Board of Commissioners Meeting December 5, 2013 Summit Pacific Medical Center, Elma, WA

Transcription

1 Board of Commissioners Meeting December 5, 2013 Summit Pacific Medical Center, Elma, WA Grays Harbor County Public Hospital District No.1 Agenda 1. 6:00 - CALL TO ORDER a. Introductions as needed b. Business from audience 2. 6:05 - CONSENT AGENDA See separate Consent Agenda 3. 6:07 Committee Reports a. 6:07 - Quality Committee Report b. 6:20 CEO Renée Jensen i. Executive Report ii. Primary Care Department Team Accomplishments iii. LEAPT Awards Announcement iv. Insurance Enrollment Status report v. Chelan conference attendance for 2014 c. 6:45 CMO Report Dr. William Hurley i. Hospitalist Program Update 4. 6:55 Finance Amy Thomason a. Financial summary b. Financial dashboards and statements 5. 7:10 Commissioner Business a. Medical Staff Bylaws b. Disruptive Provider Policy c. Impaired Provider Policy d. Medical staff privileges i. Vincent Ball, M.D., Appointment to Emergency Department ii. Owen L. McGrane, M.D., Appointment to Emergency Department iii. Benjamin E. Good, M.D., Appointment to Emergency Department iv. Jon Kooiker, M.D., Reappointment to Consulting for Neurology v. Young bin Choi, M.D., Reappointment to Consulting for Neurology Adjournment Renée K. Jensen, Chief Executive Officer 600 E Main, Elma, WA Ph. (360) Fax: (360) Owned and Operated by Grays Harbor County Public Hospital District No. 1 SPMC is an equal opportunity provider and employer.

2 Board of Commissioners Meeting December 5, 2013 Summit Pacific Medical Center, Elma, WA Grays Harbor County Public Hospital District No.1 Consent Agenda A very useful technique involves the use of a consent agenda. The board agenda planners (usually the executive or governance committee, but occasionally the board chair with the CEO) divide agenda issues into two groups of items. The first are those items that must be acted on because of legal, regulatory, or other requirements, but are not significant enough to warrant discussion by the full board. Such issues are combined into a single section of the board agenda book; members review these materials prior to the meeting, and if no one has any questions or concerns, the entire block of issues is approved with one board vote and no discussion. This frees up a tremendous amount of time that would otherwise be squandered on minor issues. Any member can request that an item be removed from the consent agenda and discussed by the full board. The success of the consent agenda is predicated upon all board members reading the material in the consent agenda section of the board agenda book. If they do not, then the board becomes a veritable rubber stamp. The second group of agenda items are those important issues that require discussion, deliberation, and action by the board. These are addressed one by one. Executive Session Justification Executive Session is convened to discuss the following topics, as permitted by the cited sections of the Revised Code of Washington (RCW): Executive session (RCW ) (a) national security (b) (c) real estate (d) negotiations of publicly bid contracts (e) export trading (f) complaints against public officers/employees (g) qualifications of applicant or review performance of public employee/elective office (h) evaluate qualifications of candidate for appointment to elective office (i) discuss claims with legal counsel existing or reasonably expected litigation litigation or legal risks expected to result in adverse legal or financial consequences presence of legal counsel alone does not justify executive session QI/peer review committee documents and discussions Final action must be in open meeting Renée K. Jensen, Chief Executive Officer 600 E Main, Elma, WA Ph. (360) Fax: (360) Owned and Operated by Grays Harbor County Public Hospital District No. 1 SPMC is an equal opportunity provider and employer.

3 AGENDA CALL TO ORDER CONSENT AGENDA BUDGET 2014 COMMITTEE REPORTS BOARD OF COMMISSIONER S MEETING October 24, 2013 DISCUSSION/CONCLUSIONS 6:00 - CALL TO ORDER The Summit Pacific Medical Center Board of Commissioners Meeting was called to orderat 6:00 p.m. Present: Commissioners present: Amy Thomason, Louie Figueroa, Drew Hooper, Brent Meldrum, Chad Searls Also Present: Renée Jensen, Jerri Peckham, Dr. William Hurley, Ron Hulscher, Will Callicoat, Brenda West, John Swope Introductions as needed Chris Vessey, running for Mayor of McCleary Carrie Fruen, running for Hospital Commissioner Public comment Mr. Vessey said that he enjoyed the Budget meeting, and thought more people should attend. He also thought the facility was very nice. Ms. Fruen was not present for Public Comment at the end of the meeting; she left before 6:30 pm. CONSENT AGENDA-SEE SEPARATE CONSENT AGENDA RESOLUTION OPERATING BUDGET RESOLUTION LEVY LIMIT FACTOR ADOPTION (4.6 MILLION DOLLARS PER YEAR UNCOMPENSATED CARE PER YEAR PROVIDED BY DISTRICT; 743,267 PER YEAR RECEIVED IN TAX REVENUES) Quality Committee Report-Louie Figueroa No health care acquired infections Hand hygiene improving after having a decline in early September RECOMMENDATIONS/AC TIONS/FOLLOW-UP A motion was made bydrew Hooper to approve the consent agenda; ;Amy Thomason secondeded the motion, and it was approved by a unanimous vote. A motion was made by Chad Searls to adopt Resolution Operating Budget. Louie Figueroa seconded the motion, and it carried by a unanimous vote. A motion was made by Amy Thomason to adopt Resolution Levy Limit Factor Adoption. Chad Searls secondeded the motion, and it carried by a unanimous vote.

4 BOARD OF COMMISSIONER S MEETING October 24, 2013 John Swope explained that the State requirement is based on gel product usage There were several drills performed in September Tele-pharmacy, which provides access to a pharmacist 24/7 has been implemented. Louie explained that the terminology Medication Error on the Quality Report has been changed to Medication Concerns. The Pharmacy review is complete, and we scored 73 out of 100. They are returning on Friday. Door to physician in Emergency Department is 24 minutes, which is excellent. Patient satisfaction: Many great comments and opportunities for improvement. Flu Shot Best Practices Board Discussion-Chad/Louie John Swope shared handouts regarding influenza that explain how contagious the flu virus is, how effectivee the vaccine is, and how the flu vaccine cannot give a person the flu. It is recommended that all health care workers be vaccinated against the flu virus. Most hospitals in Washingtonn state have adopted policies regarding vaccination against influenza. Many have adopted policies stating that having the vaccine is a condition of employment. Eventually, vaccination rates for hospitals will be posted online to the Compare data website. There was discussion regarding reasons why some employees have elected not to receive the influenza virus. Drew Hooper stated that he strongly supports and encourages 100% of staff to receive their flu vaccines. CEO-Renée Jensen Executive Report Renee commended Finance department on completion of the budget. She explained the capital purchase process that the management team will participate in. Renee shared that our pharmacist, Judy Cullen resigned but we have hired a local pharmacist, Andrew Burton, in her place. Renee just participated in a Regional Planning Summit. Brenda West met with the Elma High School Sports Medicine instructor to Drew Hooper made a motion to support efforts to encourage 100% influenza vaccine of staff. Louie Figueroa seconded the motion, and it carried by a unanimous vote.

5 BOARD OF COMMISSIONER S MEETING October 24, 2013 explore ways to provide educational opportunities to his students. WSHA Awards SPMC received the Community Health Leadership Award. The Community Health Leadership Award is given annually to the healthcare organizations that best serve their community's broader health needs. Note that in this era where health care organizations are increasingly called upon to address the health needs of their community s population, we re particularly interested in projects that go beyond an organization s expected strategic plan. Mindy Portschy received the Special Claims award from the WSHA Workers Compensation Board Physician Recruitment: Dr. Bunge will be starting as a hospitalist January 6 th and will develop a hospitalistt program which should be able to expand our acute care program as well as provide outpatient services. Dr. Kari Lima will be leaving in January; Bonnie McReynolds, A.R.N.P. started this week. Recruiting for A.R.N.Ps and physicians continues. There was an all-staff education provided regarding narcotics and narcotics use, as well as prescribing laws and diversion by patients. M-Team development: Renee is working with Wally Wilkins to provide education to M-Team on building a culture of yes, team building, and conflict resolution in February. Employee satisfaction survey: the results are still being tallied and will be shared with the board after they are shared with the Management Team. Facility: Facilities Director position was changed to Facilities Manager. EFM phones: The phone system at EFM is now live, and can be answered at either EFM or SPMC. The Board recommended that there be a celebration for staff for this award. Strategic Planning Summary Board Discussion-Brent A new Mission Statement was crafted at the annual Board Strategic Planning session. Feedback from staff has been positive. New Mission Statement: In partnership with our community, we passionately advance the health of all individuals with an emphasis on quality, access and compassion. A motion was made by Amy Thomason to approve the new mission statement; Drew Hooper seconded the motion, and it carried by a unanimous vote.

6 BOARD OF COMMISSIONER S MEETING October 24, 2013 LEAPT Awards Announcement We have been selected to participate in the WSHA LEAPT program. WSHA received a 15 million dollar grant to facilitate this state wide effort and SPMC was selected as one of the participants. The Washington State Hospital Association (WSHA) with guidance from the WSHA Patient Safety Committee is inviting our Partnership for Patients hospitals to participate in an advanced program to develop and spread best practices. It is called Leading Edge Advanced Practice Topics (LEAPT). LEAPT was developed by Centers for Medicare & Medicaid Services as part of the Partnership for Patients. CMO Report-Dr. William Hurley Dr. Hurley discussed the work happening on the Medical Unit. We ve been approached by a hospitalist group as well as two Emergency department providers that want to work with us. Dr. Hurley mentioned that the relationship with EMS is strengthening. Brenda West discussed how far we have come in building relationships with EMS. She also discussed a cardiac patient we had earlier this month who was transported from here to a cardiac catheterization laboratory within 85 minutes. The goal is 90 minutes. Drew Hooper shared that he is attending a Satsop Fire/EMS Department meeting November 6 th. Dr. Hurley shared that the Emergency Department now has a very high tech ventilator, and training will be provided for staff and EMS. Finance- Drew Hooper Financial Summary Will made a correction to revenue: The net revenue should read $11.5 million, or 9 % over budget. Drew discussed the slight decrease in patient days, but this is the trend that is appropriate for our inpatients. Volumes are still doing well. Expenses: Supplies will increase sharply next month as the final asset listing is completed. Financial Dashboards and statements

7 COMMISSIONER BUSINESS ADJOURNMENT BOARD OF COMMISSIONER S MEETING October 24, 2013 Resolution Surplus Property A laptop is being surplused. Renee shared that this laptopp would be donated to the WWRHCC Medical Staff Privileges None for October The meeting was adjourned at 8:10 pm Drew Hooper made a motion to approve Resolution Surplus Property; Chad Searls secondeded the motion and it carried by a unanimous vote. Brent Meldrum made a motion to adjourn the meeting; Drew Hooper seconded the motion and it carried by a unanimous vote. RECORDING SECRETARY BOARD SECRETARY

8 Grays Harbor County Public Hospital District No.1 Consent Agenda Minutes October 24, 2013 Meeting Minutes Payroll Warrants $ 617, A/P Operations Disbursements $ 661, A/P Construction Disbursements $ 699, Community Care $ 128, Bad Debts $ 170, Property tax Credit $ 1, TOTAL $ 2,278, NOTE: For the Period October 1-31, 2013 Renée K.Jensen, Chief Executive Officer 600 East Main, Elma, Washington Ph Fax: Owned and Operated by Grays Harbor County Public Hospital District No. 1 Summit Pacific is an equal opportunity employer.

9 13 month Payroll Operations A/P Disbursements Construction A/P Disbursements Comm. Care Bad Debt Prop. Tax Credit Oct-12 $310, $ 480, $3,929, $55, $50, $ Nov-12 $431, $ 794, $106, $307, $ Dec-12 $427, $ 396, $2,035, $69, $133, $ Jan-13 $642, $ 425, $1,415, $37, $147, $ Feb-13 $493, $ 951, $58, $8, $ Mar-13 $501, $ 393, $1,471, $66, $149, $ Apr-13 $488, $ 618, $465, $96, $147, $1, May-13 $553, $ 1,007, $92, $243, $ Jun-13 $515, $ 698, $34, $106, $255, $ Jul-13 $513, $ 635, $93, $84, $275, $ Aug-13 $722, $ 488, $263, $90, ($7,395.00) $ Sep-13 $527, $ 887, $262, $104, $10, $ Oct-13 $617, $ 661, $699, $128, $170, $1, Average per month $530, $650,476 $820, $84, $145, $ $4,500, $4,000, $3,500, $3,000, $2,500, $2,000, Payroll Operations A/P Construction A/P $350, $300, $250, $200, $150, Comm. Care Bad Debt Prop. Tax Credit $1,500, $100, $1,000, $50, $500, $0.00 $0.00 ($50,000.00)

10 Chief Executive Officer Report November 2013 November 26, 2013 The following is a summary of the major work efforts across the strategic areas of work since the last board meeting in October Stewardship Cultivate responsible growth, developmentand management of resources to achieve ourmission and vision Nursing contract - The negotiation team has been meeting with the nursing representatives about the upcoming nursing contract renewal. There are many requests from the nurses that the administration team is trying to accommodate. So far there have been two meetings with good progress however there the two teams are having a difficult time making changes to the current meal and rest break language. We will need additional meeting to try and work through this issue. See finance summary for more details on this bucket. Collaboration Build collaborative relationships andpartnerships to improve the well-being of our community. Pharmacy Conducted a follow up phone call with the DOH discussing process improvements for the pharmacy survey. The pharmacy passed inspection on the second DOH visit however there were two recommendations that did not impact scoring but were debatable as to the appropriateness of the requirement for our facility and scope of services. These two topics of concern were expressed to the DOH during this call. Mason General Hospital HR Executive Lauri Bolton has been hired and will be starting January 6 th, three days a week at Mason General and two days at SPMC. Further details about specific days and times pending. McDonald Creek Restoration A community tree planting and creek clean-up are planned for December 7 th at Join Key McMurry and SPMC staff in planning willow trees on the creek bank as well as pulling non-native weeds and trash pick-up. This is a great community project in partnership with Grays Harbor Stream team, Key Environmental, and the Elma High School. Local Bank Leadership Meeting We are hosting a meeting for local bank leaders to learn about healthcare reform implementation and how they can assist in the process while meeting their community support requirement under the new laws. This will also be a planning meeting the banks and SPMC to coordinate a community outreach event to assist with enrollment and bank account attainment. Organizational Development Foster a culture of passion, performanceand innovation that attracts, develops and retains the highest caliber talent SPMC received the WSHA Community Health Leadership Award. A community celebration and reception have been scheduled for December 6 th, 11-1pm. Executive Chief Brandon Smith will feature appetizers and small bites to promote the new café opening to the public in January. Awards Tammy Davis, ARNP has been notified that she will be honored at the national conference for Nurse Practitioners as the Washington State Nurse Practitioner of the Year. This event takes place in the summer; we will honor Tammy s achievement more formally at that time. Renee K. Jensen, Chief Executive Officer 600 East Main Street, Elma, Washington Ph. (360) Owned and Operated by Grays Harbor County Public Hospital District No. 1, SPMC is an equal opportunity provider and employer

11 Chief Executive Officer Report November 2013 Strategic Planning The management team completed their two day planning session followed up by two additional one hour sessions to complete the strategies, and tactics for the plan. The final touches are being completed now and additional assignments are being made to staff. The final plan will be presented to the board at the December meeting. The community health needs assessment was reviewed, discussed and incorporated into the strategic plan as well. Physician Recruitment Dr. Bunge (medical director for hospitalist services) has done a fantastic job recruiting physicians for the inpatient coverage. We have had many interviews with very qualified physicians. The new internal medicine group will begin coverage in January. Once the inpatient coverage is stabilized, we will begin plans to extend the IM services to the outpatient setting. We have interviewed a Canadian physician for primary care who would be a great fit for our team. We are working through the process to determine if we will be able obtain an H1-b visa for her. Primary Care Department We have officially hired Heather Latham, ARNP. She will begin training in December and will become the emd s super user for the providers. Final decision on her practice location is pending. We have hired Lindsay Carlson PA-C, she will begin in February at Elma Family Medicine. Terra Grandmason ARNP will be moving her practice from EFM to SPHC in January. We have an open offer to one additional PA-C who would be placed at EFM or McCleary depending acceptance. This position would likely start in February as well. Staff Satisfaction Survey the survey was conveyed to the management team during the strategic planning session. The staff feedback was incorporated into the strategic plan. The results will be shared with the staff pending presentation to the board at the November meeting. Board Elections Louie Figueroa and Drew Hooper were successfully elected for their respective positions. Brent Meldrum will be leaving the board at the end of December and our new Commissioner Gary Thumser of McCleary will be joining us in January. We are excited for Gary to be joining our board with his great background in business and helping to ensure the residents of McCleary are well represented at the board level. Welcome Gary! Physical Environment Develop and maintain a physical environment that inspires our team to achieve the highest possible results Facility We have hired a facility manager, Danny Scott. He will begin his position in early December. We have completed the one year warranty inspection with the USDA and construction team. Everything is positive with the only outstanding issues being some flooring replacement due to staining from ink beneath the surface and the HVAC continues to have on going heating and cooling issues. The contractor and subcontractor have been working daily on resolving the issue. At this point there is not one clear problem so it is a troubleshooting game. The major impact is the ED waiting area and administration which dips to 60 s when the system is not working properly. We are working with the finance team to finalize any purchases that need to be included with the USDA loan. We hope to complete the last draw on the loan funds by the end of the year. Land Payment We have approached the county about the possibility of making an early final land payment which is due in October of We hope that there would be a discount offered for early payment which would be a win-win for both SPMC and the county. Signs the sign project continues. The footings for the two additional directional signs along Main street were poured this week. We are planning for the completion of the installation in the next two weeks. The additional signage on the roof is delayed due to engineering review by the city. Waiting for contractor on the schedule for this work. Renee K. Jensen, Chief Executive Officer 600 East Main Street, Elma, Washington Ph. (360) Owned and Operated by Grays Harbor County Public Hospital District No. 1, SPMC is an equal opportunity provider and employer

12 Chief Executive Officer Report November 2013 Effective & Efficient Operations Continuously develop effective, efficient and well-coordinated processes to ensure patient centered care LEAPT We have been selected to participate in three focus areas that are part of the WSHA LEAPT program. Due to our capacity and staying focused with our strategic plan we will be limiting our participation to two measures, sepsis and the culture of safety. We are currently participating in kick-off meetings and learning the scope of the work ahead. At the end of the process, the project teams will receive compensation as part of successful participation. This money will be used to offset the cost of the participation such as travel, staff time, equipment, system implementation etc. Compensation is based on organization size and outcomes. Chief Medical Officer We have renewed Dr. Hurley s CMO contract and have extended his coverage to six administrative days per week. He is doing a fantastic job for this organization, we are fortunate to have him. Primary Care Department This is a very active committee which is results and action oriented. See attached summary of achievements for the year. State Radiation Exposure Policy Joy Iversen from Diagnostic Imaging has been representing SPMC and other small rural hospitals at the State advisory board for implementing new radiation exposure laws. This will be an ongoing project and we appreciate Joy s experience and knowledge being heard at this committee. Clarity Referral Service We have gone live with the Clarity referral program which will automate and assist with patient referrals and preauthorization s for outpatient services. The program is too new to provide an update of progress however, initial reports from the referral coordinator indicate a very positive responses. Respectfully, RENÉE K. JENSEN Renee K. Jensen, Chief Executive Officer 600 East Main Street, Elma, Washington Ph. (360) Owned and Operated by Grays Harbor County Public Hospital District No. 1, SPMC is an equal opportunity provider and employer

13 Primary Care Department Team Highlights /10/13 Charter developed goal and objectives include: o Ensure patient centered care and the Patient Centered Medical Home (PCMH) are integrated throughout SPMC. o Improve consistency across all Primary Care Clinics. o Ensure the strategic direction of the District has input from the Primary care team. o Improve communication between the primary care team and other medical staff specialties. o Provide an avenue for the primary care team voice. o Conduit for Primary Care in the strategic planning process. o Ensure effective, consistent communication between the clinical and administrative functions of primary care. o Reduce the number of meetings while improving the effectiveness of necessary meetings for all primary care team members. o Ensure accountability and follow through on projects. 6/27/13 Forms Committee developed, ticket system for new forms submission 7/8/13 Lab draws at EFM sent to SPMC as of July 8 th Developed form to get providers information on their patients when admitted Lab Results Patient Follow Up Policy created 7/18/13 Admit and Discharge forms created and put in use 8/8/13 Changed process in medical records to include daily review for information needing to be faxed to providers on their patients who discharged Process change to include copying and faxing pertinent information for discharged patients every morning (including weekends) Finalized Sports Physical Template 8/22/13 Controlled Substance Agreement in emds Access to all staff for on-call calendars 9/9/13 Contract with Clarity Health for prior authorizations to reduce denials go LIVE is 11/19 9/19/13 Medicare wellness form (thanks Dr. Lima) 9/24/13 Telepharmacy implemented 24 hour pharmacist access

14 9/26/13 Appointment scheduling went live Lab contingency plan developed all staff now know how to reset Orchard 10/3/13 PharmD Lunch and Learn with Dr. Gonzalez on Lawful Prescribing and the Prevention of Diversion was attended by over 20 staff and providers Patient Care Center Home pain project CHOICE is willing to extend a pilot project on patient centered care from Thurston County to East Grays Harbor We have started the next phase of Patient Centered Medical Home Collaborative which is facilitated by DOH. We are developing 3 measures that will be tracked and reported on through mid Chronic Pain Management is a core measurement that we are using as the foundation of this phase of PCMH. 10/10/13 Patient Dismissal and No Show policies reviewed Scheduling process for patients streamlined Rules are activated Code Stroke and Chest Pain drills now include clinics 10/31/13 Partnering with Elma Pharmacy to improve service/relationship

15 HEALTH COVERAGE ENROLLMENT REPORT OCTOBER 2013

16 Table of Contents Website Statistics...1 Enrollment Status of All Applications...2 Enrollment by County...3 Enrollment by Age...4 Enrollment by Metal Level...6 Enrollment by Gender...7 Family Size on Applications...8 Enrollments by Federal Poverty Level...9 Call Center Data...10 *This report represents data taken from Oct. 1, 2013 through Oct. 31, 2013.

17 Website Statistics Web Visits 2,710,921 = 100,000 Unique Visitors Page Views 498,006 = 100,000 Accounts Created 11,527,730 Unique Page Views 118,531 = 10,000 8,180,172 = 1 Million 1

18 Enrollment Status of Applications Enrollments Completed Enrolled in Total QHP (Tax Credit) 4,835 QHP (No Tax Credit) 1,516 Medicaid 51,379 Total 57,730 QHP (No Tax Credit), 1,516 QHP (Tax Credit), 4,835 Medicaid, 51,379 QHP Tax Credit: Includes individuals who have purchased a qualified health plan (private health plan) that qualified for a tax credit to lower their monthly insurance premiums. QHP No Tax Credit: Includes individuals who purchased a qualified health plan that either did not qualify for a tax credit or did not apply for financial help. Medicaid: Includes Individuals who have qualified and enrolled in a Medicaid Plan. In Process Applications Application Status Total QHP (Need To Pay) 21,671 In Process 72,136 Total 93,807 QHP (Need to Pay): Includes individuals who have completed an application for a Qualified Health Plan that is awaiting payment due by Dec. 23, 2013 for coverage that begins on Jan. 1, In Process: Includes individuals who have started applications or completed applications that need to be finalized. 2

19 Enrollment by County COUNTY QHP (Tax Credit) QHP (No Tax Credit) Medicaid* % of Total Enrolled KING 1, , % PIERCE , % SPOKANE , % SNOHOMISH , % CLARK , % THURSTON ,066 4% WHATCOM , % Yakima , % KITSAP , % BENTON , % COWLITZ , % SKAGIT % CLALLAM % CHELAN % LEWIS % ISLAND % FRANKLIN % MASON % GRAYS HARBOR % GRANT % JEFFERSON % KITTITAS % STEVENS % OKANOGAN % WALLA WALLA % DOUGLAS % PACIFIC % WHITMAN % SAN JUAN % KLICKITAT % ADAMS % ASOTIN % PEND OREILLE % LINCOLN % SKAMANIA % WAHKIAKUM % FERRY % COLUMBIA % GARFIELD % Total 4,835 1,516 51,368 57,719 *Medicaid enrollment includes 11 additional enrollees in Other County. 3

20 Medicaid Enrollment by Age AGE Enrollment Percentage < 18 13, % , % , % , % , % , and older 4.03% Total 51, % < and older 4

21 Qualified Health Plan Enrollment by Age AGE Enrollment Percentage < % % , % , % , % , % 65 and older % Total 6, % < and older Note: Individuals who are eligible for Medicare are not eligible to enroll in health insurance coverage through Washington Healthplanfinder. Some individuals over the age of 65 may enroll through Washington Healthplanfinder if they are not eligible for Medicare. 5

22 Enrollment by Metal Level Metal Level Enrollment Percentage Bronze 1, % Catastrophic % Gold 1, % Silver 4, % Total 6, % Gold Plans: Cover 80 percent of the cost of essential health benefits, while the patient pays 20 percent. Silver Plans: Cover 70 percent of the cost of essential health benefits, while the patient pays 30 percent. Bronze Plans: Cover 60 percent of the cost of essential health benefits, while the patient pay 40 percent. 20% 0% 16% 64% Bronze Catastrophic Gold Silver Note: Health insurance carriers in Washington did not submit any Platinum plans for regulatory approval to be offered in Washington Healthplanfinder. 6

23 Enrollment by Gender Medicaid Enrollments by Gender Gender Enrollment Male 22,257 Female 29,122 Total 51,379 43% 57% Qualified Health Plan Enrollments by Gender Gender Enrollment Male 2,716 Female 3,635 Total 6,351 43% 57% 7

24 Family Size on Applications Household Members Applications 1 28, , , , Total 37,698 Note: Health insurance carriers in Washington did not submit Platinum plans for regulatory approval to be offered in Washington Healthplanfinder. The total applications on this chart includes applications for individuals who are fully enrolled. 8

25 Enrollments by Federal Poverty Level FPL Enrollment <100% 46 > <= 150 % 448 > <= 200 % 1578 > 200- <= 251 % 917 > <= 300 % 595 > <= 400 % 593 >=100 - <= 138 % <100% > <= 150 % > <= 200 % > 200- <= 251 % > <= 300 % > <= 400 % >=100 - <= 138 % 9

26 Call Center Data Call Center Total Total Call Volume 91,722 Average Talk Time Total Spanish Language Calls Total Calls for other Languages other than Spanish and English 12 minutes, 51 seconds* 7,197 3,115 *Since Oct. 14 the average talk time averaged approximately 18 minutes per call. Note: Data for enrollments through the toll-free Customer Support Center are not yet available. 10

27 Finance Summary for October 2013 Summary Volumes continue to be stable and consistent. In fact, admits, acute care days, and average length of stay were the exact same in October as they were in September. Outpatient volumes and related revenue were above average. Lab and infusion services particularly had high volumes. Volumes Acute care inpatient admissions have averaged 25 per month since moving into the new hospital. In October, we had 28 admissions, generating 80 patient days, which, as previously mentioned is the exact same statistics as the prior month. The average length of stay (ALOS) was 2.9, which is more in line with the budget and prior year. Year to date, the ALOS is 4.0. The 8 swing bed admissions generated an additional 53 patient days, for a total patient day count of 133. The facility s overall average daily census of acute care and swing bed was 4.3 in October. There were 765 emergency department visits. The clinics had a stellar visit count with 1,875 visits. This helped with the total outpatient revenue. Overall, the diagnostic imaging modalities leaned closer to the mean, except for MRI, which increased. The mobile MRI came each of the 5 Thursdays in October. We provided 22 MRI exams total for the month. Revenue Gross revenue for the year is $32 million, which is exceeding the $24.5 million budget by 31 percent. The net revenue is $13 million, or 11 percent over budget. Expenses As mentioned last month, an additional $800,000 in mostly supplies expense and to a lesser degree, purchased services all related to the new hospital project, are being expensed in October. The American Hospital Association issues a field guide titled, Estimated Useful Lives of Depreciable Hospital Assets every year. This provides guidance on the useful life of an asset. Our policy and industry norms then guide whether or not a particular asset should be expensed as a stand-alone item, or group with others (to exceed the capitalization threshold). Hospital beds are a good example of this. The Finance Manager reviewed the movable equipment listing and determined which items should be immediately expensed versus depreciated over a longer term based on our capitalization policy. This resulted in expensing nearly $800,000 in the current year versus depreciating over a longer term. The USDA bond funds supported these purchases, so October financials represent an accounting loss, but does not represent a loss in operating cash flow. (See later discussion about cash.) The final results of the broader Cost Segregation study should be completed by the firm in November. EBITDA and Net Income Despite the additional $800,000 expense, earnings before interest, taxes, depreciation and amortization are positive $686,000 year to date. When adding $1.7 million in interest and depreciation expenses, and $972,000 in non-operating revenue, the net loss year to date is $62,000. This loss will shrink in November and December, and by year end should be breakeven or better. Balance Sheet The District s cash position increased from $2.4 million to $2.5 million. However, the days cash on hand value decreased from 61 to 50. Days cash on hand is calculated by dividing the average daily expense into the total cash available. Total cash increased (numerator), but the average daily expense (denominator) increased because of the Renee K. Jensen, Chief Executive Officer 600 East Main Street, Elma, Washington Owned and Operated by Grays Harbor County Public Hospital District No. 1, SPMC is an equal opportunity provider and employer

28 $800,000 hit on expenses. Had this not occurred, days cash on hand would have increased from 61 to 63. Days in AR increased from 77 to 83. The last three months of high volumes have outpaced the claims processing. In fact, days in AR have trended upward since the summer. Finance has developed a plan to provide resources to the revenue cycle process, but part of that plan will occur after the T-System has completed the physician order entry implementation. The current portion of long-term debt (debt due within 12 months) increased from $325,000 to $1.2 million to account for the new debt payments, last land payment, and payment on old bonds. W. Callicoat Renee K. Jensen, Chief Executive Officer 600 East Main Street, Elma, Washington Owned and Operated by Grays Harbor County Public Hospital District No. 1, SPMC is an equal opportunity provider and employer

29 11/27/2013 INCOME STATEMENT October 31, 2013 VARIANCE VARIANCE CURRENT % YTD % CURRENT MONTH OVER YEAR TO DATE OVER ACTUAL BUDGET PRIOR YEAR VARIANCE BUDGET ACTUAL BUDGET PRIOR YEAR VARIANCE BUDGET GROSS OPERATING REVENUE 583, , , ,548 94% INPATIENT REVENUE 5,057,742 2,489,435 2,018,643 2,568, % 822, , , ,131 30% OUTPATIENT REVENUE 6,529,811 5,939,675 5,099, ,136 10% 150, , ,374 43% SPHC OUTPATIENT REVENUE 971, , ,376 16% 101,952 81, ,160 20,009 24% MRHC OUTPATIENT REVENUE 875, ,986 1,032,969 66,242 8% 78, , ,336 (63,103) -44% EFM OUTPATIENT REVENUE 883,721 1,279,195 1,109,998 (395,474) -31% 2,050,949 1,148,589 1,036, ,360 79% EMERGENCY REVENUE 17,733,456 13,119,258 11,439,552 4,614,198 35% 3,787,888 2,409,569 2,024,308 1,378,319 57% GROSS PATIENT REVENUE 32,051,687 24,476,902 20,700,734 7,574,785 31% REVENUE DEDUCTIONS 882, , , ,637 89% MEDICARE CONTRACTUALS 7,167,751 4,744,514 4,613,865 2,423,237 51% 627, , , ,906 78% MEDICAID CONTRACTUALS 5,312,769 3,575,280 2,767,111 1,737,489 49% 315, , ,803 75,773 32% OTHER CONTRACTUALS 2,667,559 2,435,057 2,246, ,502 10% 318,064 89,485 57, , % BAD DEBT EXPENSE 2,691,335 1,025,588 1,414,492 1,665, % 128,796 93,973 55,662 34,823 37% COMMUNITY CARE 866, , ,964 (88,063) -9% 53,291 5,313 49,801 47, % ADMIN. ADJUSTMENTS 602, , , , % 2,326,202 1,247,506 1,010,741 1,078,696 86% TOTAL REVENUE DEDUCTIONS 19,308,122 12,850,092 12,332,398 6,458,030 50% 44,699 12,335 14,713 32, % CLINIC ENHANCEMENTS 224, , , ,074 82% 6, ,914 OTHER OPERATING INCOME 46, ,572 46, DISPROPORATIONATE SHARE 44, ,561 44,019 1,513,299 1,174,398 1,028, ,901 29% NET OPERATING REVENUE 13,058,691 11,750,160 8,631,999 1,308,531 11% OPERATING EXPENSES 616, , ,754 85,987 16% SALARIES AND WAGES 5,639,298 5,631,178 4,220,440 8,120 0% 140, ,686 94,634 20,687 17% EMPLOYEE BENEFITS 1,251,481 1,242, ,296 8,650 1% 261, , , , % PROFESSIONAL FEES 1,677,984 1,025, , ,927 64% 861,622 49,300 70, , % SUPPLIES 1,850, , ,456 1,257, % 24,691 33,588 2,479 (8,897) -26% UTILITIES 268, , ,958 (86,618) -24% 160, ,870 97,091 56,221 54% PURCHASED SERVICES 1,115,187 1,186,395 1,165,361 (71,208) -6% 14,956 17,518 11,564 (2,562) -15% INSURANCE 143, , ,737 (31,286) -18% 65,052 86,846 87,402 (21,794) -25% OTHER EXPENSES 322, , ,894 57,186 22% 8,177 8,901 8,728 (724) -8% RENTALS AND LEASES 102,848 97,724 95,813 5,124 5% 2,153,587 1,054, ,949 1,098, % EXPENSES SUBTOTAL 12,372,157 10,571,512 8,265,208 1,800,645 17% (640,288) 119,410 39,749 (759,698) -636% EBITDA 686,534 1,178, ,791 (492,114) -42% 62,512 60,904 3,532 1,608 3% INTEREST EXPENSE 518, ,430 52, ,973 37% 122, ,481 17, % DEPRECIATION & AMORTIZATION EXPENSE 1,202, , , ,038 20% 2,338,920 1,238,373 1,009,981 1,100,547 89% TOTAL EXPENSES 14,092,780 11,947,124 8,494,108 2,145,656 18% (825,621) (63,975) 18,717 (761,646) 1191% NET INCOME (LOSS) FROM OPERATION (1,034,089) (196,964) 137,891 (837,125) 425% NON-OPERATING REVENUES 58,848 63,664 55,730 (4,816) -8% TAX REVENUES 611, , ,690 (25,474) -4% 466 1,334 1,513 (868) -65% MISC. NON-OPERATING REV. 361,143 13, , , % 59,314 64,998 57,243 (5,684) -9% TOTAL NON-OPERATING REV. 972, , , ,329 50% (766,307) 1,023 75,960 (767,330) % NET INCOME OR (LOSS) (61,780) 453, ,904 (514,796) -114% -1-

30 11/27/2013 BALANCE SHEET As of October 31, 2013 CURRENT LAST DECEMBER 31, CURRENT LAST DECEMBER 31, MONTH MONTH 2012 MONTH MONTH 2012 ASSETS LIABILITIES CURRENT ASSETS CURRENT LIABILITIES OPERATING CASH 319,746 2,174,595 1,154,437 NOTES PAYABLE LGIP & RERSERVE 2,175, , ,012 ACCOUNTS PAYABLE 409, , ,887 ACCOUNTS RECEIVABLE 10,104,551 9,313,702 6,018,701 OTHER PAYABLES 67, ,392 19,378 ALLOWANCE FOR BAD DEBTS (2,538,776) (2,370,673) (1,120,656) PAYROLL & RELATED LIAB 762, , ,396 ALLOWANCE CONTRACTUAL ADJ (3,483,657) (3,055,142) (2,486,300) OTHER ACCRUED EXPENSES 15, ,050 2,227 RECEIVABLES - TAXES 202, ,741 62,536 EXCISE TAX PAYABLE RECEIVABLES - OTHER 5,852 5,109 16,701 DUE TO THIRD PARTY PAYORS 933, , ,417 M & M RECEIVABLES PATIENT REFUND PAYABLE 8,994 1,508 10,746 INVENTORY 104, , ,695 CURRENT PORTION LONG TERM 1,198, , ,142 PREPAID EXPENSES 19,438 15,555 7,942 TOTAL CURRENT ASSETS 6,909,881 6,606,411 4,408,068 TOTAL CURRENT LIABILITIES 3,396,231 2,888,808 2,181,193 BOARD DESIGNATED ASSETS FUNDED DEPRECIATION GROSS LONG TERM DEBT DESIGNATED CONSTRUCTION LAND & BONDS PAYABLE 20,728,451 20,038,749 16,331,865 XRAY EQUIP PAYABLE ,144 TOTAL BOARD DESIGN ASSETS TOTAL GROSS LONG TERM DEBT 20,728,451 20,038,749 16,367,009 PROPERTY, PLANT & EQUIP LAND AND IMPROVEMENTS 803, , ,993 LESS CUR. PORTION LTGO/CT (1,198,639) (325,142) (325,142) BUILDINGS 1,108,814 1,120,169 1,120,168 FIXED EQUIPMENT 4,615,537 1,701,083 1,701,083 NET LONG TERM DEBT 19,529,812 19,713,607 16,041,867 CONSTRUCTION IN PROGRESS 17,679,330 21,277,926 17,312,989 TOTAL PROP,PLANT, & EQUIP 24,207,674 24,903,171 20,938,233 TOTAL LIABILITIES 22,926,043 22,602,415 18,223,060 LESS: ACCUM DEPRECIATION (3,510,611) (3,461,023) (2,388,648) EQUITY NET PROP, PLANT & EQUIP 20,697,063 21,442,148 18,549,585 UNRESTRICTED FUND BALANCE 4,742,682 4,742,682 4,146,499 EXCESS REVENUE/(EXPENSE) (61,781) 704, ,183 DEFERRED FINANACING COSTS - - 1,065 8,089 TOTAL UNRESTRICTED FUND 4,680,901 5,447,209 4,742,682 TOTAL ASSETS 27,606,944 28,049,624 22,965,742 TOTAL LIABILITY & EQUITY 27,606,944 28,049,624 22,965,742

31 STATISTICS October 31, 2013 MONTH YEAR TO DATE ACTUAL BUDGET PRIOR MONTH ACTUAL BUDGET PRIOR YEAR INPATIENT STATISTICS ADMISSIONS PATIENT DAYS EMERGENCY ADMITS LENGTH OF STAY SWING BEDS ADMISSIONS PATIENT DAYS OUTPATIENT STATISTICS OBSERVATION HOURS 2,762 1,831 1, EMERGENCY ROOM VISITS 7,067 5,386 4, MRHC CLINIC VISITS 5,051 4,159 5, EFM CLINIC VISITS 4,841 6,495 5, SPHC CLINIC VISITS 5,366 4, , OTHER OUTPATIENT VISITS 9,795 8,840 8,252 ANCILLARY STATISTICS 6,093 3,830 5,035 LAB BILLABLE TEST 47,783 43,742 39, XRAY RVUS 4,525 3,042 2, CT EXAMS 1,785 1,263 1, ULTRASOUND EXAMS MRI EXAMS OTHER STATISTICS Goal December 31, 2012 DAYS IN A/R DAYS IN PAYABLE EXCL 3RD/DEBT 6 < 15 9 DAYS IN CASH 50 > CURRENT RATIO

32 11/27/2013 Financial Dashboards October 31, 2013 CURRENT PRIOR BUDGET LEGEND _ Gross Patient Services Revenue Salary & Benefits Days Cash on Hand 4,000 3,500 3,000 2,500 2,000 1,500 J F M A M J J A S O N D $950 $850 $750 $650 $550 $450 $350 J F M A M J J A S O N D J F M A M J J A S O N D $2,500 $2,300 $2,100 $1,900 $1,700 $1,500 $1,300 $1,100 $900 $700 $500 Operating Expense J F M A M J J A S O N D FTE'S Paid FTE's Worked FTE's J F M A M J J A S O N D Days in A/R J F M A M J J A S O N D $300 $100 $(100) $(300) $(500) $(700) $(900) Operating Income - Loss J F M A M J J A S O N D $34,000 $29,000 $24,000 $19,000 $14,000 $9,000 $4,000 Overtime $ J F M A M J J A S O N D $300 $100 $(100) $(300) $(500) $(700) $(900) Net Income-Loss J F M A M J J A S O N D Cockpit Finance October 2013.xlsx New Charts

33 11/27/2013 Volume Dashboards October 31, 2013 LEGEND: CURRENT PRIOR. _. _. _. _ BUDGET _ Acute Care Patient Days Swing Bed Days Laboratory Tests 160 6, , ,500 5,000 4,500 4, , J F M A M J J A S O N D 0 J F M A M J J A S O N D 3,000 J F M A M J J A S O N D Observation Hours J F M A M J J A S O N D Emergency Dept Visits J F M A M J J A S O N D X-Ray - RVU's J F M A M J J A S O N D Ultrasound Exams J F M A M J J A S O N D CT Exams J F M A M J J A S O N D MRI Exams J F M A M J J A S O N D MRHC Visits vs. Budget EFM Visits vs. Budget SPHC Visits vs. Budget 1,100 1, J F M A M J J A S O N D 1,100 1, J F M A M J J A S O N D 1,100 1, J F M A M J J A S O N D Cockpit Volume October 2013.xlsx

34 SUMMIT PACIFIC MEDICAL CENTER MEDICAL STAFF BY LAWS Summit Pacific Medical Center Staff Bylaws 1 May 2013 Back to Table of Contents

35 Table of Contents PREAMBLE 3 DEFINITIONS 4 ARTICLE I: NAME 5 ARTICLE II: PURPOSES 5 ARTICLE III: CATEGORIES 5 ARTICLE IV: MEMBERSHIP 7 ARTICLE V: CLINICAL PRIVILEGES 11 ARTICLE VI: OFFICERS OF THE MEDICAL STAFF 11 ARTICLE VII: COMMITTEES OF THE MEDICAL STAFF 13 ARTICLE VIII: STAFF FUNCTIONS 14 ARTICLE IX: DEFINITIONSPERTAINING TO DUE PROCESS 15 ARTICLE X: INITIAL PROCESSES PERTAINING TO DUE PROCESS 16 ARTICLE XI: AUTOMATIC SUSPENSION 16 ARTICLE XII: PRECAUTIONARY SUSPENSION 17 ARTICLE XIII: PEER REVIEW 18 ARTICLE XIV: INVESTIGATION BY THE MEDICAL 19 STAFF AS A WHOLE ARTICLE XV: FAIR HEARING WITH THE BOARD 21 OF COMMISSIONERS ARTICLE XVI: APPELLATE REVIEW 25 ARTICLE XVII: CONFIDENTIALITY, IMMUNITY AND LIABILITY 28 ARTICLE XVIII: ADOPTION OF BYLAWS AND/OR 28 BYLAWS AMENDMENTS ARTICLE XIX: RELATED PROTOCOLS AND MANUALS 28 Summit Pacific Medical Center Staff Bylaws 2 May 2013 Back to Table of Contents

36 PREAMBLE WHEREAS, Summit Pacific Medical Center in Elma, Washington, (hereinafter, the "Hospital") is owned and operated by Grays Harbor County Public Hospital District No. 1, a non-profit corporation organized under the laws of the State of Washington; and WHEREAS, the purpose of the hospital is to provide patient care and carry out the mission of the Hospital District, and; WHEREAS, it is recognized that the Board of Commissioners of the Hospital District has ultimate responsibility for the quality of medical care in the hospital; and WHEREAS, it is recognized that the discharge of the Board of Commissioner s responsibility requires the rendering of medical judgment and the evaluation of medical competence which are rightfully performed by the Medical Staff; and WHEREAS, it is recognized that the cooperative efforts of the Medical Staff and the Board of Commissioners are necessary to fulfill the hospital's obligations to its patients; NOW, THEREFORE, the physicians, podiatrists, physician s assistants and nurse practitioners practicing at Summit Pacific Medical Center hereby organize themselves into a Medical Staff in conformity with these bylaws and the Rules and Regulations are promulgated hereunder. Summit Pacific Medical Center Staff Bylaws 3 May 2013 Back to Table of Contents

37 DEFINITIONS 1. The term "Medical Staff," the Medical Staff as a Whole, or "Staff" is defined as the formal organization of all duly licensed medical and osteopathic physicians, podiatrists, physician s assistants and nurse practitioners who are privileged to admit and attend patients in the hospital or who regularly provide patient care in the hospital s affiliated clinics. 2. The term "Board of Commissioners" means the governing body of Grays Harbor County Public Hospital District No. 1, State of Washington. 3. The term "Hospital" means Summit Pacific Medical Center, Elma, Washington. 4. The term "Administrator" is defined as the individual appointed by the Board of Commissioners to act on its behalf in the overall management and administration of the hospital. 5. The CMO is the Chief Medical Officer as appointed by the Board of Commissioners and the Administrator. 6. The term "member" is defined as any physician (M.D. or D.O.), podiatrist (D.P.M.), physician s assistant (P.A.), or nurse practitioner (A.R.N.P.) appointed to and maintaining membership in any category of the Medical Staff in accordance with these bylaws. 7. The term "Allied Health Professional" or "AHP" is defined as an appropriately licensed or otherwise duly qualified individual in the allied health sciences who may be granted clinical privileges or the privilege of performing other specified functions in the hospital, to such extent and under such conditions as may be provided either in Rules and Regulations of the Medical Staff or otherwise applicable documents. 8. The term "Medical Staff year" shall refer to a period of twelve months, commencing on the first day of January and ending on the 31 st day of December each year. 9. The term "Bylaws" is defined as this document by which the Medical Staff regulates itself. 10. The term "Practitioner" is defined as any M.D., D.O., D.P.M., P.A. or A.R.N.P. who is applying for Medical Staff membership and/or clinical privileges, or who is a Medical Staff member and/or who exercises clinical privileges in this hospital or its affiliated clinics. Summit Pacific Medical Center Staff Bylaws 4 May 2013 Back to Table of Contents

38 ARTICLE I: NAME The name of this organization shall be "The Medical Staff of Summit Pacific Medical Center," hereinafter referred to as the Medical Staff). ARTICLE II: PURPOSES OF THE MEDICAL STAFF 1. To provide care to all patients admitted to or treated in any of the departments or services of the hospital and its affiliated clinics in accordance with the hospital's mission and with full respect for the individual dignity of the patients. 2. To facilitate a professional level of performance by all members of the Medical Staff and other individuals who are authorized to practice in the hospital and its affiliated clinics, to provide the appropriate delineation of the clinical privileges that may be exercised in the hospital and clinics, and to evaluate the performance of all individuals who are privileged to provide patient care services in the hospital and affiliated clinics. 3. To initiate and maintain rules and regulations for the government of the Medical Staff. 4. To provide a basis for discussion of issues and for the development of working relationships among the Board of Commissioners, the Administrator, and the Medical Staff. ARTICLE III: CATEGORIES OF THE MEDICAL STAFF There shall be seven (7) categories of Medical Staff membership: Active, Courtesy, Consulting, Temporary, Emergency Room, Allied, and Honorary. Section 1: The Active Medical Staff The Active Medical Staff shall consist of providers (MDs, DOs, ARNPs, PAs, and Podiatrists) who regularly admit patients to the hospital, or otherwise regularly provide professional services for patients in the hospital and its affiliated clinics. The Active Medical Staff shall be responsible for the activities of the Medical Staff, including the review and evaluation of the quality and appropriateness of medical care and treatment provided to patients in the hospital. Members of the Active Medical Staff shall be eligible to vote, hold office and participate on Medical Staff Committees as reviewed in Article VII. Members of the Active Medical Staff shall be required to attend Medical Staff meetings as described in the Medical Staff Rules and Regulations. Summit Pacific Medical Center Staff Bylaws 5 May 2013 Back to Table of Contents

39 Section 2: The Courtesy Medical Staff The Courtesy Medical Staff shall consist of physicians otherwise qualified for Active Medical Staff membership but who only occasionally admit and/or treat patients in the hospital and who maintain active privileges at another hospital in Washington State. Courtesy Medical Staff members shall not be eligible to vote or hold office in this Medical Staff organization. Courtesy Medical Staff may participate on Medical Staff Committees as reviewed in Article VII. Section 3: The Consulting Medical Staff The Consulting Medical Staff consists of physicians of recognized professional ability who are not members of another category of the Medical Staff, and who may be called in for consultation or assistance by any member of the Medical Staff (for example, the radiologists who interpret diagnostic images or health providers contracted with the hospital to provide services via video feeds, telephone, or other electronic means of communication). Consulting Medical Staff may not vote, hold office or participate on Medical Staff Committees. They may attend patients who are under the active care of a Medical Staff Member who has admitting privileges for the duration of the specific consultation for which they were called, and may not admit patients. They may see an unlimited number of patients in specialty clinics at the Hospital, in their recognized specialty, or interpret an unlimited number of diagnostic images. Section 4: Temporary/Locums Tenens Staff The Temporary Medical/Locums Tenens Staff consists of physicians otherwise qualified for Active Medical Staff privileges but who intend to only practice at the Hospital for a limited time. Physicians coming to the Hospital to mentor or proctor other members of the Medical Staff are included in this designation. Temporary privileges shall be granted for no less than 30 days at a time and for a maximum of 120 days in a year beginning from the date privileges have been granted by the Board of Commissioners. Temporary/Locums Tenens Medical Staff may not vote, hold office or participate on Medical Staff Committees. A practitioner whose temporary privileges are terminated or suspended shall not be entitled to the procedural rights of Due Process as outlined in the Bylaws. Section 5: The Emergency Department Medical Staff The Emergency Department Medical Staff consists of physicians (MDs and DOs) who work primarily in the Hospital Emergency Department through third party contracts, direct independent contracts, or are employed by the Hospital District. Emergency Department Medical Staff may attend patients in the hospital as defined in the Rules and Regulations of the Medical Staff. Summit Pacific Medical Center Staff Bylaws 6 May 2013 Back to Table of Contents

40 Emergency Department Medical Staff who regularly work 80 or more clinical hours at Summit Pacific each month will be considered active Medical Staff. Emergency Department providers who work less than 80 clinical hours per month or work greater than 80 clinical hours, but less than 6 months per year at Summit Pacific Medical Center will be considered courtesy medical staff. The Emergency Department Medical Staff Members shall have privileges to admit or discharge patients at Summit Pacific Medical Center. Such physicians should: 1) Initiate inpatient admission orders with consultation with a member of the Active Medical Staff; and may 2) Admit patients over the weekend at the request of the on-call physician or nurse practitioner; and 3) Emergency Department Medical Staff may admit patients for observation as defined in the Rules and Regulations. Section 6: Allied Health Professional The Allied Health Professional category consists of non-physician health care providers (e.g. PA-Cs) who shall practice only under the supervision of a physician who is a Member of the Medical Staff. Allied Health Professionals may not practice beyond the scope or have privileges beyond those of their supervising physician. Members of the Allied Health Professional Medical Staff shall have a vote, but shall not be able to hold office. They are granted procedural rights of Due Process as outlined in the Bylaws. Section 7: Honorary Medical Staff The Honorary Medical Staff shall be appointed by the Board of Commissioners upon recommendation of the Medical Staff. They may be physicians, dentists, podiatrists, ARNPs, or PA-Cs who have retired from active hospital practice and are of outstanding reputation. Honorary Medical Staff need not reside in the community. Honorary Medical Staff shall not be eligible to admit patients, to vote, or to hold office, but may attend any Medical Staff meeting or event and may participate on Medical Staff Committees. Section 1: The Privileging Committee ARTICLE IV: MEMBERSHIP APPOINTMENT The duties of the Privileging Committee as defined in Article VII, Section 4 shall be to: a) Draft for approval by the Medical Staff all policies and procedures pertaining to the granting of privileges at the Hospital. Summit Pacific Medical Center Staff Bylaws 7 May 2013 Back to Table of Contents

41 b) Review and evaluate qualifications of each practitioner applying for initial appointment, reappointment, or modification of clinical privileges on behalf of the Medical Staff. The recommendations of the Privileging Committee shall go before the Medical Staff for approval and then forwarded to the Board of Commissioners in compliance with the Bylaws as well as the Rules and Regulations of the Medical Staff. c) Establish individual criteria for members granted Provisional status under Article IV, Section 9 which must be fulfilled prior to promotion to full membership. d) May grant requests for a decrease level of practitioner privileges with subsequent acknowledgement by the Medical Staff. Section 2: Qualifications of Membership Doctors of Medicine, Osteopathy, and Podiatry, Physicians Assistants and Nurse Practitioners shall be qualified for Medical Staff membership only if they: a) Document their licensure to practice in the State of Washington. They must also have the experience, background, training, demonstrated ability, and judgment, such that any patient treated by them will receive care of the generally recognized professional level of quality and efficiency. b) Are determined, on the basis of documented references, including references from all hospitals with which the applicant has been associated, to adhere strictly to the lawful ethics of their respective professions, to work cooperatively with others in the hospital setting, to be willing to participate in and properly discharge Staff responsibilities, and to be willing to commit to and regularly assist the Medical Staff in fulfilling its obligations related to patient care within the areas of their professional competence and credentials. c) Are located closely enough (office and residence) to the Hospital to provide continuous care to their patients, as defined in the Rules and Regulations and established on the basis of the period of time within which a practitioner must respond, depending on the staff category and clinical privileges which are involved and the feasibility of arranging alternative coverage. d) Are free of or have under adequate control any significant physical or mental health impairment that cannot be reasonably accommodated, without imposing an undue hardship on the Hospital, in order to permit the practitioner to safely and competently exercise the clinical privileges requested. In addition, they are free from abuse of any type of substance or chemical that affects cognitive, motor or communication ability in a manner that interferes with or presents a reasonable probability of interfering with the essential functions of his/her area of practice or meeting the standards of care in the community. Summit Pacific Medical Center Staff Bylaws 8 May 2013 Back to Table of Contents

42 e) Document that they have adequate liability insurance. Section 3: Nondiscrimination No applicant shall be denied nor granted medical Staff membership or clinical privileges on the basis of age, sex, race, creed, sexual preference, or on the basis of any other protected classification. Section 4: Other Affiliations. No physician, podiatrist, physician assistant or nurse practitioner shall be entitled to membership on the Medical Staff or to the exercise of particular clinical privileges in the Hospital merely by virtue of licensure to practice medicine, osteopathy, or podiatry in this or any other state, by virtue of membership in any professional organization, or by virtue of having or having had similar membership or privileges at this institution or elsewhere. Section 5: Burden of Providing Information a) Individuals seeking appointment and reappointment have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, character, ethics, and other qualifications for resolving any doubts. b) Individuals seeking appointment and reappointment have the burden of providing evidence that all the statements made and information given on the application are accurate. c) 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. Any application that continues to be incomplete 30 days after the individual has been notified of the additional information required shall be deemed to be withdrawn. d) The individual seeking appointment or reappointment is responsible for providing a complete application, including adequate responses from references. An incomplete application will not be processed. Section 6: Basic Responsibilities of Medical Staff Membership Each member of the Medical Staff shall: Summit Pacific Medical Center Staff Bylaws 9 May 2013 Back to Table of Contents

43 a) Provide patients with care at the generally recognized professional level of quality and efficiency. b) Retain responsibility within his/her area of professional competence for the continuous care and supervision of each patient in the hospital for whom he/she is providing services, or arrange for a suitable alternative to assure such care and supervision; c) Abide by the Medical Staff bylaws and rules and regulations and by all other lawful standards, policies, and rules of the Medical Staff; d) Discharge such Medical Staff, committee and hospital functions, including, but not limited to peer review, quality assurance activities, utilization review, emergency service and backup functions for which he/she is responsible by virtue of his/her Staff category assignment, appointment, election, utilization of Allied Health Professionals, or exercise of privileges, prerogatives, or other rights of the hospital; e) Agree to act in an ethical, professional and courteous manner and to provide all patients the same level of quality of care on a non-discriminatory basis. f) Prepare and complete in a timely fashion the medical and other required records for all patients admitted to or treated in the hospital. Section 7: Duration of Appointment a) Initial appointments and reappointments to the Medical Staff shall be made by the Board of Commissioners. The Board of Commissioners shall act on all appointments, reappointments, or revocation of appointments only after there has been recommendation from the Medical Staff in accordance with these bylaws. b) Appointment to the Medical Staff will be for no more than two (2) years. c) Reappointments to the Medical Staff and/or renewal of clinical privileges will be for periods of two (2) years. Section 8: Expedited Review Expedited privileges may be granted by two (2) Active Members of the Medical Staff serving on the Privileging Committee, only after a completed application has been received and there has been verification of the applicant s training, licensure, and there has been no evidence or suggestion of prior malpractice, disciplinary actions, or licensure restrictions In the exercise of such privileges the provider shall be under the direct supervision of the Chief Medical Officer or an individual designated by the Chief Medical Officer. Privileges that have been expedited shall be granted for no more than 120 days. During this time the Member s application shall be required to go through the routine appointment process with ultimate approval by the Board of Commissioners. An extension of this period may only be Summit Pacific Medical Center Staff Bylaws 10 May 2013 Back to Table of Contents

44 made with the approval of the majority of the Active Medical Staff and approval of the Board of Commissioners. Due Process provisions of these Bylaws shall not be available to the Medical Staff with expedited privileges until they go through full review as outlined in the Medical Staff s policies and procedures and receive appointment or reappointment by the Board of Commissioners. Section 9: Provisional Status The Privileging Committee may recommend a period of provisional status for any category of Medical Staff with the exception of Honorary Medical Staff and the Temporary/Locum Tenens Staff. Provisional status allows a member to practice at the hospital within the confines of training or mentoring, program. Members granted provisional status shall work with the Privileging Committee to create, execute, and document a plan for this additional training within a specified period of time not to exceed 120 days. This period may be extended at the discretion of the Medical Staff. Members holding provisional status are not granted the procedural rights of Due Process as outlined in the Bylaws. Section 10: Release of Information All applicants shall consent to the release of information for any purpose set forth in these Bylaws as long as such release of information is done in good faith and without malice. All applicants also release from liability and agree to hold harmless any person or entity furnishing or releasing such information concerning his application or medical staff status. Members of the Medical Staff and any hospital representatives who are involved in credentialing and privileging activities are immune from liability. Applicants to the Medical Staff shall sign and consent to the release of information and hold harmless agreement in conformance with the purpose of this section. ARTICLE V: CLINICAL PRIVILEGES Every physician or other practitioner practicing at Summit Pacific Medical Center by virtue of Medical Staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges delineated and specifically granted by the Medical Staff and the Board of Commissioners, except as provided in the Rules and Regulations of the Medical Staff dealing with Temporary/Locum Tenens and Emergency Privileges. Said privileges must be within the scope of any license, certificate or other legal credential authorizing him/her to practice in this State and consistent with any restrictions thereon. Section 1: President. ARTICLE VI: OFFICERS OF THE MEDICAL STAFF Summit Pacific Medical Center Staff Bylaws 11 May 2013 Back to Table of Contents

45 Recognizing the small size of the Medical Staff, the Medical Staff organization of Summit Pacific Medical Center cannot include all of the customary subdivisions and departments. One of its members shall be elected every two (2) years as the President of the Medical Staff. He or she shall be responsible to the other members of the Medical Staff and to the hospital Administrator and the Governing Body for the functioning of the clinical organization of the hospital and shall keep, or cause to be kept, careful supervision over the clinical work in all departments. He or she shall be elected to his position by a majority of the Medical Staff. Section 2: Officers. The officers of the Medical Staff shall be the President and Secretary. The officers shall be elected, or re-elected, every two (2) years. These elections shall be held at the last regular Medical Staff meeting of even-numbered years and office will be held from January 1 to December 31. Only members of the Active Medical Staff shall be eligible to vote. Section 3: Hospital Departments. Hospital departments shall consist of the Medical Service, Emergency Service, the Laboratory and the Diagnostic Imaging Department. The Emergency Department shall be headed by a Board Certified Emergency Room Physician, the Laboratory shall be headed by a Certified Pathologist and the Diagnostic Imaging Department shall be headed by a Board Certified radiologist. Section 4: Qualifications of Officers All officers shall be members in good standing of the Active Medical Staff at the time of election and shall remain qualified as members in good standing during their terms of office. Failure to maintain such status shall immediately create a vacancy in the office involved. Section 5: Vacancies in Office Vacancies in office during the Medical Staff Year shall be filled by an election during a regular Medical Staff meeting. Section 6: Removal from Office An officer whose election is subject to these bylaws may be removed from office for valid cause, including, but not limited to, gross neglect or malfeasance in office, or serious acts of moral turpitude. Failure to maintain Active Medical Staff status shall immediately result in removal from office. Removal of any officers of the Medical Staff during their term of office may be initiated by a majority vote of all active Medical Staff members but no such removal shall be effective unless and until it has been ratified by the Board of Commissioners. Summit Pacific Medical Center Staff Bylaws 12 May 2013 Back to Table of Contents

46 Section 7: Duties of Officers a) President: The President shall preside at all regular meetings of the Medical Staff and shall perform all other duties pertaining to this office as defined herein; act in coordination and cooperation with the Administrator in all matters of mutual concern within the Hospital; and represent the views, policies, needs and grievances of the Medical Staff to the Board of Commissioners and to the Administrator. b) Secretary: The Secretary shall keep or arrange the keeping of accurate records of the proceedings of the Medical Staff and shall be custodian of its records, and shall review and sign all minutes of the meetings of the Medical Staff. ARTICLE VII: COMMITTEES OF THE MEDICAL STAFF Section 1: Committee of the Whole The Medical Staff serves as a Committee of the Whole for the purpose of fulfilling Medical Staff committee and function responsibilities unless otherwise stated. Section 2: Quality Improvement Committee The Quality Assurance/Performance Improvement Committee shall consist of an eligible independent member of the Medical Staff as selected by the Active Medical staff, the Emergency Department Director, the Chief Nursing Officer and the Chief Medical Officer who will serve as Chair of the Committee. This committee shall regularly review cases as to potential quality issues involving both provider care, as well as, hospital systems issues as defined in its Charter. Section 3: Pharmacy and Therapeutics Committee The Pharmacy and Therapeutics Committee shall consist of an eligible independent member of the Medical Staff as selected by the Active Medical staff, the Chief Nursing Officer and the Chief Medical Officer who shall serve as Chair of the Committee. The committee shall meet quarterly to comply with Washington State Board of Pharmacy regulations and more often as needs arise, and will review the following items at all meetings: the hospital s formulary for recommended additions and deletions, antibiotic usage, medication errors, and adverse drug reactions as defined in its Charter. Section 4: Privileging Committee The Privileging Committee shall consist of an eligible member of the Medical Staff as selected by the Active Medical staff, the Chief Medical Officer, a representative from the hospital nursing staff, an elected member of the Board of Commissioners and the President of the Medical Staff who shall serve as Chair of the Committee. Members shall serve two year terms and may be reappointed for additional terms. The Administrator shall serve as an ex-officio member. Its primary purpose is to review all initial and re-appointments to Medical Staff and report its findings to the Medical Staff as defined in its Charter. Summit Pacific Medical Center Staff Bylaws 13 May 2013 Back to Table of Contents

47 Section 5: Infection Control Committee The Infection Control Committee shall consist of an eligible member of the Medical Staff as selected by the Active Medical Staff, the Chief Nursing Officer and the Chief Medical Officer who shall serve as Chair of the Committee. The committee shall meet quarterly to comply with Washington State regulations and more often as needs arise, and will review the following items at all meetings: the hospital s infection control policies and programs for recommended additions and deletions as defined in its Charter. Section 6: Additional Committees Additional Medical Staff committees will be appointed by the Medical Staff on an as-needed basis including but not limited to a Provider Health Committee and/or the Appellate Review Committee as defined herein. ARTICLE VIII: STAFF FUNCTIONS Provision shall be made in these bylaws for the effective performance of the staff functions specified in this section and described in the Rules and Regulations and policies and procedures of the Medical Staff and of other staff functions as the Medical Staff and the Board of Commissioners shall reasonably require. These staff functions are: a) Monitor and evaluate care provided at Summit Pacific Medical Center and develop clinical policy relating to continuous quality improvement; b) Conduct or coordinate quality and appropriateness and improvement activities, including invasive procedure, blood usage, drug usage reviews, medical record and other reviews; c) Conduct or coordinate utilization review activities; d) Conduct or coordinate credentials investigations regarding staff membership and grants of clinical privileges and specified services; e) Provide continuing education opportunities responsive to quality assessment/improvement activities; new developments in medicine, and other perceived needs; f) Develop and maintain surveillance over drug utilization policies and practices; g) Investigate and control nosocomial infections and monitor the hospital's infection control program; h) Plan for response to fire and other disasters; Summit Pacific Medical Center Staff Bylaws 14 May 2013 Back to Table of Contents

48 i) Assist in planning for hospital growth and development, and for the provision of services required to meet the needs of the community; j) Coordinate the care provided by members of the Medical Staff with the care provided by the nursing service and with the activities of other hospital patient care services; k) Provide mechanisms which include fair hearing and appeal processes for addressing adverse decisions for applicant regarding medical staff appointment or reappointment and granting of initial or renewed/revised clinical privileges; and l) Engage in other functions reasonably requested by the Medical Staff and the Board of Commissioners. ARTICLE IX: DEFINITIONS PERTAINING TO DUE PROCESS The following definitions apply to the provisions of Due Process. 1) Investigation means a formal process which may or may not at its end result in an adverse action being taken against a member. 2) Peer Review is a Quality Improvement process protected by the rule as outlined in the Revised Code of Washington, specifically RCWs , , and ) Affected Member means the applicant or Member of the Medical Staff against whom an adverse action may or may not be recommended or taken. 4) Special Notice means written notification delivered personally, with written evidence of delivery. 5) Referral back or refer back means the process whereby the Board of Commissioners, or the Appellate Review Committee, requires a body to reconsider its previous recommendation. Any referral back shall state the reasons, set a limit within which a subsequent recommendation must be made, and may include a directive for additional investigation or hearing. 6) Adverse action means a recommendation or action by the Medical Staff, Administrator or Board of Commissioners to reduce, restrict, condition, suspend, revoke, deny, defer, or fail to renew requested clinical privileges. Adverse action shall not mean such a recommendation or action based on the failure to maintain medical records as provided in applicable Rules and Regulations. In the case of a suspension pursuant to these bylaws, adverse action shall mean the action of the Administrator after a recommendation by the Board of Commissioners. ARTICLE X: INITIAL PROCESSES PERTAINING TO DUE PROCESS Summit Pacific Medical Center Staff Bylaws 15 May 2013 Back to Table of Contents

49 Section 1: Initial Complaint The Due Process Procedure is used when a complaint alleges that the conduct or activities of the Member fall below the standards of the Medical Staff, violates Medical Staff bylaws or policies, or disrupts hospital operations. Complaints about a Member come from a variety of sources, including, without limitation, patients and their families. Cases of concern also may come to Quality Improvement Committee from any of the following sources: 1) Information that is collected routinely Hospital-wide, as part of the ongoing monitoring systems. 2) Information that is collected and analyzed as a result of studies specific to a diagnosis, procedure or health professional. 3) Information collected and analyzed as a result of a specific written complaint filed against a health professional related to competence or professional conduct. Section 2: Initial Information A complaint regarding a Member will include the complaint information in written form and other supporting documentation. All pertinent information will be collected by the Chief Medical Officer, including the identity of all involved parties (patients, family members, staff, Members). Section 3: Initial Review The CMO will review each complaint and collect any additional information required to prioritize the complaint within 5 business days of receipt. If the CMO is unavailable, or if the CMO is directly involved in the complaint, the President of the Medical Staff will serve as the initial reviewer. If the complaint is considered egregious, or is identified as a pattern of behavior, the CMO will notify the Medical Staff President, who will jointly determine the appropriate course of action. If there is concern that the Member s practice may result in an imminent danger to the health and/or safety of any individual or to the orderly operations of the Hospital, a Precautionary Suspension may be imposed in accordance with Article XI, Section 1. Section 1: Imposition of Automatic Suspension ARTICLE XI: AUTOMATIC SUSPENSION a) A Member s membership and privilege will be automatically suspended when the following occur: i) Suspension, restriction, probation or revocation of State licensure; ii) Suspension, restriction, probation or revocation of DEA registration certificate; iii) Failure to maintain professional liability insurance required by the Medical Staff Bylaws or Policies iv) Failure to satisfy a request to appear before the Quality Improvement Committee or the Medical Staff as a whole when requested as part of Due Process; Summit Pacific Medical Center Staff Bylaws 16 May 2013 Back to Table of Contents

50 v) Failure to complete medical records in a timely manner; vi) Failure to participate in evaluation of qualifications for medical staff membership and privileges; vii) Criminal conviction or a plea of no contest to a felony or misdemeanor involving a charge of moral turpitude; or viii) Exclusion from participation in the Medicare, Medicaid or other Federal health care programs or being listed on the Office of Inspector General s List of Excluded Individuals/Entities. b) Hearing and appellate review rights do not apply to the imposition of automatic suspension. Notice of the automatic suspension or limitation shall be promptly forwarded to the Privileging Committee, the Chair of the Board of Commissioners, and the appropriate Hospital departments, and to the Member by documented telephone call, , or in writing by courier service, within 24 hours. Section 2: Continuity of Patient Care Immediately upon the imposition of an automatic suspension, the Medical Staff President shall have the responsibility to provide for alternative medical coverage for the patients of the suspended Member still in the Hospital at the time of such suspension. The wishes of the patient and the Member under suspension shall be considered in the selection of such alternative coverage. Section 1: Imposition of Abeyance ARTICLE XII: ABEYANCE OF PRIVILEGES a) Any two (2) of: the President of the Medical Staff, the Chief Medical Officer, or the CEO shall have authority to summarily abey all or any portion of the clinical privileges of a Member whenever failure to take such action may result in an imminent danger to the health and/or safety of any individual, or to the orderly operations of the Hospital. Such an abeyance shall become effective immediately upon imposition. Notice of abeyance of priviliges shall promptly be forwarded to the Medical Staff President, the CMO, the CEO and the Chair of the Board of Commissioners, and shall be directly delivered to the affected Member with written evidence of receipt requested. b) The Member s privileges to attend patients, practice in the Hospital, and participate in Medical Staff affairs are immediately suspended, pending the outcome of an inquiry. If the Member supervises a Provider Extender, that Provider Extender s privileges are also automatically suspended. An abeyance of priviligescannot exceed 5 business days. Such an abeyance shall be deemed an interim precautionary step and is not a complete professional review action in and of itself. It shall not imply any final finding of responsibility for the situation that caused the suspension. Section 2: Continuity of Patient Care Summit Pacific Medical Center Staff Bylaws 17 May 2013 Back to Table of Contents

51 Immediately upon the imposition of an abeyance of priviliges, the Medical Staff President shall have the responsibility to provide for alternative medical coverage for the patients of the suspended Member still in the Hospital at the time of such suspension. The wishes of the patient and the Member under suspension shall be considered in the selection of such alternative coverage. Section 3: Notification of Allegations a) The Member shall be notified in writing by those who imposed the abeyance of the entitlement to an informal meeting with the parties who imposed the abeyance, within 5 business days of imposition. At this informal meeting, the Member will be advised of the specific allegations and be invited to discuss, explain or refute them. This meeting does not constitute a Fair Hearing and the rules pertaining to the Fair Hearing or Appellate Review do not apply. b) Within 2 business days of this meeting, any two (2) of the CMO, Administrator, and President of the Medical Staff may modify, continue, or terminate the terms of the abeyance, and that action will take effect immediately. The Medical Staff President shall promptly notify the Board of Commissioners, with written notice to the Member. Written notice shall be personally delivered to the affected Member with written evidence of receipt requested. c) The Member has the right to full Due Process, and will be notified in writing of his or her rights with a copy of the Due Process procedure. The Medical Staff President will notify Chair of the Board of Commissioners of the actions. d) If the Member fails to request an official notification of allegations within 5 business days of imposition, the Due Process procedure will be continued to the Quality Improvement Committee as outlined in Article XIII. Section 1: Peer Review ARTICLE XIII: PEER REVIEW a) If the complaint is not considered egregious it will be reviewed by the Quality Improvement Committee within 20 business days of the CMO s initial review. The Quality Improvement Committee will have access to all of the information collected by the CMO and may choose to request additional information from the Member. If the Member fails to appear when their presence has been requested without good cause automatic suspension will result in line with Article XI. Summit Pacific Medical Center Staff Bylaws 18 May 2013 Back to Table of Contents

52 b) The Quality Improvement Committee can offer an opinion on the complaint, including dismissal with no further action, or they may choose to open an investigation. A preliminary summary of the review will be presented in writing to the Member. Section 2: Request for Reconsideration Upon receipt of the preliminary summary of the review by the Quality Improvement Committee the Member may choose to meet with the Quality Improvement Committee for reconsideration. The Member must notify the CMO of this intention for reconsideration within 5 business days of receipt of the summary. The Quality Improvement Committee and the Member must meet within 5 business days of the CMO s notification and the Quality Improvement Committee may then choose to finalize their summary as is or modify it. ARTICLE XIV: INVESTIGATION BY THE MEDICAL STAFF AS A WHOLE Section 1: Referral to the Medical Staff as a Whole for Investigation a) The Quality Improvement Committee, the imposers of an abeyance of privilgesor the Member involved in a complaint may refer a complaint to the Whole of the Medical Staff. Any complaints referred to the Medical Staff must be in writing and go through the President of the Medical Staff. The President of the Medical Staff must convene a meeting of the Medical Staff within 10 business days upon receiving the referral to initiate an investigation. One Member designated by the President of the Medical Staff will not attend the meeting in anticipation of appeal as outlined in Article XV. b) The President of the Medical Staff may require the presence of the Member. Failure to appear without good cause will result in automatic suspension in line with Article XI. Notification of the requirement to appear must be documented to have taken place via phone, , or letter at least 5 business days in advance of the meeting. The Member may contact the President of the Medical Staff for more details about the issue. c) The Member shall be informed of the evidence supporting the review requested and shall be invited to discuss, explain or refute it. A written record is maintained in the Member s credentials file reflecting the substance of the interview. If the Member fails or declines to participate in the interview, the appropriate corrective action may be initiated. This meeting need not be conducted according to the procedural rules provided in Articles XV and XVI. After the review is completed, a summary of the conclusions is placed in the Member s credentials file. d) The investigation by the Medical Staff as a Whole must be completed within 20 business days of the initial meeting. Any decisions by the Medical Staff as a Whole shall require agreement by a majority of the Members present. Failure to act within this time or failure to come to a majority agreement will result in a dismissal of the complaint. Section 2: Action by the Medical Staff as a Whole Summit Pacific Medical Center Staff Bylaws 19 May 2013 Back to Table of Contents

53 The Medical Staff as a Whole may issue a dismissal of the complaint; issuance of a warning; a letter of admonition or reprimand; suspension; reduction, restriction, condition, or termination of privileges; suspension or termination of Medical Staff membership; imposition or a requirement that a preceptor be appointed or that the Member secure consultation or assistance; or any other appropriate action. The President of the Medical Staff must notify the Member and the Board of Commissioners in writing within 5 business days of the end of the investigation. Section 3: Special Notice of Adverse Action to Member The President of Medical Staff shall notify the Affected Member in writing via courier service of an adverse recommendation or action taken under Article XIV, Section 2. The notice shall: 1. Notify the Affected Member of the adverse recommendation or action, the reasons therefore, and his or her right to a Fair Hearing with the Board of Commissioners and an Appeal of the Due Process Procedure; 2. Summarize the rights of the Affected Member in the hearing; 3. Specify that the Affected Practitioner has 20 business days after receiving the notice to submit a written request for a hearing to the President of the Medical Staff and to the Board of Commissioners; 4. State that failure to request a hearing within 20 business days will result in loss of rights to any hearing or appellate review related to the notice; 5. State that any higher authority required or permitted under this plan to act on the matter will not be bound by the adverse recommendation or action, but may take any action that it deems warranted by the circumstances; 6. State that upon receipt of the Affected Practitioner s hearing request, the President of the Medical Staff will notify him or her of the date, time and location of the hearing; 7. State that if the Affected Practitioner wishes representation by an attorney, he or she notify the President of the Medical Staff at least 5 days before the hearing; and. 8. Include a complete copy of the Medical Staff Bylaws. Section 4: Request of Waiver of Fair Hearing with the Board of Commissioners a) Request for Hearing - The Affected Member shall have 20 business days after receiving the notice under Section 3 to file a written request for a hearing. The request must be delivered to the President of the Medical Staff and the Chair of the Board of Commissioners either in person or by certified or registered mail. Summit Pacific Medical Center Staff Bylaws 20 May 2013 Back to Table of Contents

54 b) Waiver by Failure to Request a Hearing - An Affected Member who fails to request a hearing within the time and manner specified in Section A will lose his or her right to any hearing or appellate review to which he or she might otherwise have been entitled. The President of the Medical Staff shall promptly send the Affected Member Special Notice of Forfeiture. ARTICLE XV: FAIR HEARING WITH THE BOARD OF COMMISSIONERS Section 1: Special Notice of Fair Hearing with the Board of Commissioners a) Notification of Time, Date, and Location of Fair Hearing - The Chair of the Board of Commissioners shall notify the Member in writing via courier of the date, time and location of the hearing. The date shall not be less than 20 business days nor more than 30 business days after the receipt of the request for a hearing, except when the Affected Member requests an expedited hearing, in which case the hearing shall be held no less than 10 nor more 15 business days after such request. b) Statement of Events, Issues and Witnesses- The Special Notice of hearing from the Chair of the Board of Commissioners also shall include a written notice, prepared by the President of the Medical Staff, which states concisely the reasons for the adverse recommendation or action, including the events that were reviewed, and a list of any medical records in question. The notice of hearing also shall include a list of proposed witnesses, if any, expected to testify at the hearing in support of the adverse recommendation or action. This statement, the proposed witness list, and list of supporting medical records may be amended or added to at any time, even during the hearing, as long as the additional material is relevant to the subject of the adverse action, and as long as the Affected Member and his or her counsel have no less than 2 business days and no more than 7 business days to study this additional information and to prepare any rebuttal. Section 2: Personal Presence a) The hearing shall be conducted within 10 business days of receipt of Fair Hearing request and only in the presence of the President of the Medical Staff, the Chief Medical Officer, the Affected Member, and the entire Board of Commissioners less one member in the event of an appeal as outlined in Article XVI. The Chair of the Board of Commissioners shall preside and shall, with the advice of the Committee, make all necessary rulings. b) The use of a hearing officer to assist with procedural matters at the Hearing is optional and is to be determined by the Chair of the Board of Commissioners. The Chair shall decide whether the hearing officer shall provide advice only or whether he or she shall preside at the hearing. A hearing officer may or may not be an attorney at law, but must be experienced in Summit Pacific Medical Center Staff Bylaws 21 May 2013 Back to Table of Contents

55 conducting hearings. A hearing officer may not vote and may not be a partner, associate, competitor or relative of the Affected Member. c) The personal presence of the Affected Member is required at the hearing. An Affected Member who fails to appear at the hearing, or fails to respond to questions, without good cause, shall lose his or her right to a hearing. Section 3: Representation a) The Affected Member may be accompanied and represented at the hearing by an attorney or may instead choose to be accompanied by another Member in good standing, or a member of the local professional society ( the Washington State Medical Association). The Affected Member must notify the President of the Medical Staff and the Chair of the Board of Commissioners of their representation at least 5 business days prior to the hearing. An attorney accompanying the Affected Member to the hearing may consult with the Member but may not directly speak for the Affected Member during the hearing or cross examine members of the hearing committee. b) If an Affected Member elects to be represented by an attorney, he or she will be solely responsible for payment of all his or her attorney fees no matter which party prevails at the hearing. c) Only if the Affected Member has requested representation by an attorney at the Hearing may the Medical Staff be allowed such representation. The President of the Medical Staff shall then give the Affected Member his or her attorney notice of who will represent the Medical Staff. The foregoing provisions shall not be deemed to deprive the Affected Member, the Medical Staff, or the right to legal counsel in connection with preparation for a hearing or an appellate review. d) In the event that the Affected Member chooses not to be represented by an attorney, the Medical Staff as a Whole shall appoint one of its members or another Member in good standing to represent it at the hearing, to present the events, issues and facts that support its recommendation, and to examine witnesses. Section 4: Rights of Parties a) During the hearing, each party may present written evidence; call, examine, and crossexamine witnesses; and introduce exhibits. Each party may request that the record of the hearing be made using a court reporter or an electronic recorder. If a court reporter is used at the Affected Member s request, it shall be at his or her expense. If the Affected Member does not request a court reporter he or she shall be given a copy of the record upon payment of the actual cost of transcription or duplication. Written evidence must be submitted at least 5 business days before the hearing. If the Affected Member does not testify on his or her own behalf, he or she may be called and examined as though under cross-examination, at the request of the President of the Medical Staff. Summit Pacific Medical Center Staff Bylaws 22 May 2013 Back to Table of Contents

56 b) The Affected Member requesting the hearing shall provide a written list of the names and addresses of the individuals expected to offer testimony or evidence on his or her behalf within10 business days after receiving the notice of hearing. The witness list shall include a brief summary of the nature of the anticipated testimony. The witness list of either party may, at the discretion of the Chair of the Board of Commissioners or Hearing Officer, be amended or added to, provided that notice of changes is given to the other party. The Chair of the Board of Commissioners or Hearing Officer shall have the authority to limit the number of witnesses. Section 5: Procedure and Evidence The hearing need not be conducted according to rules of law relating to the examination of witnesses or presentation of evidence. Any relevant matter upon which responsible persons might customarily rely in the conduct of serious affairs may be considered regardless of the admissibility of such evidence in a court of law. The Board of Commissioners also is entitled to consider all other relevant information that can be considered under the Bylaws in connection with credentials matters. Each party shall be entitled, before the close of the hearing, to submit memoranda concerning any issue of law or fact. Such memoranda shall become part of the hearing record. Oral evidence shall be taken only on oath or affirmation. Section 6: Official Notice In reaching their decision, the Board of Commissioners may take Official Notice, by recognizing the existence and truth of certain facts, without production of evidence, that are relevant to the subject of the hearing and are generally regarded as true. This may include generally accepted scientific or technical matters germane to the hearing. Both parties must be informed of matters to be noticed, and those matters must be documented in the Hearing Record. Any party shall be given opportunity to make a timely request that a matter be officially noticed, and to refute any officially noticed matter by evidence, or by written or oral presentation of authority, as determined by the Board of Commissioners. Section 7: Scope of Review and Burden of Proof The President of the Medical Staff shall have the initial duty to present evidence for each issue the case in support of its recommendation or action. Thereafter, the burden shall shift to the Affected Member to present evidence in response. After all evidence has been presented by both sides the Board of Commissioners shall recommend in favor of the Medical Staff unless it finds that recommendation or action was not supported by substantial evidence, or that the recommendation prompting the hearing was arbitrary or capricious. Section 8: Hearing Record A hearing record must be kept that is sufficient to permit an informed judgment to be made by any group that may be called later to review the record and render a decision or recommendation. The Board of Commissioners may select the method to be used to make the record, such as a court reporter, an electronic recorder, detailed transcription, or minutes of the proceedings. The Summit Pacific Medical Center Staff Bylaws 23 May 2013 Back to Table of Contents

57 hearing record shall contain all exhibits or other documentation considered written statements submitted by the parties, and correspondence between the parties, or between the Board of Commissioners and the parties, if any, during the hearing. The Affected Member shall be provided with a copy of the hearing record, upon payment of the actual cost of transcription or duplication. Section 9: Postponement The Board of Commissioners may in its discretion and for good cause, grant requests for postponing the commencement of the hearing. When an expedited hearing is requested, the hearing may not be postponed more than 5 business days, unless the Affected Practitioner consents, in writing, to a longer postponement. Section 10: Presence of Committee Members Vote The entire Board of Commissioners except the one member as outlined in Article XV, Section 2, must be present throughout the hearing and for all deliberations. All issues shall be decided by majority vote. Section 11: Recesses and Adjournment a) The Board of Commissioners may, without special notice, recess the hearing and reconvene it for the convenience of all parties, or for the purpose of obtaining new or additional evidence or consultation. No combination of recesses shall exceed 10 business days, without written consent from the Affected Practitioner. b) Upon conclusion of the presentation of oral and written evidence, the hearing shall be closed. The Board of Commissioners shall deliberate outside the presence of all parties, and at its own convenience. Upon conclusion of deliberations the hearing shall be adjourned, which shall be no later than 10 business days after the hearing is closed. Section 12: Decision of the Board of Commissioners a) Report by the Board of Commissioners -Within 5 business days after adjournment, the Board of Commissioners shall make a written report, including its recommendations, and shall forward it to the Medical Staff as a Whole for its consideration. This report will include a copy of the hearing record. A copy of the report also shall be sent to the Affected Member by Special Notice. 1) If the decision by the Board of Commissioners is favorable to the Affected Member, it will be considered final; 2) If the Board of Commissioners decision is modified from the action taken by the Medical Staff as a Whole, but remains adverse, or if the decision is in accordance with that of the Summit Pacific Medical Center Staff Bylaws 24 May 2013 Back to Table of Contents

58 Medical Staff as a Whole the Affected Member shall be informed by Special Notice of his or her right to request an Appellate Review. b) Notification of Request for Appeal -The Affected Member must submit a request for Appellate Review, in writing, to the President of the Medical Staff and the Chair of the Board of Commissioners within 10 business days after receipt of the Board of Commissioners decision. If the Affected Member fails to request Appellate Review within 10 business days, he or she will lose that right, and the Board of Commissioners decision will be considered final. ARTICLE XVI: APPELLATE REVIEW Section 1: Initiation and Prerequisites for Appellate Review a) Request for Appellate Review - If after a Fair Hearing the decision of the Board of Commissioners is adverse, an Affected Member shall have 10 business days after receiving Special Notice to file a written request for an appellate review. The request must be delivered to the President of the Medical Staff and the Chair of the Board of Commissioners in person or by certified or registered mail. b) Failure to Request Appellate Review - An Affected Member who fails to request an appellate review within the time and in the manner specified loses any right to an appellate review. c) Notice of Time and Place for Appellate Review- The President of the Medical Staff shall schedule and arrange for an Appellate Review that shall be not less than 15 business days nor more than 25 business days after receipt of the request. At least 10 business days prior to the appellate review, the President of the Medical Staff shall send the Affected Member Special Notice of the time, place and date of the review. The time may be extended by the Appellate Review Committee for good cause and if the request is made as soon as is reasonably practical after discovery of the need for extension. d) Appellate Review Committee- The Appellate Review Committee shall consist of 1 Active Member of the Medical Staff, 1 Member of the Board of Commissioners, and 1 Member of the Hospital administration as appointed by the CEO. No Member of the Appellate Committee shall be a person who has instigated or participated in earlier proceedings in the case. e) Representation at the Appellate Review- If the Affected Member wishes to be represented by an attorney at any appellate review, he or she must so notify the President of the Medical Staff at least 5 business days prior to the Appellate Review. Summit Pacific Medical Center Staff Bylaws 25 May 2013 Back to Table of Contents

59 1) If an Affected Member elects to be represented by an attorney, he or she will be solely responsible for payment of all his or her attorney fees no matter which party prevails at the hearing. 2) Only if the Affected Member has requested representation by an attorney at the Appellate Review may the Medical Staff be allowed such representation. The President of the Medical Staff shall then give the Affected Member his or her attorney notice of who will represent the Medical Staff. Section 2: Appellate Review Procedure and Final Action a) Nature of Proceedings - The proceedings by the Appellate Review Committee are a review based upon Quality Improvement Committee (if applicable), the Medical Staff investigation and recommendations, and the Fair Hearing with the Board of Commissioners. 1) The purpose of appellate review is to review the record of earlier proceedings to determine if the recommendations and the action taken: (1) involve substantial procedural compliance with the Due Process as outlined in the Bylaws; (2) are not arbitrary or capricious. 2) The Appellate Review Committee may make a recommendation different than the recommendation and action appealed from only if the Appellate Review Committee finds that one or more of the requirements in subsection A are not supported by the record. b) Written Statements - The Affected Practitioner may submit a written statement containing objections to the findings, actions, and procedural rulings, together with his or her reasons. This written statement may cover any matters raised at any step in the Due Process procedure. The statement shall be submitted to the Appellate Review Committee and the other parties through the President of the Medical Staff at least 10 business days prior to the scheduled date of the review, except if the review committee waives the time limit. A similar statement may be submitted by the Board of Commissioners, whose adverse action occasioned the review. If submitted, the President of the Medical Staff shall provide a copy to the Affected Member at least 5 business days prior to the scheduled date of the appellate review. c) Chair: The chair of the Appellate Review Committee is the presiding officer and will be selected by the Committee from among its members. He or she determines the order or procedure during the review, makes all required rulings with the advice of the committee, and maintains decorum. d) Consideration of New or Additional Matters: New or additional factual evidence not raised or presented during the original investigation and hearing or in the hearing report and not otherwise reflected in the record will be cause for the Appellate Review Committee Chair to refer the matter back to the Medical Staff for consideration. Summit Pacific Medical Center Staff Bylaws 26 May 2013 Back to Table of Contents

60 1) The party requesting consideration of the new or additional evidence must demonstrate that it could not have anticipated the production of such evidence at an earlier point in the proceedings or it will not be considered. 2) The requesting party shall submit to the Appellate Review Committee Chair a written description of the new or additional evidence as soon as it becomes aware of the evidence, but in no event later than 3 business days prior to the scheduled date of the review. If the Chair determines this evidence is significant and could not have been previously anticipate, he or she shall immediately transmit the description to the Medical Staff President, and shall refer the matter back to the Medical Staff. 3) The Medical Staff may affirm, modify or change their original recommendations. These recommendations will be forwarded to Board of Commissioners within 5 business days of receipt by the Medical Staff. The actions of Board of Commissioners shall, at this point, shall be similar to those taken after the Fair Hearing with the Board of Commissioners. The above reconsideration does not negate the Affected Member s right to appellate review if he or she was entitled to it before the review of new or additional evidence, as defined above. e) Presence of Members and Vote - All members of the Appellate Review Committee must be present throughout the review and deliberations. f) Recesses and Adjournments -At the conclusion of the oral statements, if allowed, the Appellate Review shall be closed. The Committee shall then, at a time convenient to itself, conduct its deliberations outside the presence of the parties. The Appellate Review shall be adjourned at the conclusion of those deliberations. g) Action by Appellate Review Committee -The Appellate Review Committee may recommend that the Board of Commissioners affirm, modify or reverse the adverse result or action, The Committee shall, within 15 business days, forward a report containing its recommendation, the Appellate Hearing Record, and all documentation to the Board of Commissioners. A copy of the report shall be sent to the Affected Member by Special Notice. h) Final Action by Board of Commissioners -Within ten business days after Receipt thereof, the Board of Commissioners shall act upon the Recommendation of the Appellate Review Committee. 1) Members of the Board of Commissioners who voted previously on the same complaint (e.g. Fair Hearing, Appellate Review Committee) may participate in these deliberations. 2) The Board of Commissioners decision shall be immediately effective as the final decision on the matter. There is no appeal of the Board of Commissioners decision. The Board of Commissioners may convene in executive session pursuant to the appropriate statutes for such, without the presence of the Affected Member for deliberations. The Board of Commissioners shall take final action in an open public meeting of which the Affected Summit Pacific Medical Center Staff Bylaws 27 May 2013 Back to Table of Contents

61 member appear to hear the decision. The Board of Commissioners also shall inform the Affected Member of its decision by Special Notice. ARTICLE XVII: REPORTING RESULTS OF DUE PROCESS AND INVESTIGATIONS The chief executive officer of Summit Pacific Medical Center shall report to the Department of Health when the practice of a health care practitioner (MD, DO, ARNP, or PA) is restricted, suspended, limited, or terminated or any voluntary restriction or termination of the practice of a health care practitioner occurs. The report should be made within fifteen (15) days of the date of the action. Summit Pacific Medical Center and the chief executive officer who files a report are immune from suit in any civil action unless it is proven that the report was not made in good faith. Please refer to the Summit Pacific Medical Center Disruptive Provider Policy for more details. ARTICLE XVIII: CONFIDENTIALITY, IMMUNITY AND LIABILITY No representative of the Hospital or Medical Staff shall be liable for damages or other relief for any action, statement or recommendation made within the scope of the person's duties as a representative, if such representative acts in good faith, makes a reasonable effort to ascertain the truthfulness of the facts and reasonably believes that the action, statement, or recommendation is warranted by such facts. No representative of the Hospital, medical Staff, or third party shall be liable for damages or other relief by reason of providing information, including otherwise privileged or confidential information, to a representative of the Hospital, Medical Staff, or other health care facility, or organization of health professionals concerning a practitioner who is or has been an applicant or a member of the staff, or who did nor does exercise clinical privileges or provide specified services at the Hospital, provided that such representative or third party acts in good faith. ARTICLE XIX ADOPTION OF BYLAWS AND/OR BYLAWS AMENDMENTS These Bylaws shall be reviewed by the Medical Staff and Board of Commissioners at least every four (4) years. Adoption of or amendments to these bylaws may be made by: 1) A majority vote of the Medical Staff members and Board of Commissioners who are eligible to vote at any regular meeting of the Medical Staff and the Board, provided that written notice and the text of the Bylaws, or the amendments thereto, have been mailed at least seven (7) days prior to said meeting. 2) Adoption of the Bylaws or amendments shall become effective upon approval by the Board of Commissioners. Summit Pacific Medical Center Staff Bylaws 28 May 2013 Back to Table of Contents

62 3) These bylaws may not be amended unilaterally by the Medical Staff or the Board of Commissioners. 4) Once adopted and approved, all previous Bylaws and any appended policies and procedures shall be considered hereby repealed. ARTICLE XX: RELATED PROTOCOLS AND MANUALS The Medical Staff will recommend to the Board of Commissioners Medical Staff Rules and Regulations which further define the general policies contained in these bylaws. Upon adoption by the Board, these Rules and Regulations will become part of these Medical Staff Bylaws. ADOPTED by the Medical Staff of Summit Pacific Medical Center and approved by the Board of Commissioners on, President, Medical Staff President, Board of Commissioners Grays Harbor County Public Hospital District No. 1 Revised **NOTE: Date of next review: October December 2014 for approval January 2015 Summit Pacific Medical Center Staff Bylaws 29 May 2013 Back to Table of Contents

63 600 E Main Street Elma WA Title: Disruptive Provider Policy Department: Administration Policy #: Pages: 3 Effective Date: 09/12/2012 Revised: 11/2013 Cross Reference Department: Approval: Board Signature CEO Signature Date document scanned into system: CMO Signature Author name/title: John Rodakowski, MD The Medical Staff and Administration of Summit Pacific Medical Center recognize the importance to ensure optimum patient care by promoting a safe, cooperative and professional health care environment, and to prevent or eliminate, to the extent possible, conduct (such as harassment or inappropriate acts) which disrupts the operation of the hospital, affects the ability of hospital employees, or other medical staff members to do their jobs, or interferes with an individual s ability to practice competently. It is the policy of Summit Pacific Medical Center that all individuals within its facilities be treated courteously, respectfully, and with dignity. To that end, Mark Reed requires that all individuals, employees, physicians and other allied health professionals conduct themselves in an appropriately professional and cooperative manner in the facility. If a medical staff member or allied health professional fails to conduct him or herself in an appropriately professional and cooperative manner and is disruptive, the matter shall be addressed in accordance with the following policy. Definition of Disruptive Behavior Disruptive behavior is behavior, which by its nature, inhibits or interferes with the professional activities and interactions of hospital employees and medical staff members. This may include, but is not limited to: 1. Sexual harassment and/or misconduct, assault, fraud, throwing equipment/records, or inappropriate provider behavior. 2. Attacks (verbal or physical) leveled at other members of the medical staff, hospital personnel or patients that are personal or go beyond the bounds of fair professional conduct. 3. Impertinent and inappropriate comments (or illustrations) made in patient medical records or other official documents impugning the quality of care in the hospital, or attacking particular providers, nurses or hospital policies. 4. Non-constructive criticism addressed to its recipient in such a way as to intimidate, undermine confidence, belittle or imply stupidity or incompetence. Reviewed by Date Disruptive Provider Policy Final reviewed by Policy Coordinator Date Page 1 of 3

64 Reporting Any provider, employee, patient or visitor may report disruptive behavior of a provider or allied health professional. 1. The report should be in writing and should include, but not be limited to: (a) The date and time of the alleged disruptive behavior. (b) The name of the patient, employee or other person(s) involved. (c) The circumstances that resulted in the alleged disruptive behavior. (d) An objective description of the alleged disruptive behavior. (e) Remedial steps taken including date, time, place, action(s), and name(s) of those intervening. (f) Name and signature of the person making the report, with time and date of report. 2. The report shall be submitted to the Chief Medical Officer either directly or through the Administration. 3. All reports will be subject to an initial evaluation (not to be construed as a formal investigation) by the Chief Medical Officer and/or designee in consultation with the President of the Medical Staff. 4. If the initial evaluation reveals that it is more likely than not that the policy has not been violated, the complaint shall be dismissed and the individual initiating the report shall be informed. 5. If the initial evaluation reveals that it is more likely than not that the policy has been violated (a confirmed incident), then one of the following action shall be taken: A single confirmed incident of disruptive behavior shall result in either one of the following two actions: (a) An exploratory and remedial discussion between the offending provider and the Chief Medical Officer and the President of the Medical Staff. Documentation of the complaint investigation, including the exploratory and remedial discussion should be placed in the providers re-credentialing file and may be considered in any subsequent medical staff action. OR (b) If the nature of the episode warrants it in the judgment of the Chief Medical Officer and or the President of the Medical Staff, it will be referred to the Quality Improvement Committee for investigation and corrective action according to Article XIII of the Medical Staff Bylaws. A second, or more, confirmed incident of disruptive behavior shall result in either: (c) Direct referral to the Quality Improvement Committee for investigation and corrective action according to Article XIII of the Medical Staff Bylaws, if the nature of the incident warrants it in the judgment of the Chief Medical Officer and or the President of the Medical Staff; OR Reviewed by Date Disruptive Provider Policy Final reviewed by Policy Coordinator Date Page 2 of 3

65 (d) A discussion between the Affected Provider, the Chief Medical Officer, the CEO and the President of the Medical Staff, after which: (i) The results of the discussion shall be reported to the Privileging Committee for information purposes. (ii) The results of the discussion shall be documented by a letter to the Affected Provider and a copy shall be placed in his/her re-credentialing file. (iii) The Affected Provider may submit an explanatory letter or a letter of rebuttal and the letter shall be placed in his/her re-credentialing file. 6. If the Chief Medical Officer and/or President of the Medical Staff find that there are further confirmed incidents of disruptive behavior, then the matter shall be automatically referred for investigation and corrective action according to Articles X through XIV of the Medical Staff Bylaws. 7. Per RCW the chief executive officer of Summit Pacific Medical Center shall report to the Department of Health when the practice of a health care practitioner (MD, DO, ARNP, or PA) is restricted, suspended, limited, or terminated based upon a conviction, determination, or finding by the hospital that the health care practitioner has committed an action defined as unprofessional conduct under RCW The executive officer shall also report any voluntary restriction or termination of the practice of a health care practitioner while the practitioner is under investigation or the subject of a proceeding by the hospital regarding unprofessional conduct, or in return for the hospital not conducting such an investigation or proceeding or not taking action. The report should be made within fifteen (15) days of the date a conviction, determination, or finding is made by the hospital or the voluntary restriction or termination of the practice of a health care practitioner is accepted by the hospital. Summit Pacific Medical Center and the chief executive officer who files a report are immune from suit in any civil action related to the filing or contents of the report, unless the conviction, determination, or finding on which the report and its content are based is proven to not have been made in good faith. Per law, the prevailing party in any action brought alleging the conviction, determination, finding, or report was not made in good faith, shall be entitled to recover the costs of litigation, including reasonable attorneys' fees. Reviewed by Date Disruptive Provider Policy Final reviewed by Policy Coordinator Date Page 3 of 3

66 600 E Main Street Elma WA Title: Impaired Provider Policy Department: Administration Policy #: Pages: 3 Effective Date: 09/12/2012 Revised: 11/2013 Cross Reference Department: Approval: Board Signature CEO Signature Date document scanned into system: CMO Signature Author name/title: John Rodakowski, MD The Medical Staff and Administration of Summit Pacific Medical Center recognize the importance to ensure optimum patient care by promoting a safe, cooperative and professional health care environment, and to prevent or eliminate, to the extent possible, conduct (such as harassment or inappropriate acts) which disrupts the operation of the hospital, affects the ability of hospital employees, or other medical staff members to do their jobs, or interferes with an individual s ability to practice competently. It is the policy of Summit Pacific Medical Center that all individuals within its facilities be treated courteously, respectfully, and with dignity and that health care providers are able to perform their jobs in a safe and competent manor. If a medical staff member or allied health professional fails to conduct him or herself in an appropriately professional manner, the matter shall be addressed in accordance with the following policy. Definition of Impairment Impairment is a functional classification which exists on a dynamic continuum of severity and can change over time rather than being a static phenomenon. Illness by itself does not constitute impairment. When functional impairment exists, it is often the result of an illness (including the illness of addiction) in need of treatment. With appropriate treatment, the issue of potential impairment may be resolved while the diagnosis of illness may remain. Impairment is the inability of a provider or allied health professional to practice medicine with reasonable skill and safety as result of any or all of the following conditions: 1) A mental disorder 2) A physical illness or condition, including but not limited to those illnesses or conditions that would adversely affect cognitive, motor, or perceptive skills 3) Substance-related disorders including abuse and dependency of drugs and alcohol. Goals of the Policy Reviewed by Date Impaired Provider Policy Final reviewed by Policy Coordinator Date Page 1 of 3

67 1. All health care providers engaging in professional practice should refrain from ingesting an amount of alcohol that has the potential to cause impairment of performance or create a hangover effect. They should also not engage in the inappropriate use of mood or mindaltering substances. 2. Reporting to the appropriate Summit Pacific Health Care leadership and the appropriate state agency instances in which a licensed health care provider is impaired and may be providing unsafe treatment. 3. Maintain the confidentiality of any health care provider being investigated or seeking referral or treatment except as limited by applicable law, ethical obligations, or when the health and safety of a patient is immediately threatened. 4. Evaluation of the credibility of a complaint, allegation, or concern. 5. Referral of any health care provider to appropriate professional resources for evaluation, diagnosis and treatment for conditions of concern. 6. Monitoring of the health care provider who is in a rehabilitation program until rehabilitation is complete or periodically thereafter if required Reporting Any provider, employee, patient or visitor may report impaired behavior of a provider or allied health professional. 9. The report should be in writing and should include, but not be limited to: (a) The date and time of the alleged impairment. (b) The name of the patient, employee or other person(s) involved. (c) The circumstances that resulted in the alleged impaired behavior. (d) An objective description of the alleged impaired behavior. (e) Remedial steps taken including date, time, place, action(s), and name(s) of those intervening. (f) Name and signature of the person making the report, with time and date of report. (g) Alternatively, a provider or allied health professional may make a voluntary self report if they feel that they are impaired. 10. The report shall be submitted to the Chief Medical Officer either directly or through the administration. Investigation 11. 1) All reports will be subject to an initial evaluation (not to be construed as a formal investigation) by the Chief Medical Officer and/or designee in consultation with the President of the Medical Staff. 2) If the initial evaluation reveals that it is more likely than not that there is not a problem with impairment, the complaint shall be dismissed and the individual initiating the report shall be informed. 3) If the initial evaluation reveals that it is more likely than not that there is a problem with Reviewed by Date Impaired Provider Policy Final reviewed by Policy Coordinator Date Page 2 of 3

68 impairment, (a confirmed incident), then a formal investigation shall be initiated: (a) Direct referral to the Quality Improvement Committee for investigation and corrective action according to Article XIII of the Medical Staff Bylaws, if the nature of the incident warrants it in the judgment of the Chief Medical Officer and or the President of the Medical Staff; OR (b) A discussion between the Affected Provider, the Chief Medical Officer, the CEO and the President of the Medical Staff, after which: (i) The results of the discussion shall be reported to the Privileging Committee for informational purposes. (ii) The results of the discussion shall be documented by a letter to the Affected Provider and a copy shall be placed in his/her re-credentialing file. (iii) The Affected Provider may submit an explanatory letter or a letter of rebuttal and the letter shall be placed in his/her re-credentialing file. (c) The individual should be referred to Summit Pacific s Physician Assistance Program ( or the Washington Physicians Health Program ( or or Summit Pacific s Employee Assistance Program ( or as appropriate. 4) If the Chief Medical Officer and/or President of the Medical Staff find that there are further confirmed incidents of impaired behavior, then the matter shall be automatically referred for investigation and corrective action according to Articles X through XIV of the Medical Staff Bylaws. 5) This formal process may be initially bypassed in the event that it is determined that a patient s or staff s safety is in immediate danger because a provider is obviously impaired and they should not be practicing at that time. Provisions will be made to cover their work and a formal investigation will be started as soon as is reasonably possible. 6) Per RCW the chief executive officer of Summit Pacific Medical Center shall report to the Department of Health when the practice of a health care practitioner (MD, DO, ARNP, or PA) is restricted, suspended, limited, or terminated based upon a conviction, determination, or finding by the hospital that the health care practitioner has committed an action defined as unprofessional conduct under RCW The executive officer shall also report any voluntary restriction or termination of the practice of a health care practitioner while the practitioner is under investigation or the subject of a proceeding by the hospital regarding unprofessional conduct, or in return for the hospital not conducting such an investigation or proceeding or not taking action. The report should be made within fifteen (15) days of the date a conviction, determination, or finding is made by the hospital or the voluntary restriction or termination of the practice of a health care practitioner is accepted by the hospital. Summit Pacific Medical Center and the chief executive officer who files a report are immune from suit in any civil action related to the filing or contents of the report, unless the conviction, determination, or finding on which the report and its content are based is proven to not have been made in good faith. Per law, the prevailing party in any action brought alleging the conviction, determination, finding, or report was not made in good faith, shall be entitled to recover the costs of litigation, including reasonable attorneys' fees. Reviewed by Date Impaired Provider Policy Final reviewed by Policy Coordinator Date Page 3 of 3

69

70

71