting requires a 24 hour notice before the time of the meeting {Government Code 54956}. Meetings of the Board of Directors shall be noticed and held in compliance with the applicable California Code for Health Care Districts. {The Ralph M. Brown Act - Government Code 54950} Sections and of the Health and Safety Code of the State of California, as amended, indicate the attendance and quorum requirements for members of the Board of Directors of any health care district in the State of California. For general business the Board may operate under the rules of a small committee, however, upon the request of any member of the Governing Body immediate implementation of the Standard Code of Parliamentary Procedure (Roberts Rules of Order) shall be adopted for the procedure of that meeting. Section 6 The President of the Board of Directors shall appoint the committees of the Board and shall appoint the Chairperson and designate the term of office in a consistent and systematic approach. All committees of the Governing Body shall have no more than two (2) members of the Governing Body upon the committee and both Board members shall be present prior to the Board March 27, 2017June 25, 2018 Page 6 of 2122

388 committee meeting being called to order. All committees of the Governing Body shall serve as extensions of the Governing Body and report back to the Governing Body for action. Minutes of all committee meetings shall be distributed to all members of the Governing Body in such fashion that discussion and recommendations to the Governing Body are clearly presented. The President of the Board of Directors may appoint, with concurrence of the Board of Directors, any special committees needed to perform special tasks and functions for the District. Any special committee shall limit its activities to the task for which it was appointed, and shall have no power to act, except as specifically conferred by action of the Board of Directors. The Chief of Staff shall be notified and shall facilitate Medical Staff participation in any Governing Board Committee that deliberates the discharge of Medical Staff responsibility. The standing committees of the Governing Body are: A. Audit and Compliance Committee The membership of this committee shall consist of two (2) Board members (the Board President or Secretary/Treasurer shall be a standing member of this committee), the Chief Executive Officer (CEO), Chief Financial Officer (CFO), Chief Operating Officer (COO), the Director of Internal Auditor, Compliance and Privacy Officer, Compliance Specialist, legal counsel, and any other members designated by the Board President. The Committee will engage an outside auditor, meet with them pre audit and post audit, and review the audit log of the internal auditor. The Committee will examine and report on the manner in which management ensures and monitors the adequacy of the nature, extent and effectiveness of compliance, accounting and internal control systems. The Committee shall oversee the work of those involved in the financial reporting process including the internal auditors and the outside auditors, to endorse the processes and safeguards employed by each. The Committee will encourage procedures and practices that promote accountability among management, ensuring that it properly develops and adheres to a compliant and sound system of internal controls, that the internal auditor objectively assesses management's accounting practices and internal controls, and that the outside auditors, through their own review, assess management and the internal auditor's practices. This committee shall supervise all of the compliance activities of the District, ensuring that Compliance and Internal Audit departments effectively facilitate the prevention, detection and correction of violations of law, regulations, and/or District policies. The Compliance and Privacy Officer will review and forward to the full Board a written Quarterly Compliance Report. This committee, on behalf of the Board of Directors, shall be responsible for overseeing the recruitment, employment, evaluation and dismissal of March 27, 2017June 25, 2018 Page 7 of 2122

389 the Compliance and Privacy Officer and the Director of Internal Audit. These responsibilities shall be performed primarily by the CEO and/or the CEO s designees, but final decisions on such matters shall rest with this committee, acting on behalf of the full Board. B. Human Resources The membership of this committee shall consist of two (2) Board members, the Chief Executive Officer (CEO), the Vice President of Human Resources, the Chief Nursing Officer (CNO) and any other members designated by the Board President. This committee shall review and approve all personnel policies. This committee shall annually review and recommend changes to the Salary and Benefits Program, the Safety Program and the Workers Compensation Program, This committee will annually review the workers compensation report, competency report & organizational development report. C. Finance / Property, Services & Acquisition Committee The membership of this committee shall consist of two (2) Board members - (the Board President or Secretary/Treasurer will be a standing member of this committee), the Chief Executive Officer (CEO), the Chief Financial Officer (CFO), the Chief Operations Officer (COO), VP Strategic Planning and of Business Development, the Facilities Planning Directors, and any other members designated by the Board President. This committee will review the financial reports, recommend action for non-budgeted expenditures, review investments and review changes or additions to service lines. This committee shall review financial policies and strategies in an effort to keep Kaweah Delta Health Care District in a sound financial position. This committee shall assist the CEO in preparing the budget for the approval of the Board of Directors and shall recommend policies to the Board related to the short term and long range financial needs of the District. This committee shall evaluate the condition of the plant, grounds, and other real property holdings of Kaweah Delta Health Care District to assure that all of these areas are kept in a constant state of good repair for proper functioning, as well as maintain of aesthetic values. This committee shall oversee the acquisition and sale of property which is essential to the Health Care District to carry out its mission of providing high quality, customer-oriented, and financially strong healthcare services. This committee shall evaluate new or expanded business opportunities relative to the District s mission level of investment, expected financial performance, and financial operational capacity. The Finance / Property, Services, and Acquisition Committee will review and forward to the full Board the following reports: March 27, 2017June 25, 2018 Page 8 of 2122

390 1. Internal Financial Statements (Balance Sheet, Income Statement, Cash Flow Statement & Budget Variance Analysis) Reviewed by the Committee (bimonthly) and by the Board (February, May, and Decembermonthly) 2. Financiale Dashboard Statements Reviewed Submitted monthly to the Board. quarterly by Board 3. Investments Reviewed by Committee (Condensed Summary Information) and semi-annually by Board (Comprehensive Information)(February and October) 4. Annual Budget and Financial Forecast Reviewed Annually by Committee and Board (June) 5. Audited Financial Statement Reviewed Annually by Committee (September) and Board (October) 6. Joint-Ventures (Financial, Performance Improvement and Patient Safety) Reviewed Annually by Committee and Board a. Sequoia Regional Cancer Center b. SRCC Medical Oncology c. TKC Development d. Quail Park e. Sequoia Surgery Center f. Kaweah Delta Medical Foundation 1. Community-Based Planning Committee The membership of this sub-committee shall consist of two (2) Board members {Board President or Secretary/Treasurer shall be a standing member of this committee}, CEO, Facilities Planning Director and any other members designated by the Board President as they deem appropriate to the topic(s) being considered: community leaders including but not limited to City leadership, Visalia Unified School District (VUSD) leadership, College Of the Sequoias leadership, County Board of Supervisors, etc. The membership of this sub-committee shall meet with other community representatives to develop appropriate mechanisms to provide for efficient implementation of current and future planning of District facilities and services and to achieve mutual goals and objectives. D. Governance & Legislative Affairs Committee The membership of this committee shall consist of two (2) Board members {the Board President or the Board Secretary/Treasurer}, the CEO and any other members designated by the Board President. Committee activities will include; reviewing Board committee structure, calendar, bylaws and, planning the Board self-evaluation, and monitor conflict of interest. Legislative activities will include; establishing the legislative program scope & direction for the District, annually review appropriation request to be submitted by the District, effectively March 27, 2017June 25, 2018 Page 9 of 2122

391 communicating and maintaining collegial relationships with local, state, and nationally elected officials. E. Information Systems Steering Committee The membership of this committee shall consist of two (2) Board members, the CEO, CFO, COO, CNO, CMO, the Chief Information Officer (CIO), the Medical Director of Informatics, and any other members designated by the Board President. This committee shall supervise the Information Systems projects of the District. F. Marketing and Public Affairs Committee The membership of this committee shall consist of two (2) Board members and the CEO, the VP Strategic Planning and Business Development of Development, the Marketing Director, and any other members designated by the Board President. This committee shall oversee marketing and public affairs activities in the District in order to increase the primary and secondary market share in all service areas. Additionally, creates by creating a brand that builds preference for Kaweah Delta in the minds of consumers and creates a public image that instills trust, confidence, and is emblematic of Kaweah Delta s mission statement. Further develops and fosters a positive perception that will attract the highest caliber of employees and medical staff. and that attracts the highest caliber employees and Medical Staff. G. Quality Council The membership of this committee shall consist of two (2) Board members, the CEO or designate, the CMO, COO, CNO, CIO, the Chief of the Medical Staff, the chair of the Professional Staff Quality Committee (Prostaff), the Medical Directors of Quality and Patient Safety, Director of Quality and Patient Safety, Director of Risk Management, and members of the Medical Staff as designated by the Board. This committee shall review and recommend approval of the annual QI Plan and Patient Safety plans to the Board of Directors, determine priorities for improvement, monitor key outcomes related to Quality Focus Team activities, evaluate clinical quality, patient safety, and patient satisfaction, monitor and review risk management activities and outcomes, evaluate the effectiveness of the performance improvement program, foster commitment and collaboration between the District and Medical Staff for continuous improvement, and review all relevant matters related to Quality within the institution, including Performance Improvement, Peer Review, Credentialing/Privileging and Risk Management. the education plan, Performance Improvement related issues, risk management and peer review, review credentialing process and review the peer review process. H. Strategic Planning Committee The membership of this committee shall consist of two (2) Board members, the CEO, VP of Strategic Planning and Business Development, March 27, 2017June 25, 2018 Page 10 of 2122

392 other Executive Team members, Medical Staff Officers, Immediate past Chief of Staff along with other members of the Medical Staff as designated by the Board and the CEO. This committee shall review the budget plan, review the strategic plan and organize objectives, review changes or additions to service lines and plan MD / Board retreat. The Strategic Planning Committee will provide oversight and forward to the full Board the following reports: 1. Review of the Strategic Plan Annually 2. Strategic Plan initiatives progress and follow-up monthly to full Board. I. Independent Committees The following independent committees will have Board member participation. 1. Quail Park 2. Sequoia Surgery Center 3. Sequoia Regional Cancer Center Medical & Radiation 4. KDHCD Retirement Committee 5. Kaweah Delta Hospital Foundation Board of DirectorsOther Healthcare organizations 6. TKC Development, LLC The Board President shall serve as General Manager for TKC Development, LLC. 7. Medical Staff Organization s Graduate Medical Education Committee (GMEC) 8. Cypress Company LLC 9. The Professional Staff Quality Committee Prostaff Kaweah Delta Medical Foundation Sequoia Integrated Health Board of members J. Medical Affairs 1) A member of the Board, as appointed by the President, shall also serve on the following Medical Staff Committees: a) Joint Conference & Planning Committee - This committee shall regularly meet to discuss current issues/concerns with Medical Staff, Board, and Administration. b) Credentials Committee - The Board shall participate in this committee to observe the Medical Staff process. Section 7 The Governing Body Bylaws: The Governing Body Bylaws and any changes thereto may be adopted at any regular or special meeting by a legally constituted quorum of the Governing Body. All portions of Governing Body Bylaws must be in compliance with applicable California Code, which is the ruling authority. March 27, 2017June 25, 2018 Page 11 of 2122

393 Section 8 Section 9 Section 10 Section 11 Any member of the Governing Body may request a review for possible revision of the Bylaws of the District. The Chief Executive Officer and the Governing Body shall review the Bylaws and recommend appropriate changes every year. Members of the Governing Body shall annually sign a job description which outlines the duties and responsibilities of the Governing Body members including but not limited to adherence to the Board conflict of interest policy {Board of Directors policy - BOD5 Conflict of Interest}, District confidentiality, and the Brown Act. Members of the Governing Body are publicly elected. The members of the Governing Body are expected to participate actively in the functions of the Governing Body and its committees and to serve the constituency who elected them. Notwithstanding any other provision of law, the term of any member of the board of directors shall expire if he or she is absent from three consecutive regular meetings, or from three of any five consecutive meetings of the board and the board by resolution declares that a vacancy exists on the board {Health and Safety Code }. The Chief Executive Officer shall provide an orientation program to all newly elected members of the Governing Body. {Board of Directors policy BOD1 Orientation of a New Board Member} All members of the Board of Directors shall be provided with current copies of the District Bylaws and the Medical Staff Bylaws and any revisions of these Bylaws. All members of the Governing Body shall be provided with a copy of the Bylaws which govern the Board of Directors, a job description for the District Governing Body and the Board President or Individual Board Member as applicable. Article III Officers of the Board Section 1 Section 2 The offices of President, Vice President, and Secretary/Treasurer shall be selected at the first regular meeting in December of a non-election year of the District. To hold the office of President, a Board member must have at least one year of service on the Board of Directors. These officers shall hold office for a period of two (2) years or until the successors have been duly elected (or in the case of an unfulfilled term, appointed) and qualified. The officer positions shall be by election of the Board itself. The duties and responsibilities of the Governing Body President are: A. Keep the mission of the organization at the forefront and articulates it as the basis for all Board action. B. Understand and communicate the roles and functions of the Board, committees, Medical Staff, and management. March 27, 2017June 25, 2018 Page 12 of 2122

394 C. Understand and communicate individual Board member, Board leader, and committee chair responsibilities and accountability. D. Act as a liaison between the Board, management, and Medical Staff. E. Plan agendas. F. Preside over the meetings of the Board. G. Preside over or attend other Board, Medical Staff, and other organization meetings. H. Enforce Board and hospital bylaws, rules, and regulations (such as conflict of interest and confidentiality policies). I. Appoint Board committee chairs and members in a consistent and systematic approach. J. Act as a liaison between and among other Boards in the healthcare system. K. Direct the committees of the Board, ensuring that the committee work plans flow from and support the hospital and Board goals, objectives, and work plans. L. Provide orientation for new Board members and arrange continuing education for the Board. M. Ensure effective Board self-evaluation. N. Build cohesion among the leadership team of the Board President, CEO, and Medical Staff leaders. O. Lead the CEO performance objective and evaluation process. Section 3 Section 4 Section 5 The Secretary/TreasurerVice President shall act as President in the absence of the President, and so acting shall have all the power and authority of the President. The Secretary/Treasurer shall act as the Secretary for the Board of Directors of Kaweah Delta Health Care District and in so doing shall: A. maintain minutes of all meetings of the Board of Directors; B. be responsible for the custody of all records and for maintaining records of the meetings; C. be assured that an agenda is prepared for all meetings. The Secretary/Treasurer shall be custodian of all funds of Kaweah Delta Health Care District as well as the health care facilities operated by the District. The Secretary/Treasurer shall assure that administration is using proper accounting systems; that this is a true and accurate accounting of the transactions of the March 27, 2017June 25, 2018 Page 13 of 2122

395 District; that these transactions are recorded and accurate reports are regularly reported to the Board of Directors. The Secretary/Treasurer in conjunction with the Board Audit and Compliance Committee shall see that a major accounting firm provides ongoing overview and scrutiny of the fiscal aspects of the District, and shall further assure that an annual audit is prepared by a major accounting firm and presented directly to the Board of Directors. Article IV The Medical Staff Section 1 Section 2 Section 3 Section 4 The Governing Body shall appoint the Medical Staff composed of licensed physicians, surgeons, dentists, podiatrists, clinical psychologists, and all Allied Health Practitioners (including Physician Assistants, Nurse Practitioners and Nurse Midwives) duly licensed by the State of California { Health and Safety Code of the State of California, Section 32128}. The Governing Body, upon consideration of the recommendations of the Medical Staff coming from the Medical Executive Committee, through the Credentials Committee, affirms or denies appointment and privileges to the Medical Staff of Kaweah Delta Health Care District in accordance with the procedure for appointment and reappointment of medical staff as provided by the standards of the Joint Commission on Accreditation of Healthcare Organizations {Joint Commission Standard MS }. The Board of Directors shall reappoint members to the Medical Staff every two (2) years, as set forth in the Medical Staff Bylaws. The Governing Body requires that an organized Medical Staff is established within the District and that the Medical Staff submits their Bylaws, Rules and Regulations and any changes thereto, to the Governing Body for approval. Members of the Medical Staff are eligible to run in public election for membership on the Governing Body in the same manner as other individuals. All public meetings of the Governing Body may be attended by members of the Medical Staff. The Chief of Staff of Kaweah Delta Health Care District shall be notified and invited to each regular monthly meeting of the Governing Body and the Chief of Staff s input shall be solicited with respect to matters affecting the Medical Staff. The Chief of Staff of Kaweah Delta Health Care District shall be invited to all meetings of the Governing Body at which credentialing decisions are made concerning any member of the Medical Staff of Kaweah Delta Hospital or at which quality assurance reports are given concerning the provision of patient care at Kaweah Delta Hospital. Quality assurance reports shall be made to the Board periodically. Credentialing decisions shall be scheduled on an as-needed basis. The Chief of Staff shall be encouraged to advise the Board on the content and the quality of the presentations, and to make recommendations concerning policies and procedures, the improvement of patient care and/or the provision of new services by the District. March 27, 2017June 25, 2018 Page 14 of 2122

396 Annually, the Governing Body shall meet with the leaders of the Medical Staff to review and analyze the health care services provided by the District and to discuss long range planning for the District as noted in Article II, Section 4, Item C7. Section 5 The District has an organized Medical Staff that is accountable to the Governing Body {Joint Commission Standard LD }. The organized Medical Staff Executive Committee shall make recommendations directly to the Governing Body for its approval. Such recommendations shall pertain to the following: A. the structure of the Medical Staff; B. the mechanism used to review credentials and delineate clinical privileges; C. individual Medical Staff membership; D. specific clinical privileges for each eligible individual; E. the organization of the performance improvement activities of the Medical Staff as well as the mechanism used to conduct, evaluate, and revise such activities; F. the mechanism by which membership on the Medical Staff may be terminated; G. the mechanism for fair hearing procedures. Section 6 Section 7 Section 8 The Governing Body shall act upon recommendations concerning Medical Staff appointments, re-appointments, termination of appointments, and the granting or revision of clinical privileges within 120 days following the regular monthly meeting of the Governing Body at which the recommendations are presented through the Executive Committee of the organized Medical Staff. The Governing Body requires that only a member of the organized Medical Staff with admitting privileges at Kaweah Delta Hospital may admit a patient to Kaweah Delta Hospital and that such individuals may practice only within the scope of the privileges granted by the Governing Body and that each patient's general medical condition is the responsibility of a qualified physician of the Medical Staff. The Governing Body requires that members of the organized Medical Staff and all Allied Health Practitioners (including Physician Assistants, Nurse Practitioners and Nurse Midwives) maintain current professional liability insurance with approved carriers and in the amounts of $1,000,000/$3,000,000 (per occurrence / annual aggregate) or such other amounts as may be established by the Governing Body by resolution. Section 9 The Governing Body holds the Medical Staff responsible for the development, adoption, and annual review of its own Medical Staff Bylaws, Rules and Regulations that are consistent with the District policy, applicable codes, and other regulatory requirements. Neither the Medical Staff nor The Governing Body may make unilateral amendments to the Medical Staff Bylaws or the Medical Staff Rules and Regulations. March 27, 2017June 25, 2018 Page 15 of 2122

397 The Medical Staff Bylaws and the Rules and Regulations adopted by the Medical Staff, and any amendments thereto, are subject to, and effective upon, approval of the Governing Body, such approval not to be unreasonably withheld. Section 10 Section 11 Section 12 Section 13 Section 14 The Medical Staff is responsible for establishing the mechanism for the selection of the Medical Staff Officers, Medical Staff Department Chairpersons, and Medical Staff Committee Chairpersons. This mechanism will be included in the Medical Staff Bylaws. The Governing Body requires the Medical Staff and the Management to review and revise all department policies and procedures as often as needed. Such policies and procedures must be reviewed at least every three (3) years. In adherence with Title 22, {70203} Policies relative to medical service {those preventative, diagnostic and therapeutic measures performed by or at the request of members of the organized medical staff} shall be approved by the governing body as recommended by the Medical Staff. In adherence with Title 22, {70213} Nursing Service Policies for patient care shall be developed, maintained and implemented by nursing services; policies which involve the Medical Staff shall be reviewed and approved by the Medical Staff prior to implementation. The hospital administration and the governing body shall review and approve all policies that relate to nursing services every three years or more often, if necessary. Individuals who provide patient care services (other than District staff members), but who are not subject to the Medical Staff privilege delineation process, shall submit their credentials to the Interdisciplinary Practice Committee of the Medical Staff which shall, via the Executive Committee, transmit its recommendations to the Governing Body for approval or disapproval. The quality of patient care services provided by individuals who are not subject to Medical Staff privilege delineation process, shall be included as a portion of the District s Performance Improvement program. The Governing Body specifies that under the privacy regulations of the Health Insurance Portability and Accountability Act (HIPAA), the Medical Staff and the District are in an Organized Health Care Arrangement (OHCA). The OHCA is a clinically integrated care setting in which individuals receive heath care from more than one provider and the providers hold themselves out to the public as participating in a joint arrangement. The Medical Staff is in an OHCA with the District for care provided at District facilities. This joint arrangement is disclosed to the patients in the Notice of Privacy Practices given to patients when they access care at any of the District s facilities. Article V Joint Committees March 27, 2017June 25, 2018 Page 16 of 2122

398 Section 1 The President of the Governing Body or a member of the Board appointed by the President shall participate, along with the Chief Executive Officer, in the Joint Conference Committee, which is a committee of the Medical Staff of Kaweah Delta Health Care District. This committee shall serve as a systematic mechanism for communication between members of the Governing Body, the Administration, and members of the Medical Staff of Kaweah Delta Health Care District. Specifically, issues which relate to quality of patient care shall be regularly addressed. Additionally, other matters of communication which are of importance to maintaining a sound working relationship between the Governing Body and the Medical Staff shall be discussed. These meetings shall be held at a minimum of every other month and minutes, if any, shall be kept by the organized Medical Staff under the direction of its President. The proceedings and records of this committee are protected by Section 1157 of the evidence Code. Article VI Chief Executive Officer Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Section 7 The Governing Body shall be solely responsible for appointment or dismissal of the Chief Executive Officer. {Board of Directors policy BOD2 Chief Executive Officer (CEO) Transition} The Governing Body shall assure that the Chief Executive Officer is qualified for his responsibilities through education and/or experience {Board of Directors policy BOD3 Chief Executive Officer (CEO) Criteria}. The Chief Executive Officer shall act on behalf of the Governing Body in the overall management of the District. In the absence of the Chief Executive Officer, a Vice President designated by the Chief Executive Officer or by the President of the Governing Body shall assume the responsibilities of this position. The Governing Body retains final authority to name the person to act during the absence or incapacity of the Chief Executive Officer. Annually the Governing Body shall meet in Executive session to monitor the performance of the Chief Executive Officer. The conclusions and recommendations from this performance evaluation will be transmitted to the Chief Executive Officer by the Governing Body. The Chief Executive Officer shall select, employ, control, and have authority to discharge any employee of the District other than any individual with the title or equivalent function of Senior Vice President, Vice President, the Compliance and Privacy Officer, and the Director of Internal Audit, or Board Clerk. Employment of new personnel shall be subject to budget authorization granted by the Board of Directors of Kaweah Delta Health Care District. The Chief Executive Officer shall organize, and have the authority to reorganize the administrative structure of the District, below the level of CEO, subject to March 27, 2017June 25, 2018 Page 17 of 2122

399 Section 8 Section 9 Section 10 Section 11 Section 12 Section 13 Section 14 Section 15 Section 16 Section 17 the limitations set forth in in Section 6 above. the Compliance and Privacy Officer, and the Director of Internal Audit. The District s organizational chart shall reflect that the Compliance and Privacy Officer, and the Director of Internal Audit have direct, solid-line reporting relationships to the Board (functional) and to the CEO (administrative). The Chief Executive Officer shall report to the Board at regular and special meetings all significant items of business of Kaweah Delta Health Care District and make recommendations concerning the disposition thereof. The Chief Executive Officer shall, directly and through the District s Vice Presidents, keep the Compliance and Privacy Officer, and the Director of Internal Audit wellinformed of District operations and shall promptly inform them of any matter that may expose the District to a material legal, regulatory or financial liability. The Chief Executive Officer shall submit regularly, in cooperation with the appropriate committee of the Board, periodic reports that may be required by the Board. The Chief Executive Officer shall attend all meetings of the Board when possible and shall attend meetings of the various committees of the Board when so requested by the committee chairperson. The Chief Executive Officer shall serve as a liaison between the Board and the Medical Staff of Kaweah Delta Hospital. The Chief Executive Officer shall cooperate with the Medical Staff and secure like cooperation on the part of all concerned with rendering professional service to the end that patients may receive the best possible care. The Chief Executive Officer shall make recommendations concerning the purchase of equipment and supplies and the provision of services by the District, considering the existing and developing needs of the community and the availability of financial and medical resources. The Chief Executive Officer shall keep abreast and be informed of new developments in the medical and administrative areas of hospital administration. The Chief Executive Officer shall oversee the District s physical plants and ground and keep them in a good state of repair, conferring with the appropriate committee of the Board in major matters, but carrying out routine repairs and maintenance without such consultation. The Chief Executive Officer shall supervise all business affairs such as the records of financial transactions, collections of accounts and purchase and issuance of supplies, and be certain that all funds are collected and expended to the best possible advantage. The Chief Executive Officer shall supervise the preservation of the permanent medical records of the District and act as overall custodian of these records. The Chief Executive Officer shall keep abreast of changes in applicable laws and regulations and shall insure that a District compliance program, appropriate March 27, 2017June 25, 2018 Page 18 of 2122

400 Section 18 Section 19 Section 20 educational programs, and organizational memberships are in place to carry out this responsibility. The Chief Executive Officer shall be responsible for assuring the organization s compliance with applicable licensure requirements, laws, rules, and regulations, and for promptly acting upon any reports and/or recommendations from authorized agencies, as applicable. The Chief Executive Officer will ensure that the busness of the Health Care Distict is conducted openly and transparently, as required by law. The Chief Executive Officer will oversee the activities of the Health Care District s community relations committees to ensure meaningful participation of community members and communication of the input and recommendation from the committee to the Board and to KDHCD management. Section The Chief Executive Officer shall perform any special duties assigned or delegated to him by the Board. Article VII The Health Care District Guild Section 1 Section 2 Section 3 The Governing Body recognizes the Kaweah Delta Health Care District Guild in support of the staff and patients of the District. The Chief Executive Officer is charged with effecting proper integration of the health care district Guild within the framework of the District organization. The President of the Guild is encouraged to attend the meetings of the Board of Directors. Article VIII Performance Improvement (PI) Section 1 Section 2 Section 3 Section 4 The Governing Body requires that the Medical Staff and the District staff implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, for identifying and resolving problems, and for identifying opportunities to improve patient care within the District. The Governing Body, through the Chief Executive Officer, shall support these activities and mechanisms. The Governing Body shall adopt a Performance Improvement Plan and Risk Management Plan for the District and shall provide for resources and support systems to ensure that the plans can be carried out. The Governing Body requires that a complete and accurate medical record shall be prepared and maintained for each patient; that the medical record of the patient shall be the basis for the review and analysis of quality of care. The Governing Body holds the organized Medical Staff of the health care district responsible for self-governance with respect to the professional work performed in the hospital and for periodic meetings of the Medical Staff to review and March 27, 2017June 25, 2018 Page 19 of 2122

401 Section 5 analyze at regular intervals their clinical experience. Results of such review will be reported to the Governing body at specific intervals defined by the Board. The quality assurance mechanisms within any of the District s facilities shall provide for monitoring of patient care processes to assure that patients with the same health problem are receiving the same level of care within the District. Article IX Conflict of Interest Section 1 Section 2 Section 3 The Administration Policy Manual of Kaweah Delta Health Care District and the Board of Directors Policy Manual has a written Conflict of Interest Policy {Administrative Policy AP23 and Board of Directors Policy BOD5} which requires the completion and filing of a Conflict of Interest Statement disclosing financial interests that may be materially affected by official actions and provides that designated staff members must disqualify themselves from acting in their official capacity when necessary in order to avoid a conflict of interest. The requirements of this policy are additional to the provisions of Government Code and other laws pertaining to conflict of interest; and nothing herein is intended to modify or abridge the provisions of the policies of Kaweah Delta Health Care District which apply to: A. members of the Governing Body, B. the executive staff of the District, C. employees who hold designated positions identified in Exhibit A of the District Conflict of Interest Code. Each member of the Governing Body, specified executives, and designated employees must file an annual Conflict of Interest Statement as required by California Code. The Board shall assess the adequacy of its conflict-of-interest/confidentiality policies and procedures {Board Of Directors Policy - BOD5 - and Administrative Policy 23 Conflict of Interest} at least every two years. Section 1 Article X Indemnification of Directors, Officers, and Employees Actions other than by the District. The District shall have the power to indemnify any person who was or is a party, or is threatened to be made a party, to any proceeding (other than an action by or in the right of the District to procure a judgment in its favor) by reason of the fact that such person is or was a director, officer or employee of the District, against expenses, judgments, fines, settlements, and other amounts actually and reasonably incurred in connection with such proceeding if that person acted in good faith and in a manner that the person reasonably believed to be in the best interest of the District and, in the case of a criminal proceeding, had no reasonable cause to believe the conduct of that person was unlawful. The termination by any proceeding by judgment, order, settlement, conviction or upon a plea of nolo contendere or its equivalent, shall not, of itself, create a presumption that the March 27, 2017June 25, 2018 Page 20 of 2122

402 person did not act in good faith and in the manner that the person reasonably believed to be in the best interests of the District person's conduct was unlawful. Section 2 Actions by the District. The District shall have the power to indemnify any person who was or is a party, or is threatened to be made a party, to any threatened, pending, or completed action by or in the right of the District to procure a judgment in its favor by reason of the fact that such person is or was a director, officer, or employee of the District, against expenses actually and reasonably incurred by such person in connection with the defense or settlement of that action, if such person acted in good faith, in a manner such person believed to be in the best interest of the District and with such care, including reasonable inquiry, as an ordinarily prudent person in a like position would use under a similar circumstance. No indemnification shall be made under this Section: A. with respect to any claim, issue or matter as to which such person has been adjudged to be liable to the District in their performance of such person's duty to the District, unless and only to the extent that the court in which that proceeding is or was pending shall determine upon application that, in view of all the circumstances of the case, such person is fairly and reasonably entitled to indemnity for the expenses which the court shall determine; B. of amounts paid in settling or otherwise disposing of a threatened or pending action, with or without court approval; C. of expenses incurred in defending a threatened or pending action that is settled or otherwise disposed of without court approval. Section 3 Section 4 Successful defense by director, officer, or employee. To the extent that a director, officer or employee of the District has been successful on the merits in defense of any proceeding referred to in Section 1 or Section 2 of this Article X, or in defense of any claim, issue or matter therein, the director, officer or employee shall be indemnified as against expenses actually and reasonably incurred by that person in connection therewith. Required approval. Except as provided in Section 3 of this Article, any indemnification under this Article shall be made by the District only if authorized in the specific case, upon a determination that indemnification of the officer, director or employee is proper in the circumstances because the person has met the applicable standard of conduct set forth in Sections 2 and 3 of this Article X, by one of the following: A. a majority vote of a quorum consisting of directors who are not parties to the proceeding; or B. the court in which the proceeding is or was pending, on application made by the District or the officer, director or employee, or the attorney or other March 27, 2017June 25, 2018 Page 21 of 2122

403 Section 5 Section 6 Section 7 Section 8 person rendering services in connection with the defense, whether or not such other person is opposed by the District. Advance of expenses. Expenses incurred in defending any proceeding may be advanced by the District before the final disposition of the proceeding upon receipt of an undertaking by or on behalf of the officer, director or employee to repay the amount of the advance unless it shall be determined ultimately that the officer, director or employee is entitled to be indemnified as authorized in this Article. Other contractual rights. Nothing contained in this Article shall affect any right to indemnification to which persons other than directors and officers of this District may be entitled by contract or otherwise. Limitations. No indemnification or advance shall be made under this Article except as provided in Section 3 or Section 4, in any circumstance where it appears: A. that it would be inconsistent with the provision of the Articles, a resolution of the Board, or an agreement in effect at the time of accrual of the alleged cause of action asserted in the proceeding in which the expenses were incurred or other amounts were paid, which prohibits or otherwise limits indemnification; or B. that it would be inconsistent with any condition expressly imposed by a court in approving a settlement. Insurance. If so desired by the Board of Directors, the District may purchase and maintain insurance on behalf of any officer, director, employee or agent of the corporation, insuring against any liability asserted against or incurred by the director, officer, employee or agent in that capacity or arising out of the person's status as such, whether or not the District would have the power to indemnify the person against that liability under the provisions of this Article. If any article, section, sub-section, paragraph, sentence, clause or phrase of these District Bylaws is for any reason held to be in conflict with the provisions of the Health and Safety Code of the State of California, such conflict shall not affect the validity of the remaining portion of these Bylaws. These Bylaws for Kaweah Delta Health Care District are adopted, as amended, this 27 th 23rd day of March 2017June, President Kaweah Delta Health Care District Secretary/Treasurer Kaweah Delta Health Care District March 27, 2017June 25, 2018 Page 22 of 2122

404 Kaweah Delta Health Care District Infection Prevention Committee Annual Board Report 2017 Dan Boken, MD, IP Medical Director Shawn Elkin, MPA, BSN, PHN, RN, CIC Infection Prevention Manager 6/27/18

405 HAI Summary 2017 Year HAI # Infections Better/Worse SSI Surgical Site Infection VAE Ventilator -Associated Event Leapfrog CLABSI* Central Line Associated Blood Steam Infection CAUTI* Catheter Associated Urinary Tract Infection *Value Based Purchasing National Benchmark 47 No Different than National Benchmark. Sustained reduction in SSI from 2015 (34% better than 2015) 12 events No National Benchmark 1 VAP ICU 4 IVAC (ICU), 1 VAP (0 NICU) reportable 17 (0 NICU) No Different than National Benchmark 14 No Different than National Benchmark Team SSI VAE CLABSI CAUTI Strategy Addressing timely administration of pre-op prophylactic antibiotics. Enhanced Recovery After Surgery (ERAS) program initiated. ICU/CVICU. Targeting manager accountability for best bedside practice. VAP: Ventilatorassociated Pneumonia Audits and Focus Studies regarding central line and peripheral line maintenance and practices. Implementation of new dressing kit and protective patch at insertion site. Staff education with annual competencies. Best practices for catheter care. Staff education with annual competencies.

406 HAI Summary Cont. HAI # Infections Better/Worse Team Strategy C.diff * Clostridium difficile 60 Worse than National Benchmark. MDRO-C Addressing the need to decrease usage of protein inhibitors and piloting cleaning with bleach on one unit. MRSA Blood* Multidrug Resistant Staph aureus 12 Worse than National Benchmark. MDRO-C Focus on peripheral IVs (re-starts) and multiple dialysis lines. 2 RNs per shift to be competent on use of Pre-View for difficult insertions. Hand Hygiene Leapfrog 89% Overall average compliance Below 95% Benchmark IPC /EOC Actual may be worse based on IP audits. Need leaders to reinforce HH every time. IP Liaison Committee working on HH Campaign. * Value-based Purchasing

407 SSI SUMMARY GRAPHICS

408 SSI SUMMARY GRAPHICS

409 IP High-Risk Surveys ( ) *TYPE LOCATION DATE **SURVEYOR Comprehensive Unit Rounds Twice a year Environment of Care Rounds Twice a year for clinical areas Once a year for non-clinical areas Find Infections: Stop Them (F.I.S.T.) Rounds All Units/Departments in the District All Units/Departments in the District 2017 year Janey, Joetta, Kristie 2017 year Janey, Joetta, Kristie 3N, 3S, 3W, ICU CLABSI CVAD dates, CVC indications MRSA Expired PIV, PIV Poster Hand Hygiene IP observations in addition to secret shoppers CAUTI Chart review Peri/Foley Care, dependent loops, secured Infection Prevention Practices Microbiology Laboratory February 2017 Melissa Janey, Joetta, Kristie Dialysis Unit Infection Prevention Practices Visalia Outpatient Dialysis March 2017 Melissa/Tina *All surveys conducted comparing to Standards of Practice (CMS, TJC, CDPH, AORN, CDC, AAMI, APIC, etc.) ** Recommendations made

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