AHMC Anaheim Regional Medical Center MEDICAL STAFF BYLAWS TABLE OF CONTENTS

Transcription

1 AHMC Anaheim Regional Medical Center MEDICAL STAFF BYLAWS TABLE OF CONTENTS MEDICAL STAFF BYLAWS DEFINITIONS... 6 PREAMBLE... 7 ARTICLE I: PURPOSE... 7 ARTICLE II: MEDICAL STAFF MEMBERSHIP ESTABLISHING CLINICAL SUBSECTIONS NATURE OF MEDICAL STAFF MEMBERSHIP QUALIFICATIONS FOR MEMBERSHIP NONDISCRIMINATION CONDITIONS AND DURATION OF APPOINTMENT ETHICAL REQUIREMENTS STAFF DUES BASIC RESPONSIBILITIES OF MEMBERS...10 ARTICLE III: CATEGORIES OF THE MEDICAL STAFF PROVISIONAL MEDICAL STAFF THE ACTIVE MEDICAL STAFF COURTESY STAFF CONSULTING STAFF MEMBERS AFFILIATE STAFF ACTIVE COMMUNITY STAFF NON-ADMITTING CATEGORY THE HONORARY MEDICAL STAFF LEAVE OF ABSENCE...13 ARTICLE IV: PRIVILEGING PRACTITIONERS PROCEDURE FOR PROCESSING APPLICATIONS FOR STAFF APPOINTMENT CREDENTIALS COMMITTEE ACTION MEDICAL EXECUTIVE COMMITTEE ACTION BOARD OF DIRECTORS ACTION CONFLICT RESOLUTION AD HOC JOINT CONFERENCE COMMITTEE COMPOSITION NOTICE OF DECISION REAPPLICATION AFTER ADVERSE APPOINTMENT DECISION TIMELY PROCESSING OF APPLICATIONS APPLICATIONS FOR ALLIED HEALTH PROFESSIONALS REAPPOINTMENT/RE-APPRAISAL...18

2 AHMC-ARMC Medical Staff Bylaws Page 2 of 49 ARTICLE IV: CLINICAL PRIVILEGES EXERCISE OF PRIVILEGES PRIVILEGES IN GENERAL TEMPORARY PRIVILEGES REASONS FOR TEMPORARY PRIVILEGES DISASTER PRIVILEGES CONDITIONS TERMINATION RIGHTS OF PRACTITIONER GRANTED TEMPORARY PRIVILEGES EMERGENCY PRIVILEGES...21 ARTICLE V: MEDICAL RECORDS ARTICLE VI: OFFICERS OFFICERS OF THE MEDICAL STAFF QUALIFICATION OF OFFICERS ELECTION OF OFFICERS TERM OF OFFICE VACANCIES IN OFFICE DUTIES OF OFFICERS REMOVAL FROM OFFICE/RECALL OF OFFICERS DISCLOSURE OF CONFLICT OF INTEREST...24 ARTICLE VI: DEPARTMENTS ORGANIZATION OF DEPARTMENTS QUALIFICATIONS, SELECTION AND TENURE OF CHAIRS FUNCTIONS OF DEPARTMENTS ASSIGNMENT TO DEPARTMENTS RESPONSIBILITIES OF DEPARTMENT CHAIR...25 ARTICLE VII: COMMITTEES MEDICAL EXECUTIVE COMMITTEE (MEC) STAFF FUNCTIONS...29 ARTICLE VIII: MEDICAL STAFF MEETINGS MEDICAL STAFF MEETINGS SPECIAL MEETINGS NOTICE OF MEETINGS QUORUM ATTENDANCE REQUIREMENTS RIGHTS OF EX-OFFICIO MEMBERS MINUTES...30

3 AHMC-ARMC Medical Staff Bylaws Page 3 of 49 ARTICLE IX: PRACTITIONER RIGHTS ARTICLE X: INVESTIGATION POLICY ROUTINE CORRECTIVE ACTION CRITERIA FOR INITIATION REQUESTS INVESTIGATION MEDICAL EXECUTIVE COMMITTEE ACTION PROCEDURAL RIGHTS OTHER ACTION INITIATION BY BOARD OF DIRECTORS SUMMARY SUSPENSION CRITERIA FOR INITIATION: ALTERNATIVE MEDICAL COVERAGE FOR PATIENTS MEDICAL EXECUTIVE COMMITTEE ACTION PROCEDURAL RIGHTS INITIATION BY BOARD OF DIRECTORS AUTOMATIC SUSPENSION LICENSE DRUG ENFORCEMENT ADMINISTRATION CERTIFICATE FAILURE TO MAINTAIN PROFESSIONAL LIABILITY INSURANCE MEDICAL EXECUTIVE COMMITTEE DELIBERATION FAILURE TO SATISFY SPECIAL APPEARANCE REQUIREMENTS MEDICAL RECORDS CONVICTION OF A FELONY FAILURE TO PAY DUES OR FINES NOTICE OF AUTOMATIC SUSPENSION...36 ARTICLE XI: HEARING AND APPELLATE REVIEW INITIATION OF HEARING GROUNDS FOR HEARING NOTICE OF ACTION OR RECOMMENDED ACTION PRACTITIONER S REQUEST FOR HEARING WAIVER BY FAILURE TO REQUEST A HEARING HEARING PREREQUISITES TIME AND PLACE FOR HEARING NOTICE OF CHARGES APPOINTMENT OF AD HOC HEARING COMMITTEE...38

4 AHMC-ARMC Medical Staff Bylaws Page 4 of POSTPONEMENTS AND EXTENSIONS PRE-HEARING PROCEDURE HEARING PROCEDURE PERSONAL PRESENCE MANDATORY REPRESENTATION THE PRESIDING OFFICER THE HEARING OFFICER RECORD OF HEARING RIGHTS OF PARTIES ADMISSIBILITY OF EVIDENCE OFFICIAL NOTICE BURDEN OF GOING FORWARD AND BURDEN OF PROOF ADJOURNMENT AND CONCLUSION DECISION OF THE AD HOC HEARING COMMITTEE BASIS FOR DECISION INITIATION OF APPELLATE REVIEW TIME FOR APPEAL REASONS FOR APPEAL TIME, PLACE AND NOTICE APPELLATE REVIEW PROCEDURE APPELLATE REVIEW COMMITTEE APPEAL PROCEDURE DECISION RIGHT TO ONE HEARING EXCEPTIONS TO HEARING RIGHTS EXHAUSTION OF REMEDIES...43 ARTICLE XII: IMMUNITY FROM LIABILITY SPECIAL DEFINITIONS AUTHORIZATIONS AND CONDITIONS CONFIDENTIALITY OF INFORMATION IMMUNITY FROM LIABILITY RELEASES CUMULATIVE EFFECT...45 ARTICLE XIII: MEDICAL STAFF REPRESENTATION ON BOARD OF DIRECTORS DESIGNATED MEDICAL STAFF MEMBERS RECOMMENDATIONS OF MEDICAL STAFF MEMBERS TO THE BOARD OF

5 AHMC-ARMC Medical Staff Bylaws Page 5 of 49 DIRECTORS NOMINATING COMMITTEE ELIGIBILITY/CONTRACT PHYSICIANS RESTRICTION FILLING VACANCY...46 ARTICLE XIV: REVIEW, REVISION, ADOPTION & AMENDMENT & GENERAL PROVISIONS MEDICAL STAFF RESPONSIBILITY AMENDMENT, ADOPTION AND REPEAL RELATED POLICIES AND MANUALS MEDICAL STAFF RULES AND REGULATIONS DEPARTMENTAL RULES AND REGULATIONS LEGAL COUNSEL...48

6 AHMC-ARMC Medical Staff Bylaws Page 6 of 49 MEDICAL STAFF BYLAWS DEFINITIONS 1. ALLIED HEALTH PROFESSIONALS (AHPs) Refer to Rules & Regulations, Allied Health Professionals. 2. BOARD OF DIRECTORS is defined as the group responsible for conducting the ordinary business affairs of AHMC Anaheim Regional Medical Center in Anaheim, California which for purposes of these Bylaws and, except as the context otherwise requires, shall be deemed to act through the authorized actions of the officers of the corporation and through the Chief Executive Officer of AHMC Anaheim Regional Medical Center. 3. CHAIN OF COMMAND is defined as notifying the respective Department Chair, and/or Chief of Staff to assist with providing direction on medical staff issues. (8/22/07) 4. CHIEF EXECUTIVE OFFICER is defined as the individual for the overall management of the Hospital. The Medical Staff may rely upon all actions of the Chief Executive Officer as being the actions of the Board of Directors taken pursuant to a proper delegation of authority by said Board. (modified 1/01) 5. CHIEF OF STAFF means the chief officer of the Medical Staff elected by the Medical Staff. 6. CLINICAL PRIVILEGES means the permission granted to a Medical Staff Member to render specific patient services. 7. CONTRACT PHYSICIAN refers to a contract hospital-based or non-hospital based physician receiving compensation from the Hospital on a regular basis. 8. EQUIVALENT QUALIFICATIONS means physicians who have practiced at the same specialty level in the community at least for the past 5 years and have maintained Active status with similar privileges and membership in good standing, in a facility similar to AHMC Anaheim Regional Medical Center (Refer to Article II, Section 2.2-E, Qualifications for Membership). 9. HOSPITAL means AHMC Anaheim Regional Medical Center (AHMC-ARMC). 10. INVESTIGATION Investigation means a process specifically instigated by the MEC to determine the validity, if any, to a concern or complaint raised against a member of the Medical Staff and does not include activity of the Physician Well-Being Committee. 11. MEDICAL EXECUTIVE COMMITTEE or EXECUTIVE COMMITTEE means the Executive Committee of the Medical Staff. 12. MEDICAL STAFF is defined as all licensed medical, osteopathic physicians, podiatrists and dentists, who are privileged to attend patients in the Hospital. 13. MEDICAL STAFF YEAR is defined as the period, which begins on October 1 and ends on September 30 of the following year or as determined by the Medical Executive Committee (MEC). 14. MEMBER is defined as any physician, podiatrist or dentist appointed to, and maintaining membership in, any category of the Medical Staff in accordance with these Bylaws. 15. PATIENT is defined as any person at the Hospital undergoing diagnostic evaluation or receiving medical treatment. 16. PHYSICIAN shall mean an individual with a M.D. or D.O. degree who is currently licensed to practice medicine in the State of California. 17. QUALITY OF CARE means medical care that meets the general standards of the community. 18. TELEMEDICINE means the use of medical information exchanged from one site to another via electronic communications for the purpose of improving patient care or for the education of a health care provider. (8/22/07)

7 AHMC-ARMC Medical Staff Bylaws Page 7 of 49 PREAMBLE These Bylaws are adopted in recognition of the mutual accountability, interdependence and responsibility of the Medical Staff and the Governing Body (as recommended by CHA-pg. 3) to provide a framework for self-government for the organization of the Medical Staff of AHMC Anaheim Regional Medical Center (AHMC-ARMC), that permits the Medical Staff to discharge its responsibilities in matters involving the quality of medical care, to govern the orderly resolution of issues and the conduct of Medical Staff functions supportive of those purposes, and to account to the Governing Body the effective performance of Medical Staff responsibilities. These Bylaws provide the professional and legal structure for Medical Staff operations, organized Medical Staff relations with the Governing Body and relation with applicants to and members of the Medical Staff. (As recommended by CHA & CMA for EP7 and incorporates SB 1325.) Notwithstanding the provisions of these bylaws, the Medical Staff acknowledges that the Governing Body must act to protect the quality of medical care provided and the competency of the Medical Staff, and to ensure the responsible governance of the hospital. In adopting these bylaws, the Medical Staff commits to exercise its responsibilities with diligence and good faith; and in approving these bylaws, the Governing Body commits to allowing the Medical Staff reasonable independence in conducting the affairs of the Medical Staff. Accordingly, the Governing Body will not assume a duty or responsibility of the Medical Staff precipitously, unreasonably, or in bad faith; and will do so only in the reasonable and good faith belief that the Medical Staff has failed to fulfill a substantive duty or responsibility in matters pertaining to the quality of patient care. ARTICLE I: PURPOSE The purpose of this Medical Staff is to bring the physicians, podiatrists, and dentists who practice at AHMC Anaheim Regional Medical Center together into a cohesive body to promote high quality medical, podiatric, clinical psychological and dental care. To this end, among other activities, the Medical Staff will screen applicants for Staff membership, review privileges of members, perform peer review, actively participate in the hospital-wide performance improvement program, educate and offer advice to the Chief Executive Officer and Board of Directors.

8 AHMC-ARMC Medical Staff Bylaws Page 8 of 49 ARTICLE II: MEDICAL STAFF MEMBERSHIP (Recommended for EP12 (copied from O&F manual-pg. 3).) 2.1 Organization of Clinical Departments & Subsections The medical staff is organized into four service departments. Department of Medical Services: The Department of medical services shall include, but not necessarily be limited to, practitioners practicing in internal medicine, family practice, emergency medicine, radiology, radiation therapy and other medical specialties such as pulmonary, gastroenterology, endocrinology, neurology, psychiatry, dermatology, hematology, oncology and other subspecialties excluding Cardiology. Department of Surgical Services: The Department of Surgical Services shall include, but not necessarily be limited to, practitioners practicing general surgery, neurological surgery, vascular surgery, proctology, urology, orthopedics, podiatry, plastic surgery, ophthalmology, otorhinolaryngology otolaryngology, dental surgery, anesthesiology, pathology, and other surgical specialties/subspecialties. Department of Women's and Children's Services: The Department of Women's & Children's Services shall include, but not necessarily be limited to, practitioners practicing obstetrics/gynecology, pediatrics, perinatology, neonatology, and other Women's and Children's specialties and subspecialties. Department of Cardiology Services: The Department of Cardiology Services shall include, but not necessarily be limited to, practitioners practicing, invasive or interventional cardiology ESTABLISHING CLINICAL SUBSECTIONS Upon approval of the Medical Executive Committee, Clinical Departments may be divided into clinical subsections, representing members practicing in the same specialty (as further described in Organization and Functions Manual, Article 1). Each subsection shall be directly responsible to the clinical Department within which it functions. The head of a subsection shall have the title of Chair NATURE OF MEDICAL STAFF MEMBERSHIP Membership on the Medical Staff of AHMC Anaheim Regional Medical Center is a privilege which shall be extended only to professionally competent physicians, podiatrists, clinical psychologists and dentists who continuously meet the qualifications, standards and requirements set forth in these Bylaws, associated policies and Rules and Regulations of the Medical Staff and AHMC Anaheim Regional Medical Center. Allied Health Professionals (AHPs) are not eligible for membership on the Medical Staff but may be granted practice prerogatives commensurate with their license and credentials as reflected in the Allied Health Rules &and Regulations QUALIFICATIONS FOR MEMBERSHIP A. Practitioners, including dentists, psychologists and podiatrists, who (1) are Board Certified by a constituent Board of the American Board of Medical Specialties or have the equivalent qualifications as determined by the Medical Executive Committee, (2) maintain a current professional license to practice in the State of California, if practicing clinical medicine, dentistry or podiatry, (3) have a current, unsuspended DEA certificate, if Practitioner has one. (4) can document their background, experience, training and demonstrated current competence, (5) demonstrate good judgment,

9 AHMC-ARMC Medical Staff Bylaws Page 9 of 49 (6) possesses the ability to perform specific privileges requested, (7) adhere to the ethics of their profession, (8) can provide the appropriate documentation requested in support of their current health status in terms of applicant s ability to practice in the area in which privileges are sought, (9) maintain a good reputation, demonstrate the ability to work cooperatively with others, with sufficient adequacy to assure the Medical Staff and the Board of Directors that any patient treated by them in the Hospital will be given the highest quality of care available within the Hospital s means and resources and consistent with the state of the healing arts and community standards of professional care, shall be qualified for membership on the Medical Staff. (10) An otherwise qualified practitioner may be deemed unqualified if it is shown that he/she manifests an inability to work with others in a Hospital setting and thereby presents a real and substantial danger to the quality of the care rendered to patients at the Hospital. B. Membership on the Medical Staff shall be limited to practitioners who have their residence and office within a proximity to AHMC Anaheim Regional Medical Center that assures an ability to appropriately respond to patient care commensurate with their practice privileges. Proof of adequate coverage for patient care in the absence of the practitioner shall be required. C. Proof of professional liability insurance, provided by a company or companies qualified to conduct a casualty insurance business in the United States, shall be provided consistent with the amount recommended by MEC and approved by the Board of Directors. D. In documentation of experience and training, completion of an ACGME, ABMS or AOA approved residency program or equivalent qualifications are required. E. Applicants requesting membership on the Medical Staff in Departments which include Services subject to exclusive contracts with the Hospital to provide services, i.e. Anesthesiology, Radiology, Pathology, Emergency Medicine, etc., may apply only upon the request of the Medical Director of that Service provided they meet the above requirements. F. Exceptions to the above may be made only by the Board of Directors upon the recommendation of the Medical Executive Committee NONDISCRIMINATION The Hospital will not discriminate in granting Staff appointments and/or clinical privileges on the basis of age, sex gender, race, creed, color, national origin, religion, sexual orientation, handicap or other healthcare organization affiliation CONDITIONS AND DURATION OF APPOINTMENT A. Initial appointments and reappointment to the Medical Staff shall be made by the Board of Directors. The Board shall act on appointments and re-appointments only after there has been a recommendation from the Medical Executive Committee in accordance with the provisions of these Bylaws. B. Appointments to the Staff will be no more than twenty-four calendar months. C. Appointment to the Medical Staff shall confer on the appointee only such clinical privileges as have been granted in accordance with the Credentials Manual. D. Procedures for the evaluation of staff applications and credentials, appointments and reappointments are outlined and granted in accordance with the Credentials Manual which is contained herein ETHICAL REQUIREMENTS A person who accepts membership on the Medical Staff agrees to act in an ethical, professional and courteous manner STAFF DUES A. Annual Medical Staff dues shall be governed by the most recent action of the Medical Executive Committee. B. Honorary and Senior Active Staff (on staff for 25 years or more) members including past chiefs of staff will not be required to pay dues. C. Dues shall be due and payable within 30 days of request. Failure to pay dues shall be construed as a voluntary resignation from the Staff. D. The MEC shall have the right to assess dues and shall utilize such dues as appropriate for the purposes of the medical staff.

10 AHMC-ARMC Medical Staff Bylaws Page 10 of BASIC RESPONSIBILITIES OF MEMBERS Each Member of the Medical Staff pledges to provide and direct continuous care of his/her patients and shall: A. Provide his/her patients with a high level of care consistent with the professional standards generally recognized in the community. B. Confine his/her medical practice to procedures and therapies that are justified based upon accepted community practices and based on the current medical literature. C. Abide by all laws, rules and regulations of governmental entities and abide by all Medical Staff Bylaws, Rules and Regulations, standards and policies. D. Discharge such Medical Staff, Department, Committee and Hospital functions for which he/she is responsible by appointment, election or otherwise. E. Prepare and complete in a timely manner the medical and other required records for all patients he/she admits or in any way provides care to in the Hospital. F. Pay dues in accordance with these Bylaws. G. Make appropriate arrangements for coverage for his/her patients in his/her absence. H. Request autopsies in accordance with the policy set forth in the General Rules and Regulations of the Medical Staff. I. Notify the Hospital as soon as possible following receipt of any PRO (Professional Review Organizations) inquiries relating to patient care activities within this Hospital in order to coordinate a timely response. J. Refrain from unlawful fee splitting or unlawful inducements relating to patient referral. K. Refrain from any unlawful harassment and/or discrimination against any person (including, but not limited to any patient, Hospital employee, Hospital independent contractor, Medical Staff member or visitor) based upon the person s age, sexgender, religion, race, creed, color, national origin, sexual orientation, health status, ability to pay, or source of payment. L. Refrain from delegating the responsibility for diagnosis or care of hospitalized patients to a Practitioner who is not qualified to undertake this responsibility or who is not adequately supervised. M. Actively participate in and regularly cooperate with the Medical Staff in assisting the Hospital to fulfill its obligations related to patient care, including, but not limited to, continuous quality improvement, peer review, utilization management, quality and related monitoring activities required of the Medical Staff, and in discharging such other functions as may be required from time to time. N. Work cooperatively with Medical Staff members, nurses, Hospital administrative staff, and others so as to promote high quality patient care and Hospital operations. O. Cooperate in peer review and quality improvement. P. Attend a special meeting if requested. Q. Notify the Hospital as soon as possible following notification of any sanctions, professional liability incidents, (including but not limited to law suits, claims, settlements, judgments pending claims and potential claims) and inquiries made by the Medical Board or other licensing agencies as defined in the Credentials Policy & Procedure Manual, Article III. R. Abide by all applicable requirements for timely completion and recording of a physical examination and medical history, as further described at Article (page 20) (EP16, CMS CoP Requirement-CHA pg. 16)

11 AHMC-ARMC Medical Staff Bylaws Page 11 of 49 ARTICLE III: CATEGORIES OF THE MEDICAL STAFF 3.1 PROVISIONAL MEDICAL STAFF Qualifications: Meet the basic qualifications for appointment to the Medical Staff, as described in Article II, Section 2.2 of these Bylaws. All new applicants for membership on the Medical Staff who are deemed eligible for Medical Staff appointment, except as otherwise permitted by these Bylaws, shall be appointed to the Provisional Staff Prerogatives: Provisional members Are eligible for membership on all committees, with the exception of the Bylaws, Medical Executive and Credentials Committees. They shall serve as ex-officio members on committees to which they have been assigned and may not serve as committee chairs. A. are not eligible to make nominations, vote or hold office. B. if granted requisite privileges, admit patients and exercise such Clinical privileges as are granted. C. See Credentials Manual regarding advancement from Provisional Status Responsibilities: A. Meet the basic qualifications and fulfill the responsibilities set forth in Article II, Medical Staff Membership. B. Participate in Quality Improvement activities as may be required by the Medical Staff or Department of which they are members. C. Undergo a period of observation by designated monitors as described in their respective department s Rules and Regulations. The purpose of observation shall be to evaluate the member s proficiency in the exercise of clinical privileges initially granted and overall eligibility for continued staff membership and advancement within staff categories Limitations: A. Provisional Staff members are not eligible to make nominations or vote on any matters presented at general and special meetings of the Medical Staff, or at meetings of the Department of which they are members. B. Provisional Staff members are not eligible to hold office in the Staff organization, or in the Department in which they are members. 3.2 THE ACTIVE MEDICAL STAFF Qualifications: Appointees to this category must: A. Admit or otherwise be involved in patient care or Medical Staff activities at the Hospital, documenting a minimum of six (6) points in a two (2) year period as specified in the Credentials Manual. Have successfully completed a minimum of twelve (12) months within the Provisional Staff category. B. Meet the qualifications and fulfill the responsibilities set forth in Article II, Medical Membership. C. In the event an appointee to the Active Medical Staff does not meet the qualifications for appointment to the Active category and if the appointee is otherwise in compliance with all Bylaws, rules, regulations and policies of the Staff, the appointee may be appointed to the Courtesy Staff Category Prerogatives: Appointees to this category may: A. Admit patients without limitation, except as otherwise provided in the Medical Staff Rules and Regulations, or by specific privilege restriction. B. Vote on all matters presented at general and special meetings of the Medical Staff, and of the Department and committees of which he/she is appointed; C. Hold office and sit on or be the chair of any committee, unless otherwise specified elsewhere in these Bylaws. D. Participate in Hospital and Medical Staff education programs as appropriate Responsibilities: Appointees to this category must: A. Contribute as defined by the Organization and Functions Manual to the organizational and administrative affairs of the Medical Staff.

12 AHMC-ARMC Medical Staff Bylaws Page 12 of 49 B. Actively participate in recognized functions of Staff appointment including quality improvement and other monitoring activities, in monitoring initial appointees during their provisional period, and in discharging other Staff functions as may be required from time to time. C. Participate in the emergency room and other specialty coverage programs as defined by the Department in which they have membership. D. Medical Staff members who have been on the active staff for more than twenty-five years or have served as Chief of Staff may be given reduced responsibilities as a Senior Active Staff member at the discretion of the MEC. 3.3 COURTESY STAFF Qualifications: Appointees to this category must: A. Admit or otherwise be involved in patient care or Medical staff activities at the Hospital, documenting a minimum of two (2) points during a two year period as specified in the Credentials Manual. B. Have successfully completed a minimum of twelve (12) months in the Provisional Staff Category. C. Meet the qualifications and fulfill the responsibilities set forth in Article II, Medical Staff Membership. In the event an appointee to the Courtesy Staff does not meet the qualifications for appointment to the Courtesy Status, his/her appointment to the Staff shall automatically terminate Prerogatives: Appointees to this category may: A. Admit patients without limitation, except as otherwise provided in the Medical Staff Rules and Regulations, or by specific privilege restriction. B. NOT nominate, vote or hold office. C. Attend meetings of the Staff and Department of which he/she is an appointee and any Staff or Hospital education programs Appointees to this category must participate in emergency room and other specialty coverage programs, if requested Courtesy Staff Members who meet the requirement for Active Medical Staff, on review by the Credentials Committee and the Medical Executive Committee, may be appointed to the Active Staff category. 3.4 CONSULTING STAFF MEMBERS Qualifications: Consulting Staff membership may be granted to practitioners who: A. Are not otherwise members of the Medical Staff and meet the basic qualifications set forth in Article II, Medical Staff Membership. B. Possess special clinical and professional expertise not available at the Hospital Responsibilities: Appointees to this category must be willing and able to come to the Hospital or promptly respond when called to render clinical services within his/her area of competence Prerogatives: Appointees to this category may: A. exercise such clinical privileges as are granted by the Department in which he/she is appointed. B. not nominate, vote or hold office in the Medical Staff Organization, but may serve upon committees. C. attend meetings of the Staff and Department of which he/she is appointed and any Staff or Hospital education programs Reappointment: Application and reappointment will be processed in the same manner as other applicants Reclassification: A Consulting Staff member may request a change of Staff status, in writing, to the Credentials Committee, who can, at their discretion, recommend the granting of Active or Courtesy Staff status. 3.5 AFFILIATE STAFF Affiliate Staff membership may be granted to those physicians who wish to be associated with the hospital, who are practicing in the local community and who are respected by their peers.

13 AHMC-ARMC Medical Staff Bylaws Page 13 of Qualifications: The Affiliate Staff shall consist of members who: A. Meet the general medical staff membership qualifications set forth in Section 2.2 B. Are required to pay an application fee and medical staff dues as established by the MEC Prerogatives: A. May attend meetings of the medical staff, including open committee meetings and educational programs Limitations: A. Affiliate Staff are not eligible to vote or hold office in the medical staff. B. Affiliate Staff do not hold clinical privileges. C. Must pre-arrange admissions with an Active, Provisional, Courtesy or Consulting member of the staff who will be responsible for the patient s care. Affiliate staff members shall not have individual surgical, procedural or order writing privileges. 3.6 ACTIVE COMMUNITY STAFF NON-ADMITTING CATEGORY Active Community Staff Non-Admitting Category Members include those practitioners who have not had inpatient activity for two years, but who wish to refer and participate in the admission of patients under the care of a practitioner with admitting privileges Prerogatives: Active Community Staff Non-Admitting Category Members shall prearrange admissions with a practitioner with admitting privileges. Such Non-Admitting Category Members will not be responsible for the patient s inpatient care, but may be privileged to perform initial H&Ps on patients to be admitted, and exercise other appropriate clinical privileges, such as surgical assisting, as are granted pursuant to Article 4 of these Bylaws, providing proctoring requirements have been previously met for clinical privileges requested. Active Community Staff Non-Admitting Category Members may, but are not required to, attend department/section and general Medical Staff meetings. They may not vote and hold office Responsibilities: the responsibilities of an Active Community Staff Non-Admitting Category Member shall include discharging the basic responsibilities of individual Medical Staff membership as set forth in Section 2.7 of these Bylaws as applicable to this staff category Limitations: Active Community Staff Non-Admitting Category Members who wish to admit patients or regularly care for patients at the Medical Center will be required to apply for appointment to the appropriate staff category before he/she may admit a patient. Active Community Staff Non-Admitting Category Members shall not have individual surgical privileges but may exercise other appropriate clinical privileges as granted pursuant to Article 4 of these Bylaws. 3.7 THE HONORARY MEDICAL STAFF The Honorary Staff shall consist of those practitioners who are not active in the Hospital and who are honored as Emeritus. These shall be practitioners who have retired from active practice, and are granted Honorary Staff privileges upon the recommendation of the Chief of Staff or the MEC with the approval of AHMC-ARMC s Board of Directors. This recommendation shall be based on the individual s well-known contributions to the Medical Staff and Hospital. This status is an honor bestowed by the Medical Staff and not a status to be requested by a medical staff member. Honorary Staff Members are not eligible to admit patients to the Hospital or to exercise Clinical privileges in the Hospital. They shall not hold office or serve as active committee members, and shall have no vote in affairs of the Medical Staff. 3.8 LEAVE OF ABSENCE Members of the Medical Staff may apply for a leave of absence. Reinstatement of Staff privileges may be requested, in accordance with policies outlined in the Credentials Manual.

14 AHMC-ARMC Medical Staff Bylaws Page 14 of 49 ARTICLE IV: Privileging Practitioners (Recommended for EP 14, copied directly from the Credentials Manual.) PROCEDURE FOR PROCESSING APPLICATIONS FOR STAFF APPOINTMENT Upon approval of the pre-application, all eligible applicants will be provided an application for appointment to the medical staff; privileges request forms, and a detailed list of requirements for completion of the application. A complete set of Medical Staff Bylaws, Rules and Regulations and pertinent Manuals will be provided or made available to the applicant as well The application is reviewed for completeness upon receipt. Should it be identified to be incomplete, the applicant is sent a letter informing him/her of the forty-five (45) day deadline as delineated in (below) A report will be made to the Credentials Committee which will include applications received The following documentation is necessary for an application to be considered complete. It is the applicant's responsibility to provide: A. A legible (completed), signed and dated application, required attachments and privilege request form B. A current photo C. A copy of current DEA certificate, if applicant has one D. A copy of current professional liability insurance policy in the minimum amounts of one (1) million per occurrence and three (3) million aggregate, that covers requested privileges; E. A complete and current Curriculum Vitae F. Documentation of relevant training and experience for clinical privileges requested; G. Present Board Status, i.e. copy of certificates or copy of letter from the appropriate specialty board indicating board admissibility H. The names and current addresses of at least three (3) peers who have recently worked with the applicant and directly observed his/her professional performance over a reasonable period of time, (a minimum of one year) and who can and will provide reliable information regarding current clinical ability, ethical character and ability to work with others. References must be from peers who practice in a field similar to the applicant; and, if possible, one or more of the references should be from a member of the medical staff of ARMC. I. Payment of the application fee J. Documentation of CME activity to support the clinical privileges requested K. Professional Sanctions: Information as to whether any of the following have ever been or are in the process of being reviewed, denied, revoked, suspended, reduced, not renewed or voluntarily relinquished: 1) Staff Membership and status or clinical privileges at any other Hospital or health care institution. 2) Membership/fellowship in local, state, or national professional organizations. 3) Specialty Board certification/eligibility. 4) License to practice any profession in any jurisdiction. 5) DEA Certificate. If any such actions ever occurred or are pending, the particulars thereof shall be included. L. Administrative Remedies: By submission of an application to the medical staff the practitioner agrees that, in the event that an adverse ruling is made with respect to his/her staff Membership, staff category and/or clinical privileges, he/she will exhaust the administrative remedies afforded by these Bylaws before seeking other remedies. M. Professional Liability Incidents: A full disclosure of any claims, complaints, or causes of action lodged against applicant which conceivably could be considered relevant to a consideration of his/her qualifications for Medical Staff Membership including, but not limited to those currently pending, as well as those paid, compromised, settled or subject to an agreement to settle or otherwise concluded. The applicant shall also report any decisions by administrative agencies, arbitration awards or court judgments that have found him/her guilty of a crime (excluding minor traffic violations) or liable for any personal injury, bodily injury or death caused by his/her intention act or omission to act, negligence, error or omission in the practice of his/her profession or his/her rendering or unauthorized professional services. The required disclosures shall be broad enough to include without limitation, any incident, the defense of which is generally covered, in whole or in part, by

15 AHMC-ARMC Medical Staff Bylaws Page 15 of 49 the standard form professional liability policy, whether or not applicant was or is covered by such a policy. N. Misrepresentations: Misrepresentation or material omissions of any information required or submitted in the application or reappointment process shall constitute cause for denial of appointment or reappointment or revocation of Medical Staff Membership and/or clinical privileges. O. Acknowledgment of release and immunity provisions: A signed statement that the applicant agrees to the scope and extent of the authorization, confidentiality, immunity and release provisions as defined in Article XI of the Medical Staff Bylaws. P. Proof of Coverage: Proof of adequate alternate coverage for patients in the applicant's absence If all information required above in Section is not submitted by the applicant within fortyfive (45) days of receipt of the application, it may be considered administratively closed and no further processing will take place. This will be reported to the Credentials Committee Upon receipt of the completed application, the Credentials Coordinator will verify its contents from the primary source and collect additional information as follows: A. Information from all prior and current insurance carriers concerning claims, suits and settlements (if any) during the past five (5) years; B. Administrative (employment verification) from all significant past settings and clinical (peer) references; C. Documentation of relevant training and/or experience, current clinical competency, and the ability to perform the privileges requested. D. Verification of the licensure status in all current or past States in which the applicant held a license; E. Information from the National Practitioners Data Bank established pursuant to the Healthcare Quality Improvement Act of 1986; and F. Verification from the source of residency training, medical school and Hospital affiliations. While it is the policy of the ARMC Medical Staff Office to make a valid attempt to obtain verification directly from the last training institution pertinent to privileges requested, the AMA (for Allopathic physicians) or AOA (for Osteopathic physicians) is used for verification of medical school, internship and residency provided that there are no identified issues. These documents are used to verify the last applicable level of training only in situations when the institutions do not respond. G. Any identified professional sanctions will be researched with the appropriate agencies. H. ECFMG / USMLE (for physicians who completed medical school outside of the US and Canada). In the event there is undue delay in obtaining the required information, the Credentials Coordinator will request assistance from the applicant. During this time period, the "time periods for processing" the application will be appropriately modified. It shall be the applicant's obligation to obtain the required information or assure that it is submitted and received by the Hospital. Failure of an applicant to adequately respond to a request for assistance will, after forty-five (45) days, result in termination of the application process as outlined in above and result in the application being filed administratively incomplete. Such termination shall not entitle the applicant to a hearing or appeal, unless specifically provided by Article XI When the application and all verifications are complete, the file will then be summarized by the Credentials Coordinator and presented for review and recommendation to the Department Chair/designee. If the provider is a member of a Section, the Section Chair must review prior to the Department Chair The applicable Department Chair/designee (following review and recommendation from the Section chair if applicable) will review the entire file and make a recommendation in writing as to membership and/or clinical privileges to be granted which will be forwarded to the Credentials Committee The Credentials Committee s recommendations, along with all supporting documentation

16 AHMC-ARMC Medical Staff Bylaws Page 16 of 49 shall be presented to the Medical Executive Committee in accordance with section 3.4 of this manual. The Medical Executive Committee shall consider the recommendation and any other relevant information and take action on the recommendation as set forth in Section 3.5 of this Manual. 3.4 CREDENTIALS COMMITTEE ACTION The committee shall transmit to the Medical Executive Committee its recommendations as to staff appointment, and if appointment is recommended as to staff category, department affiliation and clinical privileges to be granted as approved by the appropriate department chair(s) and any special conditions to be attached to the appointment. 3.5 MEDICAL EXECUTIVE COMMITTEE ACTION At its next regularly scheduled meeting, after receipt of the Credentials Committee recommendations, or as soon thereafter as possible, the Medical Executive Committee shall take action on the recommendations. The Medical Executive Committee may recommend that the Board of Directors affirm, reject or modify the recommendations or defer the decision for further consideration Deferral: Action by the Medical Executive Committee to defer the application for further consideration must be followed up at the next regularly scheduled Medical Executive Committee meeting with a subsequent recommendation for appointment with specified clinical privileges or for rejection for staff Membership Favorable Recommendation: When the recommendation of the Medical Executive Committee is favorable to the applicant, the Chief of Staff shall present it to the Board of Directors for final action. All recommendations for approval shall specify the Section/Department affiliation, clinical privileges and any special conditions to be attached to the appointment Adverse Recommendation: When the recommendation of the Medical Executive Committee is adverse to the applicant the Chief of Staff shall immediately so inform the practitioner by special notice and the practitioner shall be entitled to the procedural rights set forth in Article XI of the Medical Staff Bylaws. 3.6 BOARD OF DIRECTORS ACTION The Board of Directors may accept, reject of modify the recommendation of the Medical Executive Committee or may refer the matter back to the Medical Executive Committee for further consideration, stating the purpose for such referral and setting a reasonable time limit for making a subsequent recommendation. The following procedure shall apply with respect to action on the application: If the Medical Executive Committee issues a favorable recommendation and: A. The Board of Directors concurs in that recommendation, the decision of the Board shall be deemed final action. B. The final proposed action of the Board of Directors is unfavorable, the Chief Executive Officer shall give the applicant written notice of the final proposed action. If the Board s final proposed action is a ground for a hearing under the Bylaws Section 9.7 the applicant shall be entitled to the procedural rights set forth in Article XI of the Medical Staff Bylaws, if specifically provided for. If the applicant waives his or her procedural rights, the decision of the Board of Directors shall be deemed the final action In the event the recommendation of the Medical Executive Committee, or any significant part of it is unfavorable to the applicant, and the recommendation is a ground for hearing under Bylaws Section 9.7, the procedural rights set forth in Article XI of the Medical Staff Bylaws, shall apply, A. If the applicant waives his or her procedural rights, the recommendation of the Medical Executive Committee shall be forwarded to the Board of Directors for final action. The Board of Directors shall affirm the recommendation of the Medical Executive Committee if the decision is found to be supported by substantial evidence. B. If the applicant requests a hearing following the adverse Medical Executive Committee recommendation pursuant to this section or an adverse Board of Directors final proposed action pursuant to Section 3.6.1B, the Board of Directors shall take final action only after the

17 AHMC-ARMC Medical Staff Bylaws Page 17 of 49 applicant has exhausted his or her procedural rights as established by Article XI of the Medical Staff Bylaws. The Board of Directors decision shall be in writing and shall specify the reasons for the action taken. 3.7 CONFLICT RESOLUTION Whenever the Board of Director's final decision, pursuant to Section 3.6, is contrary to the Medical Executive Committee's recommendation, pursuant to Section 3.5, the Board of Directors shall submit the matter for review and recommendations to an Ad Hoc Joint Conference Committee. That committee shall provide a written recommendation to the Board of Directors within thirty (30) days of receipt of the matter unless good cause exists for extending that time period. Within thirty (30) days after receiving the written recommendation of the Joint Conference Committee, the Board of Directors shall make a final decision on the application. 3.8 AD HOC JOINT CONFERENCE COMMITTEE COMPOSITION The Ad Hoc Joint Conference Committee referred to the Section 3.7 shall be composed of three (3) Members of the Board of Directors, appointed by the chairman of the Board of Directors, and three (3) Members of the Medical Staff, appointed by the Medical Executive Committee. 3.9 NOTICE OF DECISION Notice of the Board of Director's final decision shall be given to the applicant through the Chief Executive Officer, to the Chief of Staff and to the Chair of the appropriate Department/Subsection A decision and notice to appoint shall include: A. The staff category to which the applicant is appointed. B. The Department and/or Section to which he/she is assigned. C. The clinical privileges he/she may exercise. D. Any special conditions attached to the appointment REAPPLICATION AFTER ADVERSE APPOINTMENT DECISION An applicant who has received a final adverse decision to deny appointment and or clinical privileges, or who has withdrawn his/her application after an adverse recommendation by the Medical Executive committee shall not be eligible to reapply to the Medical Staff for a period of two (2) years. Any such application shall be processed as an initial application and the applicant shall submit such additional information as the Medical Staff or the Board of Directors may require demonstrating that the basis for the earlier adverse action or recommendation no longer exists TIMELY PROCESSING OF APPLICATIONS Applications for Medical Staff appointments shall be considered in a timely manner by all persons and committees required by these Bylaws to act thereon. While special or unusual circumstances may constitute good cause and warrant exceptions, the following time periods provide a guideline for routine processing of complete applications: Evaluation, review and verification of the application and all supporting documents; not more than one hundred twenty (120) days after the receipt of all requested documentation; Review and recommendation by the Department Chair and Credentials Committee: not more than sixty (60) days after receipt of all requested documentation from the Medical Staff Office; Review recommendation by the Medical Executive Committee: not more than thirty (30) days after receipt of recommendation from Department Chair and Credentials Committee Final Action: not more than ninety (90) days after receipt of Medical Executive Committee recommendations or conclusion of hearings ALLIED HEALTH PRACTITIONERS Application Process The Medical Executive Committee will recommend to the Board of Directors its approval of a list of categories of AHPs eligible to apply. AHP categories not on the list will not be provided an application. They shall apply to the MEC and to the Board for adoption of their category. Prerogatives and responsibilities of AHPs shall be detailed in their Practice Prerogatives or

18 AHMC-ARMC Medical Staff Bylaws Page 18 of 49 the Rules & Regulations Applications for Allied Health Professionals All applications for AHPs shall be complete, legible, and in writing, and shall be signed by the applicant and shall be submitted on a form supplied by the ARMC Medical Staff Services Office. The application shall require the following information: The applicant's professional qualifications, education, work experience, request for practice prerogatives, and signature of the supervising or sponsoring physician; Current California licensure or certification where appropriate; Professional liability insurance in the amount of at least one million dollars ($1M) per occurrence/three million dollars ($3M) aggregate per year; Application fee set by Medical Executive Committee; Must have their primary residence and office within a proximity to ARMC that assures an ability to appropriately respond to patient care needs commensurate with their professional services. The completed application will be submitted through the Medical Staff Office and upon completion of the application process, to the Interdisciplinary Practice Committee (IDP) for review and recommendations to the Credentials Committee for forwarding to the Medical Executive Committee and the Board of Directors for final determination Reappointment/Re-Appraisal AHPs shall have a biennial (2-year) reappointment. A biennial reappraisal summarizing the performance of these individuals must be presented to the Interdisciplinary Practice Committee for review and recommendation to the Credentials Committee to be forwarded to the Medical Executive Committee and the Board of Directors for final determination of clinical competence and continued practice prerogatives. Reappointment/Reappraisal Process: required documentation for AHPs shall include; but not be limited to the information that is required from the applicant (see Applications Section, above), and the following: Practice Prerogatives (signed by physician supervisor or sponsor) (If Additional Practice Prerogatives are requested, documentation of training and/or experience are required in order to apply and require approval) AHP-provided activity log listing patients seen by the AHP at Anaheim Regional Medical Center for the previous two years will be submitted with the reappointment application. The log shall contain, at a minimum, the patient name, Medical Record number, and date of service. Findings of relevant quality improvement activities with a minimum of six charts reviewed, or a peer reference/supervising physician reference letter.