BAPTIST EYE SURGERY CENTER AT SUNRISE MEDICAL STAFF BYLAWS

Transcription

1 1 BAPTIST EYE SURGERY CENTER AT SUNRISE MEDICAL STAFF BYLAWS EFFECTIVE MARCH 28, 2014

2 2 PREAMBLE WHEREAS, Baptist Eye Surgery Center at Sunrise is an ambulatory surgical center owned and operated by Baptist Surgery and Endoscopy Centers, LLC in the State of Florida; and WHEREAS, the purpose of Baptist Eye Surgery Center at Sunrise is to operate as an ambulatory surgical center to provide quality care for eligible patients who are scheduled to undergo procedures which meet the criteria for ambulatory care; and WHEREAS, the Center s Medical Staff is subject to the ultimate authority of the Governing Board of Baptist Eye Surgery Center at Sunrise, who is responsible for the quality and appropriateness of medical care rendered at the Center; and WHEREAS, the cooperative efforts of the Medical Staff and the Governing Board are essential to the fulfillment of the Center s obligations to its patients and owners; and NOW, THEREFORE, the members of the Medical Staff practicing at the Center hereby formally organize themselves as the Center s Medical Staff in accordance with these Bylaws. The signature and approved application of each Medical Staff member serves as their acknowledgement of understanding and agreement to abide by these Medical Staff Bylaws.

3 3 DEFINITIONS As used in these Medical Staff Bylaws, the following terms are defined as follows: ASC/Center: ASC or Center means Baptist Eye Surgery Center at Sunrise. Center Leader: Center Leader means the administrator appointed by the Governing Board to provide for the overall management and supervision of the Center. Clinical Privileges: Clinical Privileges or Privileges mean the permission granted to a Practitioner to render those diagnostic, therapeutic, medical, procedural, or anesthetic services at the ASC for which they have been approved. Fair Hearing and Appeal Policy and Procedure: Fair Hearing and Appeal Policy and Procedure means the Fair Hearing and Appeal Policy and Procedure of the Center. Governing Board: Governing Board or Board means the Governing Board of Baptist Eye Surgery Center at Sunrise with ultimate authority and responsibility for all planning, quality of care and services, direction, control and management for the Center s operations. The Governing Board shall consist of 4 individuals, 2 of whom are appointed by Baptist Ambulatory Services, Inc., and 2 of whom are appointed by Physician Holding, Corp. He/Him/His/Her/She: The term is used as gender-neutral and refers to either a female or male person. Ineligible Person: Ineligible Person means an individual or entity that is currently excluded by the United States Department of Health and Human Services Office of Inspector General (OIG) from participation in Medicare, Medicaid and other federal health care programs. Licensed Independent Practitioner: Licensed Independent Practitioner or LIP means a professional licensed, certified or trained (per law) to perform patient care services under the supervision of a practitioner who has medical staff privileges (unless allowed to practice as an independent practitioner under State law), and includes, without limitation, advanced registered nurse practitioners, certified registered nurse anesthetists and physician assistants. LIP Staff: LIP Staff means all appropriately licensed LIPs, as defined herein, who have been granted membership to the LIP Staff and who have been granted clinical privileges to care for patients in the Center. Medical Director: Medical Director means the physician appointed by Physician Holding, Corp. and approved by the Governing Board who will be responsible for the direction and coordination of all medical aspects of the Center programs and serves as the Medical Director of the Center and President of the Medical Staff.

4 4 Medical Staff: Medical Staff means the formal organization of Practitioners whose credentials are approved and privileges are granted to care for patients at the Center. Practitioner: Practitioner means an individual with M.D. or D.O. degree who is fully licensed to practice medicine, surgery, or osteopathy in the State of Florida. Quality Assessment/Performance Improvement Committee: Quality Assessment/Performance Improvement Committee or QAPI Committee means the committee established by the Governing Board to make recommendations to the Governing Board concerning all quality assessment/performance improvement, clinical risk management, accreditation and regulatory standards compliance, and safety (collectively, QAPI) activities. State: State means the state of Florida.

5 5 ARTICLE I PURPOSES AND RESPONSIBILITIES 1.1 Purposes. The purposes of the Medical Staff shall be: To ensure that all patients admitted to or treated in the Center regardless of race, sex, creed, age, or national origin, receive high quality medical care To ensure a high level of professional performance among the Medical Staff of the Center To assist the Center in satisfying applicable licensure, certification, and accreditation requirements To serve as the primary means for accountability to the Governing Board for the quality and appropriateness of the professional performance and ethical conduct of the Medical Staff To provide an appropriate educational setting which will maintain scientific and clinical standards and that will lead to continuous advancement in professional knowledge and skills. 1.2 Responsibilities. The responsibilities of the Medical Staff shall be: To provide the following: A credentialing process that provides for the appropriate appointment and reappointment of Practitioners and the delineation of clinical privileges and specialized services in accordance with training and experience; Medical Staff participation in the QAPI program, which assures high quality care and safety through established and defined systems; Regular reports and recommendations to the Governing Board concerning the quality and appropriateness of patient care rendered at the Center To provide a means whereby issues concerning the Medical Staff and the Center may be discussed by the Medical Staff with the Governing Board To initiate and maintain self-governance of the Medical Staff To promote the public s confidence in and utilization of services performed by the Medical Staff of the Center.

6 To ensure that Medical Staff members participate in the review and analysis of the clinical work done in the Center, including Medical Staff peer review To ensure that all Licensed Independent Practitioners employed by a member of the Medical Staff shall be credentialed and granted appropriate privileges to provide patient care and will be under the direct authority of the Medical Staff member, who shall at all times be responsible for the actions of the Licensed Independent Practitioner To exercise the authority granted by these Bylaws as necessary to fulfill adequately the foregoing responsibilities. 1.3 Organization. The Medical Staff shall be organized as a group of all Practitioners who have been granted the right to exercise Clinical Privileges within the Center. 1.4 Meetings. The full Medical Staff shall meet at least annually at a time and place to be determined by the President of the Medical Staff, and at other times and places as requested by the President of the Medical Staff, the MEC or the Governing Board. Notice of the annual meeting shall be given to all Medical Staff members via appropriate media and mailed/posted conspicuously at least fourteen (14) days in advance of the meeting. Notice of any other meetings shall be given to all Medical Staff members via appropriate media and mailed/posted conspicuously at least five (5) days in advance of the meeting. No business shall be transacted at any special meeting unless such business is stated in the notice of such meeting. 1.5 Quorum and Voting. A majority of the Medical Staff shall constitute a quorum. Except for amendments to these Bylaws or as otherwise specified in these Bylaws, the Medical Staff shall act upon the vote of a majority of the Medical Staff members at a meeting at which a quorum is present. Notwithstanding the foregoing, if any Medical Staff member has a conflict of interest as determined by a majority of the other disinterested Medical Staff Members, such member shall not be allowed to participate in discussions of the matter for which there is a conflict or be allowed to vote on the matter. In such situations, a quorum shall consist of a majority of the disinterested Medical Staff Members. 1.6 Action Without Meeting. Action may be taken without a meeting by the presentation of the question to each Medical Staff member eligible to vote, in person, via telephone, facsimile, mail and/or electronic mail, and the vote recorded by the Center. The Medical Staff shall act upon the vote of a majority of the Medical Staff members. 1.7 Minutes. Minutes of each regular and special meeting of the Medical Staff or a Medical Staff committee shall be prepared and include a record of attendance of members and the vote on each matter. A file of the minutes of each meeting shall be maintained in accordance with State law. 1.8 Officers.

7 An officer of the Medical Staff must be a member of the Medical Staff and must remain a member in good standing during his term of office Officers shall be appointed by the Governing Board All officers shall serve a term of two (2) years from appointment date. Officers may be re-appointed to additional terms The Medical Staff s officers shall be as follows: A President The President of the Medical Staff shall be the Medical Director. The responsibilities, duties, and authority of the President are as follows: a) Call, preside at, and be responsible for the agenda of all general and special meetings of the Medical Staff in conjunction with the Center Leader. b) Serve as chairperson of the Medical Executive Committee. c) Enforce these Bylaws, Center Rules and Regulations, and applicable Center policies; implement and administer sanctions when indicated; enforce the Medical Staff s compliance with procedural safeguards in all instances when corrective action has been requested or initiated against a member of the Medical Staff. d) Communicate and represent the views, policies, concerns, needs, and grievances of the Medical Staff to the Governing Board. e) Advise the Governing Board on the effectiveness of the quality improvement program and the overall quality of patient care in the Center. f) Perform such other duties as reasonably requested.

8 8 ARTICLE II MEDICAL STAFF MEMBERSHIP AND LIP STAFF MEMBERSHIP 2.1 Nature of Medical Staff Membership. Membership on the Medical Staff and the exercise of clinical privileges at the Center is a privilege and shall be extended only to those Practitioners who continuously meet the qualifications, standards and requirements set forth in these Bylaws. Appointment to and membership on the Medical Staff shall confer on the appointee or member only such clinical privileges as have been granted by the Governing Board. Action may be initiated to terminate the membership of any Medical Staff Member who fails to meet the qualifications, standards and requirements set forth in these Bylaws. Only members of the Medical Staff shall admit or treat patients at the Center. No aspect of Medical Staff membership or particular clinical privileges shall be denied on the basis of age, sex, race, or creed. 2.2 Medical Staff Categories. The Medical Staff shall consist of one category: Active. 2.3 General Qualifications. Membership on the Medical Staff of the Center is a privilege extended only to those Practitioners who, at the time of appointment and continuously thereafter, demonstrate to the satisfaction of the Medical Staff and the Governing Board the following qualifications: Possess a current, valid license issued by the State Possess a current, valid federal and State Drug Enforcement Administration certificate, as applicable Possess a current, valid State pharmacy license, if applicable Document their professional education, training and experience, indicating a continuing ability to provide quality patient care services Are determined by the Medical Executive Committee to demonstrate current professional competence Demonstrate a willingness and capability, based on current attitude and evidence of performance: To work with and relate to other staff members, members of other health disciplines, administration, employees and visitors in a cooperative, professional manner that is conducive to quality patient care; and To adhere to generally recognized standards of professional ethics Have the physical and mental health to exercise the privileges granted.

9 Submit evidence demonstrating to the Governing Board s satisfaction that such practitioner has appropriate credentials, education, training, and experience to support his/her application Intentionally Omitted Provide proof of medical malpractice insurance in the amounts of $250,000/$750,000 unless a different amount is approved by the Governing Board Are not Ineligible Persons as verified by the Center Agree to notify and provide to the Medical Staff immediately any new or updated information that is pertinent to the individuals professional qualifications or any question on the application form, including but not limited to any change in Ineligible Person status, any change in the sanctions imposed or recommended by the United States Department of Health and Human Services or any State or State agency Provide three (3) letters of recommendation from persons who have had extensive experience in observing and working with the applicant and who can provide adequate references pertaining to the applicants professional competence and ethical character Complete all applicable State-required Continuing Medical Education Maintain BLS/ACLS certification for anesthesia providers. 2.4 Basic Responsibilities of Medical Staff Members. Each Medical Staff Member shall: Provide his or her patients with continual care at the generally recognized professional level of quality Abide by the Medical Staff Bylaws, Rules and Regulations, and policies and procedures applicable to the Center, including without limitation the Disruptive Practitioner and Impaired Practitioner policies, applicable legal regulatory requirements and standards, and accreditation standards Ensure the preparation of complete medical record documentation for each patient he or she admits, including a pertinent history and physical examination that shall be performed within 30 days, or shorter time period if required by federal or State law, before or concurrent with the admission of the patient, and the completion of all records within 30 days, or shorter time period if required by federal or State law, following discharge. If records remain incomplete 30 days following discharge, the

10 10 Medical Director will be notified and disciplinary action may be undertaken at the discretion of the MEC Ensure that a surgical operation or procedure is only performed with the written informed consent of the patient or his/her legal representative, except in an emergency Ensure that all surgical specimens removed during an operation or procedure are sent for pathology in accordance with Center policy Ensure that patients are discharged only upon the written order of the attending physician Ensure that prudence in judgment is exercised in the selection of patients appropriate for the outpatient facility Work with and relate to other staff members, members of other health disciplines, administration, employees and visitors in a cooperative, professional manner that is conducive to quality patient care Adhere to generally recognized standards of professional ethics Actively participate in the quality assessment and performance improvement activities of the Center. 2.5 Prerogatives of Medical Staff Members. The Members of the Medical Staff shall enjoy the following prerogatives: Admit and attend to patients in the Center as provided in the Center s Medical Staff Bylaws, Rules and Regulations and policies and procedures applicable to the Center Exercise only such delineated privileges granted by the Governing Board Attend and vote on matters at Medical Staff meetings (as provided for herein) Serve as a member of a Medical Staff committee (as provided for herein). 2.6 Duration of Appointment. All appointments and reappointments to the Medical Staff shall be for a period not to exceed two (2) years. Appointment to the Medical Staff shall confer to the appointee only such privileges as may hereinafter be provided. 2.7 The LIP Staff. The LIP Staff shall consist of individuals retained by Medical Staff members who are granted privileges to provide services to patients at the Center.

11 Eligibility for LIP Membership. Membership on the LIP Staff is a privilege which can be extended only to professionally competent LIPs regardless of sex, race, color, creed or national origin, who meet the qualifications, standards and requirements set forth in these Medical Staff Bylaws Qualifications for LIP Membership. A. Only LIPs who can document their background, experience, training and competence, their adherence to the ethics of their profession, their good reputation, and their ability to work with others, with sufficient adequacy to assure the Center of the LIP s clinical competence shall be eligible for membership on the LIP Staff. LIPs must have and maintain sponsorship and supervision by a member of the Medical Staff. No LIP shall be entitled to membership on the LIP Staff or to exercise particular clinical privileges in the Center, merely by virtue of the fact that he or she: (i) has a supervision agreement with a Medical Staff member; (ii) is duly licensed in Florida or any other state; (iii) that he or she is a member of any professional organization; or (iv) that he or she had in the past, or presently has such privileges at another institution. B. LIPs shall not: 1. Perform any duty without the sponsoring member of the Medical Staff s supervision; 2. Make any diagnosis independent of the supervising Medical Staff member; 3. Independently prescribe any medications; 4. Replace the supervising Medical Staff member at any time during the performance of an operation; or 5. Exercise privileges not granted, or perform services in violation of State or federal laws. C. Acceptance of membership on the LIP Staff constitutes the LIP Staff member's agreement that he or she will strictly abide by the applicable professional association and all nationally accepted quality standards, these Medical Staff Bylaws, the Rules and Regulations, and policies and procedures applicable to the Center Duration and Conditions of LIP Appointment.

12 12 A. All individuals interested in obtaining membership on the Medical Staff of the Center or obtaining membership on the LIP Staff of the Center shall follow the application process described in Article III of these Medical Staff Bylaws. B. Initial appointments and reappointments to the Medical Staff or the LIP Staff shall be made by the Governing Board upon the recommendation of the MEC. C. Initial appointments shall be for a period of not more than two (2) years. Reappointments shall be made for a period of not more than two (2) years. D. Appointment to the Medical Staff or the LIP Staff shall confer on the appointee only such clinical privileges as have been granted by the Governing Board in accordance with these Medical Staff Bylaws. E. The following requirements shall be applicable to every applicant as a condition of consideration of such application, and as a condition of continued Medical Staff appointment or LIP Staff appointment, if granted: 1. to refrain from delegating responsibility for diagnoses or care of any patient to any LIP who is not qualified to undertake this responsibility or who is not adequately supervised; 2. to refrain from deceiving patients, overtly or through omission, as to the type of procedure being performed, the identity of an operating surgeon or any other individual providing treatment or services; 3. to seek consultation whenever necessary; 4. to promptly notify the Center Leader, or his or her designee, of any change in eligibility for payments by any governmental health insurer, or for participation in Medicare or Medicaid, including any sanctions imposed or recommended by the federal Department of Health and Human Services and/or the receipt of a letter concerning alleged quality problems in patient care or the commencement of a quality of care investigation by the Department of Professional Regulation, any other state or federal agency, or by a quality committee of facility that he/she maintains privileges and/or practices; 5. to promptly notify the Center Leader, or his or her designee, of any and all changes to the information provided in the initial application for appointment, or the application for reappointment during the course of the appointment or reappointment term;

13 13 6. to abide by generally recognized ethical principles applicable to the applicant s profession; 7. to abide by ethical principles of corporate and fiduciary responsibility while putting the patient s needs and best interest first; 8. to complete, in a timely manner, the medical and other required records for all patients as required by these Medical Staff Bylaws, Rules and Regulations, and any other applicable policies and procedures of the Center; and 9. to participate in continuing medical education programs for the benefit of applicant and for the benefit of other professionals and personnel LIP Prerogatives and Responsibilities. The LIP Prerogatives are as follows: (a) Provide health care services at the Center consistent with the limitations for the LIP s Clinical Privileges and in accordance with these Bylaws, any other applicable policies and procedures of the Center or any other applicable rules and regulations of the Center, and, if applicable, under the supervision or direction of a Medical Staff Member. (b) Serve on Medical Staff and Center committees to the extent assigned thereto, except that LIP s shall not be eligible to serve on the MEC. (c) Attend meetings of the Medical Staff and education programs when requested to do so The responsibilities of an LIP are as follows: (a) Be responsible within the LIP s area of professional competence for the care and supervision of each patient in the Center for whom the LIP is providing services or arrange for a suitable alternative for such care and supervision. (b) Active participation in QAPI activities and other quality improvement and peer review activities required of the Medical Staff. (c) Satisfy the requirements for attendance at meetings of the Medical Staff which the LIP is requested to attend or committees of which the LIP is a member.

14 14 ARTICLE III PROCEDURE FOR PRACTITIONER APPOINTMENT AND REAPPOINTMENT 3.1 General Procedures. All applicants for initial appointment to the Medical Staff or LIP Staff must meet all administrative criteria of the Center, as established by and may be amended from time to time by the Governing Board, before such application shall be reviewed and considered by the Center. Unless a special circumstance exists, any applicant who fails to meet all of the administrative criteria shall be given notification that he or she failed to meet one or more of the criteria, and shall not have his or her application reviewed or considered by the Center. Any applicant denied based on the fact that he or she failed to meet the administrative criteria shall not have a right to request a fair hearing or appeal or have any other rights as set forth in these Bylaws. Individuals seeking appointment and reappointment have the burden of producing information adequate for a proper evaluation of current competence, character, ethics, and other qualifications and for resolving any doubts. Individuals seeking appointment and reappointment have the burden of providing evidence that all the statements made and information given on the application are accurate. An application will 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 will 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. 3.2 Application for Appointment All applications for appointment to the Medical Staff or the LIP Staff must be in writing, must be signed by the applicant, and must be submitted on a form prescribed by the MEC and approved by the Governing Board. The form shall require detailed information concerning the applicant's professional qualifications, and must include three (3) letters of reference from Practitioners personally acquainted with the applicant s professional and clinical performance, either in teaching facilities or other organizations who have had extensive experience in observing and working with the applicant, and can provide adequate references pertaining to the applicant's professional competence and ethical character. At least one (1) reference letter must come from a Practitioner in the applicant s specialty that is not in practice with the applicant or related to the applicant. The application shall also include information as to whether the applicant's membership status or clinical privileges have ever been revoked, suspended, reduced or not renewed by any health care facility, as to whether the applicant s membership in local, state, regional or national medical societies or his or her license to practice in any profession in any jurisdiction has ever been suspended or revoked. The application must disclose whether the applicant has ever been arrested for, charged with, indicted or convicted of any crime. The applicant must be able to account for all years of professional practice and must justify and explain all gaps or

15 15 non-continuous periods on the applicant s curriculum vitae (CV). The application must also include consent by the applicant to the release of information from present and past malpractice carriers The applicant shall certify his or her ability to perform requested privileges including certifying that no health problems exist that could affect his or her ability to perform his or her clinical privileges. By applying for appointment to the Medical Staff or LIP Staff, each applicant understands and agrees that he/she may be required to undergo an appropriate medical or psychological examination or evaluation to confirm the applicant s ability to perform the requested privileges By applying for appointment to the Medical Staff or the LIP Staff, each applicant thereby agrees to appear for interviews in regard to the application, authorizes the Center and its Medical Staff to consult with members of the medical staff(s) of other institutions with which the applicant has been associated and others who may have information bearing on his or her professional competence, character, and ethical qualifications. The applicant consents to the Center's inspection of all records and documents that may be material to an evaluation of his or her professional qualifications and the competence to carry out the clinical privileges, including review of his or her professional, moral and ethical qualifications for Medical Staff or LIP Staff membership. The applicant releases from any liability all representatives of the Center, the Governing Board, and its Medical Staff, for their acts performed in good faith in connection with evaluating the applicant, and releases from any liability all individuals and organizations who provide information to the Center, and its Medical Staff in good faith concerning the applicant's professional competence, ethics, character and other professional qualifications for Medical Staff or LIP Staff appointment and clinical privileges, including otherwise privileged or confidential information If there is any misstatement in, or omission from, the application, the Center may stop processing the application (or, if appointment has been granted prior to the discovery of a misstatement or omission, appointment and privileges may be deemed to be automatically relinquished). In either situation, there will be no entitlement to a hearing or appeal The application form shall include a statement that the applicant has received the Medical Staff Bylaws and the Rules and Regulations and that he or she agrees to be bound by the terms thereof. 3.3 Sponsorship and Supervision of LIP Staff Sponsorship: The individual applying for membership to the LIP Staff must submit with his or her application a letter from the sponsoring Medical Staff member stating:

16 16 1. that the LIP applicant is currently, or will be, employed or retained by the Medical Staff member and will be performing only those services requested on the privileges delineation form submitted with the application and under the Medical Staff member s orders and supervision; 2. that the Medical Staff member recommends the LIP applicant s appointment; 3. that the Medical Staff member agrees to oversee the LIP applicant s clinical services at the Center; 4. that the Medical Staff member agrees he or she will be responsible for any acts or omissions to act by the LIP applicant; and 5. that the Medical Staff member agrees and understands that if his/her clinical privileges expire and are not renewed or are terminated, the LIP Staff members clinical privileges shall contemporaneously expire or terminate, unless he/she is able to secure another sponsoring Medical Staff member and file all necessary collaborative agreements/protocols with the State (to the extent applicable). The LIP applicant shall meet the supervision requirements set forth in State law; and shall include a copy of his or her current collaborative agreement and protocol filed with the State (to the extent applicable) together with the letter of sponsorship Enforcement. If an LIP violates the Medical Staff Bylaws, Rules and Regulations, policies or procedures of the Center, the Medical Staff member may be subject to withdrawal of his or her authority to utilize an LIP and both the LIP and his or her sponsoring Medical Staff member may have his or her privileges to the Center revoked. 3.4 Application Action by the Credentials Committee: An application shall be submitted to the credentialing office only after it has been verified that (i) the applicant meets all administrative criteria of the Center, and (ii) the application is completed. The credentialing office shall review the applications and shall forward all completed applications to the Credentials Committee. The Credentials Committee shall consider all completed applications. The Credentials Committee shall examine the evidence of the character, professional competence, qualifications, and ethical standing of the applicant. Specifically, the Credentials Committee shall review the following:

17 17 1. Current licensure. Current licensure verified with the primary source by a letter or secure electronic communication obtained from the appropriate state licensing board; 2. Relevant education, training or experience. Relevant education, training, or experience, verified with the primary source(s) whenever feasible. Verification shall include letters from professional schools, internships, residency, or postdoctoral programs. Designated equivalent sources or other reliable secondary sources may be used provided the Center's credentialing office documents its attempt to contact the primary source; 3. Current competence. Current competence verified by reviewing the applicant s letters of recommendation and in the case of an LIP applicant, the sponsoring Medical Staff member s letter of sponsorship and supervision agreement; 4. Health Status. Ability to perform requested privileges verified by confirming the applicant s statement that no health problems exist that could affect his or her ability to exercise clinical privileges in accordance with the standard of care for such privileges; 5. The National Practitioner Data Bank ( NPDB ). The NPDB is queried in a timely manner and before finalizing appointments and granting initial privileges; and 6. Criminal Background Verification. The applicant's criminal background shall be verified to determine whether the applicant has been charged, indicted or convicted of any crime. The Credentials Committee, MEC and/or Governing Board may personally interview the applicant, if deemed appropriate. The Credentials Committee shall prepare a report of its recommendation regarding appointment and clinical privileges as soon as possible to be presented to the MEC as to whether the applicant shall be: (a) appointed to the Medical Staff or LIP Staff with the requested clinical privileges; (b) not be appointed to the Medical Staff or the LIP Staff; (c) appointed with a modified delineation of privileges; or (d) defer action on the recommendation and request additional information regarding the applicant. Any recommendations for acceptance shall include the specific delineation of privileges for the applicant Action by the MEC. The MEC shall review the recommendations of the Credentials Committee, and any other relevant information. The MEC shall prepare a report of its recommendation regarding appointment and clinical privileges as soon as possible to be presented to the Governing Board as to whether the applicant shall be:

18 18 (a) appointed to the Medical Staff or LIP Staff with the requested clinical privileges; (b) not be appointed to the Medical Staff or the LIP Staff; (c) appointed with a modified delineation of privileges; or (d) defer action on the recommendation and request additional information regarding the applicant Action by the Governing Board: If the Governing Board approves the applicant s application and clinical privileges, upon receipt of the recommendation of the MEC, the Governing Board shall, with respect to each applicant, record its approval or disapproval of each applicant or defer action and request additional information from the applicant, the MEC, or the Credentials Committee who reviewed the applicant s application. The Governing Board shall notify the applicant in writing of its decision. The applicant has the right to appeal a denial by the Governing Board of appointment to the Medical Staff or the LIP Staff or the denial of any requested clinical privileges in accordance with these Medical Staff Bylaws and the Fair Hearing and Appeal Policy and Procedure; provided that in no event is the applicant entitled to more than one (1) fair hearing arising out of an application for appointment or additional clinical privileges. 3.5 Term of Appointment. All new appointments and reappointments to the Medical Staff and LIP Staff shall be for a period not to exceed two (2) years. 3.6 Reappointment Medical Staff members and LIP Staff members must complete a reappointment application prior to the expiration of clinical privileges. A reasonable time prior to the expiration of privileges, the Credentials Committee shall review and evaluate the Medical Staff or LIP Staff member s reappointment application and all other information relevant to his or her clinical competency. At that time the Credential Committee shall conduct a reappraisal for all Medical Staff members and LIP Staff members. The reappraisal shall address current competency and shall include the following: 1. Confirmation of adherence to organization policies and procedures, rules, and regulations; 2. Review of any relevant information from organization performance improvement activities when evaluating professional performance, judgment, and clinical or technical skills; 3. Review of any results of peer review of the Medical Staff member s or the LIP Staff member s clinical performance; 4. Review of any clinical performance in the organization that is outside acceptable standards;

19 19 5. Review of any relevant education, training, and experience, if changed since initial privileging and appointment; 6. Verification of current licensure, including all action against the license; 7. Confirmation that no health problems exist that could affect the Medical Staff or LIP Staff member's ability to perform the care, treatment, and services under the clinical privileges granted. To confirm health status, the Medical Staff member or LIP Staff member may be requested to submit to a mental and physical evaluation by a physician. 8. Review of any reported restrictions on privileges at the Center or other health care organization(s); and 9. A query of the NPBD for information. Specific consideration shall be given to each Medical Staff member or LIP Staff member with respect to: 1. Record of attendance at Medical Staff and/or committee meetings; 2. Professional competency and clinical judgment in the treatment of his or her patients based upon the parameters established by the Medical Staff; 3. Documented evidence of continuing education; 4. Professional ethical conduct and professional behavior; 5. Compliance with the Medical Staff Bylaws, the Rules and Regulations and policies and procedures applicable to the Center The Credentials Committee shall make a recommendation to the MEC to: (i) reappoint the Medical Staff member or the LIP Staff member and grant the requested privileges; (ii) deny Medical Staff or the LIP Staff member s request for reappointment; or (iii) reappoint Medical Staff member or the LIP Staff member with modified clinical privileges. These recommendations shall be in writing The MEC shall make a recommendation to the Governing Board to: (i) reappoint the Medical Staff member or the LIP Staff member and grant the requested privileges; (ii) deny Medical Staff or the LIP Staff member s request for reappointment; or (iii) reappoint Medical Staff member or the LIP Staff member with modified clinical privileges. These recommendations shall be in writing.

20 The Governing Board shall approve or deny the recommendations of the MEC. These recommendations shall be in writing Where denial of reappointment or a change in clinical privileges is recommended, the reason for such recommendation shall be stated and documented. The Medical Staff member or the LIP Staff member has the right to appeal a denial of reappointment or a modification of requested clinical privileges in accordance with these Medical Staff Bylaws and the Fair Hearing and Appeal Policy and Procedure.

21 21 ARTICLE IV DELINEATION OF PRIVILEGES 4.1 Application for Clinical/Additional Privileges. Every Practitioner or LIP practicing at the Center by virtue of Medical Staff and LIP Staff membership shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically recommended by the Credentials Committee, and approved by the MEC and the Governing Board. Application for additional privileges shall be made in writing and is to contain documentation of the applicant's relevant recent training and/or experience (to the extent applicable). Such applications will be processed in the same manner as applications for initial appointment. Periodic evaluation of clinical privileges may be based upon direct observation of care provided, review of the records of the patients treated in this and other institutions, and/or review of the records of the Medical Staff or the LIP Staff, which document the evaluation of the Medical Staff or LIP Staff member s participation in the delivery of medical care. 4.2 Malpractice Claims. A Practitioner s or LIP s history of malpractice verdicts and the settlement of malpractice claims, as well as pending claims, will be evaluated. However, the mere presence of verdicts, settlements or claims may not, in and of themselves, be sufficient to deny appointment or particular clinical privileges. The evaluation shall consider the extent to which verdicts, settlements or claims evidence a pattern of care that raises questions concerning the Practitioner or LIP's clinical competence, or whether a verdict, settlement or claim in and of itself, represents such deviation from standard medical practice as to raise overall questions regarding the Practitioner or LIP's clinical competence or skill in particular clinical privilege, or general behavior. 4.3 Non Discrimination Policy. No Practitioner or LIP shall be denied permission to practice at the Center on the basis of sex, race, creed, religion, color or national origin, or on the basis of any criteria unrelated to professional qualifications or to the Center s purposes, needs and capabilities. 4.4 Fair Hearing and Appeal Process. Any recommendation for reduction, suspension or revocation of clinical privileges by the Governing Board, if a fair hearing right has not already been triggered, shall entitle the affected Medical Staff member or LIP Staff member to the rights set forth in the Fair Hearing and Appeal Policy and Procedure. 4.5 Temporary Privileges. The President of the Medical Staff, in consultation with the Center Leader, may grant temporary privileges as needed, including circumstances such as: (i) in an emergency to fulfill an important patient care treatment and service need; (ii) when an initial applicant with a complete, clean application has been approved by the MEC chairperson and the Credentials Committee, and is awaiting review and approval of the MEC and Governing Board; or (iii) for appropriately qualified persons to serve as locum tenens for a Medical Staff member or LIP Staff member.

22 In the case of reappointments, prior to granting temporary privileges, the MEC or its duly appointed committee, shall review the Medical Staff member's or the LIP Staff member's current licensure, current competence and conduct a NPDB query. All temporary privileges shall be granted in writing for one-hundred twenty (120) days or until patient care needs subside, whichever occurs first To grant temporary privileges for new applicants, the applicant must provide, and the MEC or its duly appointed committee shall verify, the following: 1. current licensure; 2. relevant education, training or experience; 3. current competence; 4. ability to perform the privileges requested; 5. that the applicant is not under investigation at any other ambulatory surgical center or hospital; 6. that the applicant has not been charged, indicted or convicted of a crime; 7. conduct a criminal background check of the applicant; 8. obtain and evaluate the results of the NPDB query; 9. a complete application; 10. no current or previous successful challenge to licensure or registration; 11. shall have not been subject to involuntary termination of professional or medical staff membership at another organization; 12. shall have not been subject to involuntary limitation, denial, or loss of privileges; and 13. shall not have been charged, indicted or convicted of a crime; and 14. any other criteria required by policies and procedures, rules or regulations The MEC shall make a written recommendation to the Governing Board of whether permanent privileges shall be granted. If the MEC recommends appointment of the applicant, the MEC shall make a written recommendation to the President of the

23 23 Medical Staff and Center Leader or his or her designee of whether temporary privileges may be granted until of the Governing Board meets to review the applicant s application and confirm the MEC s recommendation for appointment. All temporary privileges shall be granted in writing for one-hundred and twenty (120) days or until patient care needs subside, whichever occurs first Temporary privileges may be granted to an appropriately qualified Practitioner serving as locum tenens for a Member of the Medical Staff if the Practitioner satisfies the requirements of The granting of such clinical privileges hereunder shall not entitle any locum tenens Practitioners to admit or attend his own patients Termination of Temporary Privileges. The President of Medical Staff or Governing Board may at any time upon reasonable notice under the circumstances and for any reason terminate any or all temporary privileges granted. The termination of temporary privileges shall not give rise to a right to a fair hearing or appeal. 4.6 Intentionally Blank. 4.7 Disaster Privileges Granting of Disaster Privileges. If the Center s Emergency Management Plan has been activated, the Medical Director and such other individuals that the Medical Director designate, may grant disaster privileges to provide patient care to selected Practitioners consistent with medical licensing and other relevant State statutes and provided that the Practitioner presents a valid photo identification issued by a state or federal agency, such as a driver s license or passport, and at least one of the following: Current health care organization photo identification card Current medical license Identification certifying the Practitioner is a licensed independent practitioner indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT) or other recognized state or federal organization or group Identification indicating that the Practitioner is a licensed independent practitioner who has been granted authority by a federal, state, or municipal entity to administer patient care in emergencies Presentation by a current Center Medical Staff member who has personal knowledge regarding the volunteer s identity and ability to act as a Practitioner during a disaster. As soon as feasible while a Practitioner is practicing under disaster privileges after the granting of disaster privileges unless the Center

24 24 documents its inability to do so, the Center will seek to verify the practitioner s current license and current competency in the same manner as for individuals granted temporary privileges, which shall be by primary source Supervision of Practitioner Granted Disaster Privileges. A Practitioner granted disaster privileges will be required to practice under the supervision of a designated Member of the Medical Staff whose privileges at a minimum include the disaster privileges granted to the Practitioner Termination of Disaster Privileges. After a determination has been made pursuant to the Center s Emergency Management Plan that the immediate situation requiring the granting of disaster privileges has passed, the Practitioner s disaster privileges will terminate immediately. Any individual identified in the Center s Emergency Management Plan with the authority to grant disaster privileges also shall have the sole authority and discretion to terminate disaster privileges. The termination of disaster privileges shall not give rise to a right to a fair hearing or appeal.

25 25 The Medical Staff shall be organized as follows: ARTICLE V MEDICAL STAFF ORGANIZATION A. The Medical Staff shall be organized under written policies and procedures relating to certain staff privileges, anesthesia, functioning standards, staffing patterns, and quality management of the surgical suite. B. The Center shall provide within the institution or through arrangements with an outside agency, a clinical laboratory to provide those services commensurate with the Center's services and which conform to law. C. The Center may have in place, or may in the future enter into, contracts with individuals, partnerships, or corporations for the performance of certain clinical services. In the event the Governing Board grants the exclusive right to provide certain clinical services to a practitioner or a group of practitioners, no other individual may be granted or may exercise clinical privileges at the Center to provide those services. When deemed appropriate, the MEC and the Governing Board, by their joint action, may create new, eliminate, subdivide, further subdivide or combine departments.

26 26 ARTICLE VI PEER REVIEW PROCEDURES FOR QUESTIONS INVOLVING MEDICAL STAFF MEMBERS AND LIP STAFF MEMBERS 6.1 Collegial Intervention. These Medical Staff Bylaws encourage the use of progressive steps by Medical Staff leaders and administration, beginning with collegial and educational efforts, to address questions relating to an individual's clinical practice and/or professional conduct. The goal of these efforts is to arrive at voluntary, responsive actions by the individual to resolve questions that have been raised. Collegial efforts may include, but are not limited to, counseling, sharing of comparative data, monitoring, and additional training or education. All collegial intervention efforts by Medical Staff leaders and administration are part of the Center s performance improvement and professional and peer review activities. The relevant Medical Staff leader(s) will determine whether it is appropriate to include documentation of collegial intervention efforts in an individual s confidential file. If documentation of collegial efforts is included in an individual s file, the individual will have an opportunity to review it and respond in writing. The response will be maintained in that individual s file along with the original documentation. Collegial intervention efforts are encouraged, but are not mandatory, and will be within the discretion of the appropriate Medical Staff leaders and administration. The President of the Medical Staff, in conjunction with the Center Leader, will determine whether to direct that a matter be handled in accordance with another Center policy, or to direct it to the MEC for further determination. 6.2 Initial Review of Questions. Whenever a serious question has been raised, or where collegial efforts have not resolved an issue, regarding: (a) the clinical competence or clinical practice of any member of the Medical Staff, including the care, treatment or management of a patient or patients; (b) the known or suspected violation by any Medical Staff member of applicable ethical standards or the Bylaws, policies, Rules and Regulations; or (c) conduct by any member of the Medical Staff that is considered lower than the standards of the Center or disruptive to the orderly operation of the Center or its Medical Staff, including the inability of the member to work harmoniously with others, the matter may be referred to the President of the Medical Staff or the Center Leader, who will make sufficient inquiry to satisfy himself or herself that the question raised is credible and, if so, will forward it in writing to the MEC. No action taken pursuant to this Section will constitute an investigation. 6.3 Initiation of Investigation When a question involving clinical competence or professional conduct is referred to, or raised by, the MEC, the MEC will review the matter and determine whether to conduct an investigation or to direct the matter to be handled pursuant to another policy, or to proceed in another manner. In making this determination, the MEC or its designee may discuss the matter with the individual. An investigation will begin only after a formal determination by the MEC to do so.