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NEW LONDON FAMILY MEDICAL CENTER MEDICAL STAFF BYLAWS

NEW LONDON FAMILY MEDICAL CENTER MEDICAL STAFF …/media/ThedaCare Internet Files/04 Hospitals and Clinics...NEW LONDON FAMILY MEDICAL CENTER MEDICAL STAFF BYLAWS ... The Medical Staff

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Page 1: NEW LONDON FAMILY MEDICAL CENTER MEDICAL STAFF …/media/ThedaCare Internet Files/04 Hospitals and Clinics...NEW LONDON FAMILY MEDICAL CENTER MEDICAL STAFF BYLAWS ... The Medical Staff

NEW LONDON FAMILY MEDICAL CENTER

MEDICAL STAFF BYLAWS

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BYLAWS OF THE MEDICAL STAFF OF

NEW LONDON FAMILY MEDICAL CENTER

TABLE OF CONTENTS

Page

ARTICLE I PURPOSES OF THE BYLAWS.............................................................................1 ARTICLE II DEFINITIONS........................................................................................................2 ARTICLE III NAME ....................................................................................................................4 ARTICLE IV MEDICAL STAFF MEMBERSHIP ........................................................................4

4.1. NATURE OF MEMBERSHIP ........................................................................................... 4 4.1.1 QUALIFICATIONS FOR MEMBERSHIP ............................................................... 4 4.1.2 EFFECT OF OTHER AFFILIATIONS...................................................................... 6 4.1.3 NONDISCRIMINATION........................................................................................... 6

4.2. GENERAL RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP .................... 6 4.3. HARASSMENT PROHIBITED......................................................................................... 7 4.4. DIVISION OF FEES PROHIBITED.................................................................................. 8

ARTICLE V CATEGORIES OF MEMBERSHIP..........................................................................8 5.1. CATEGORIES.................................................................................................................... 8 5.2. ACTIVE MEDICAL STAFF.............................................................................................. 8

5.2.1 QUALIFICATIONS ................................................................................................... 8 5.2.2 PREROGATIVES....................................................................................................... 9 5.2.3 RESPONSIBILITIES ................................................................................................. 9

5.3. ASSOCIATE MEDICAL STAFF ...................................................................................... 9 5.3.1 QUALIFICATIONS ................................................................................................... 9 5.3.2 PREROGATIVES..................................................................................................... 10 5.3.3 RESPONSIBILITIES ............................................................................................... 10

5.4. COURTESY MEDICAL STAFF ..................................................................................... 11 5.4.1 QUALIFICATIONS ................................................................................................. 11 5.4.2 PREROGATIVES..................................................................................................... 11 5.4.3 RESPONSIBILITIES ............................................................................................... 12

5.5. CONSULTING MEDICAL STAFF................................................................................. 12 5.5.1 QUALIFICATIONS ................................................................................................. 12 5.5.2 PREROGATIVES..................................................................................................... 12 5.5.3 RESPONSIBILITIES ............................................................................................... 13

5.6. HONORARY MEDICAL STAFF.................................................................................... 13 5.6.1 QUALIFICATIONS ................................................................................................. 13 5.6.2 PREROGATIVES..................................................................................................... 13 5.6.3 RESPONSIBILITIES ............................................................................................... 13

5.7. LIMITATION OF PREROGATIVES.............................................................................. 14 5.8. WAIVER OF QUALIFICATIONS .................................................................................. 14 5.9. MODIFICATION OF MEMBERSHIP CATEGORY ..................................................... 14

ARTICLE VI -PROCEDURES FOR CREDENTIALING ..........................................................14 6.1. GENERAL PROCEDURE ............................................................................................... 14 6.2. APPLICATION ................................................................................................................ 15

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6.2.1 FORM ....................................................................................................................... 15 6.2.2 CONTENT................................................................................................................ 15

6.3. EFFECT OF APPLICATION........................................................................................... 16 6.4. PROCESSING THE APPLICATION .............................................................................. 17

6.4.1 APPLICANT’S BURDEN........................................................................................ 17 6.4.2 VERIFICATION AND EVALUATION OF APPLICATION................................. 17

6.5. CREDENTIALS COMMITTEE ACTION ...................................................................... 17 6.6. EFFECT OF MEDICAL EXECUTIVE COMMITTEE ACTION .................................. 18 6.7. BOARD ACTION ............................................................................................................ 19

6.7.1 FAVORABLE RECOMMENDATION ................................................................... 19 6.7.2 ADVERSE RECOMMENDATION......................................................................... 19 6.7.3 NOTICE OF FINAL DECISION ............................................................................. 20 6.7.4 DENIAL FOR HOSPITAL’S INABILITY TO ACCOMMODATE....................... 20 6.7.5 REAPPLICATION AFTER ADVERSE APPOINTMENT DECISION ................. 21

6.8. TIMELY PROCESSING OF APPLICATIONS .............................................................. 21 6.9. REAPPOINTMENT AND REQUESTS FOR MODIFICATION OF APPOINTMENT STATUS OR CLINICAL PRIVILEGES ......................................................................... 21

6.9.1 APPLICATION: ....................................................................................................... 21 6.9.2 EFFECT OF APPLICATION................................................................................... 22 6.9.3 STANDARDS AND PROCEDURE FOR REVIEW............................................... 22 6.9.4 BASIS FOR RECOMMENDATIONS..................................................................... 22 6.9.5 TIME PERIODS FOR PROCESSING..................................................................... 22 6.9.6 FAILURE TO FILE REAPPOINTMENT APPLICATION .................................... 23

6.10. LEAVE OF ABSENCE................................................................................................ 23 6.10.1 LEAVE STATUS ..................................................................................................... 23 6.10.2 TERMINATION OF LEAVE................................................................................... 23 6.10.3 FAILURE TO REQUEST REINSTATEMENT ...................................................... 24

ARTICLE VII MEDICAL STAFF APPOINTMENT, REAPPOINTMENT, AND REQUEST FOR MODIFICATION OF STAFF APPOINTMENT ................................................................24

7.1. GENERAL PROCEDURE ............................................................................................... 24 7.2. DURATION OF APPOINTMENT .................................................................................. 24

7.2.1 INITIAL APPOINTMENT AND MODIFICATIONS OF MEDICAL STAFF APPOINTMENT ....................................................................................................... 24 7.2.2 REAPPOINTMENTS ............................................................................................... 24

7.3. PROCTORING REQUIREMENT ................................................................................... 25 7.3.1 FOR INITIAL APPOINTMENTS............................................................................ 25 7.3.2 FOR MODIFICATIONS OF APPOINTMENT STATUS....................................... 25 7.3.3 TERM OF PROCTORING PERIOD ....................................................................... 25

7.4. REQUESTS FOR MODIFICATION OF APPOINTMENT STATUS............................ 25 ARTICLE VIII DETERMINATION OF CLINICAL PRIVILEGES...........................................25

8.1. EXERCISE OF CLINICAL PRIVILEGES...................................................................... 25 8.2. DELINEATION OF PRIVILEGES IN GENERAL......................................................... 26

8.2.1 REQUESTS .............................................................................................................. 26

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8.2.2 BASIS FOR CLINICAL PRIVILEGES DETERMINATION................................. 26 8.2.3 PROCEDURES FOR APPLYING FOR CLINICAL PRIVILEGES AND FOR RENEWAL OF CLINICAL PRIVILEGES ............................................................. 26 8.2.4 REQUESTS FOR MODIFICATION OF CLINICAL PRIVILEGES...................... 26 8.2.5 DURATION OF CLINICAL PRIVILEGES ............................................................ 27 8.2.6 FINAL AUTHORITY .............................................................................................. 27

8.3. PROCTORING REQUIREMENT ................................................................................... 27 8.3.1 INITIAL GRANTING OF CLINICAL PRIVILEGES ............................................ 27 8.3.2 MODIFICATION OF CLINICAL PRIVILEGES.................................................... 27 8.3.3 TERM OF PROCTORING PERIOD ....................................................................... 27

8.4. SPECIAL CONDITIONS FOR DENTAL AND PODIATRIC PRIVILEGES ............... 27 8.5. TEMPORARY PRIVILEGES.......................................................................................... 28

8.5.1 CIRCUMSTANCES ................................................................................................. 28 8.5.2 CONDITIONS .......................................................................................................... 29 8.5.3 TERMINATION....................................................................................................... 29 8.5.4 RIGHTS OF THE PRACTITIONER WITH TEMPORARY PRIVILEGES .......... 29

8.6. EMERGENCY PRIVILEGES.......................................................................................... 29 ARTICLE IX CORRECTIVE ACTION...................................................................................30

9.1. ROUTINE CORRECTIVE ACTION............................................................................... 30 9.1.1 CRITERIA FOR INITIATION................................................................................. 30 9.1.2 REQUESTS AND NOTICES................................................................................... 30 9.1.3 INVESTIGATION.................................................................................................... 30 9.1.4 MEC ACTION.......................................................................................................... 31 9.1.5 DEFERRAL.............................................................................................................. 31 9.1.6 PROCEDURAL RIGHTS ........................................................................................ 31 9.1.7 OTHER ACTION ..................................................................................................... 31

9.2. SUMMARY SUSPENSION............................................................................................. 32 9.2.1 CRITERIA FOR INITIATION................................................................................. 32 9.2.2 MEC ACTION.......................................................................................................... 32 9.2.3 PROCEDURAL RIGHTS ........................................................................................ 33 9.2.4 OTHER ACTION ..................................................................................................... 33

9.3. AUTOMATIC SUSPENSION ......................................................................................... 33 9.3.1 LICENSE .................................................................................................................. 33 9.3.2 BUREAU OF NARCOTICS AND DANGEROUS DRUGS (BNDD) NUMBER . 33 9.3.3 MEC DELIBERATION............................................................................................ 34 9.3.4 FAILURE TO SATISFY SPECIAL ATTENDANCE REQUIREMENT ............... 34 9.3.5 MEDICAL RECORDS............................................................................................. 34 9.3.6 NOTICE.................................................................................................................... 34

ARTICLE X INTERVIEWS, HEARINGS AND APPELLATE REVIEW .................................34 10.1. INTERVIEWS.............................................................................................................. 34 10.2. HEARINGS AND APPELLATE REVIEW................................................................. 35

10.2.1 ADVERSE MEC RECOMMENDATION ............................................................... 35 10.2.2 ADVERSE BOARD ACTION ................................................................................. 35

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10.2.3 ADVERSE ACTIONS OR RECOMMENDED ACTIONS DEFINED .................. 35 10.2.4 PROCEDURE AND PROCESS............................................................................... 36 10.2.5 EXCEPTIONS .......................................................................................................... 36

10.3. REMOVAL FROM OFFICE OF MEDICO-ADMINISTRATIVE OFFICER............ 37 ARTICLE XI ALLIED HEALTH PROFESSIONALS ................................................................37

11.1. DEFINITIONS.............................................................................................................. 37 11.2. QUALIFICATIONS ..................................................................................................... 38 11.3. CATEGORIES OF AHPS ELIGIBLE TO APPLY FOR SCOPE OF PRACTICE..... 38 11.4. PROCEDURE FOR GRANTING SCOPE OF PRACTICE ........................................ 38 11.5. PREROGATIVES ........................................................................................................ 39 11.6. RESPONSIBILITIES ................................................................................................... 40 11.7. CORRECTIVE ACTION, FAIR HEARING AND APPEAL PROCEDURES .......... 40

ARTICLE XII OFFICERS .........................................................................................................40 12.1. OFFICERS OF THE MEDICAL STAFF..................................................................... 40

12.1.1 IDENTIFICATION................................................................................................... 40 12.1.2 DUTIES OF OFFICERS........................................................................................... 40 12.1.3 PRESIDENT ............................................................................................................. 41 12.1.4 VICE PRESIDENT................................................................................................... 41 12.1.5 SECRETARY-TREASURER................................................................................... 42 12.1.6 QUALIFICATIONS ................................................................................................. 42 12.1.7 NOMINATIONS ...................................................................................................... 43 12.1.8 ELECTION ............................................................................................................... 43 12.1.9 TERM OF ELECTED OFFICE................................................................................ 44 12.1.10 REMOVAL OF ELECTED OFFICERS .............................................................. 44 12.1.11 VACANCIES IN ELECTED OFFICE................................................................. 44

12.1.12....OFFICER STIPEND............................................................................................. 44 ARTICLE XIII DEPARTMENTS AND ADVISORS..............................................................45

13.1. FORMATION, MERGER, OR ELIMINATION OF DEPARTMENTS..................... 45 13.2. DEPARTMENT ADVISORS....................................................................................... 45

ARTICLE XIV COMMITTEES AND FUNCTIONS..............................................................46 14.1. DESIGNATION AND SUBSTITUTION.................................................................... 47 14.2. MEDICAL EXECUTIVE COMMITTEE.................................................................... 47

14.2.1 COMPOSITION ....................................................................................................... 47 14.2.2 DUTIES .................................................................................................................... 48 14.2.3 MEETINGS .............................................................................................................. 50

14.3. STAFF FUNCTIONS................................................................................................... 50 14.4. DESCRIPTION OF FUNCTIONS............................................................................... 51

14.4.1 QUALITY ASSESSMENT AND IMPROVEMENT FUNCTION ......................... 51 14.4.2 UTILIZATION REVIEW FUNCTION ................................................................... 52 14.4.3 CREDENTIALS FUNCTION .................................................................................. 53 14.4.4 PEER REVIEW FUNCTION ................................................................................... 54 14.4.5 PHYSICIAN EVALUATION FUNCTION ............................................................. 54 14.4.6 CONTINUING MEDICAL EDUCATION FUNCTION......................................... 54

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14.4.7 MEDICAL RECORDS FUNCTION........................................................................ 55 14.4.8 PHARMACY AND THERAPEUTICS FUNCTION .............................................. 56 14.4.9 INFECTION CONTROL FUNCTION .................................................................... 57 14.4.10 NOMINATING FUNCTION ............................................................................... 58

14.5. PARTICIPATION OF INTERDISCIPLINARY HOSPITAL COMMITTEES .......... 58 14.6. COMMITTEES OF THE STAFF................................................................................. 58

14.6.1 COMPOSITION AND APPOINTMENT ................................................................ 58 14.6.2 TERM AND PRIOR REMOVAL ............................................................................ 58 14.6.3 VACANCIES............................................................................................................ 59 14.6.4 MEETINGS .............................................................................................................. 59

ARTICLE XV MEETINGS ........................................................................................................59 15.1. MEETINGS .................................................................................................................. 59

15.1.1 ANNUAL MEETINGS ............................................................................................ 59 15.1.2 REGULAR MEETINGS .......................................................................................... 59 15.1.3 ORDER OF BUSINESS AND AGENDA ............................................................... 59 15.1.4 SPECIAL MEETINGS ............................................................................................. 60

15.2. COMMITTEE AND DEPARTMENT MEETINGS.................................................... 60 15.2.1 REGULAR MEETINGS .......................................................................................... 60 15.2.2 SPECIAL MEETINGS ............................................................................................. 60

15.3. NOTICE OF MEETINGS ............................................................................................ 61 15.4. QUORUM..................................................................................................................... 61

15.4.1 REGULAR STAFF MEETINGS ............................................................................. 61 15.4.2 DEPARTMENT AND COMMITTEE MEETINGS ................................................ 61

15.5. MANNER OF ACTION............................................................................................... 61 15.6. MINUTES..................................................................................................................... 61 15.7. ATTENDANCE REQUIREMENTS............................................................................ 61

15.7.1 REGULAR ATTENDANCE.................................................................................... 62 15.7.2 ABSENCE FROM MEETINGS............................................................................... 62 15.7.3 SPECIAL ATTENDANCE ...................................................................................... 62

ARTICLE XVI CONFIDENTIALITY, IMMUNITY AND RELEASES ..............................62 16.1. SPECIAL DEFINITIONS ............................................................................................ 62 16.2. AUTHORIZATIONS AND CONDITIONS ................................................................ 63 16.3. CONFIDENTIALITY OF INFORMATION ............................................................... 64

16.3.1 GENERAL................................................................................................................ 64 16.4. BREACH OF CONFIDENTIALITY ........................................................................... 64 16.5. IMMUNITY FROM LIABILITY ................................................................................ 64

16.5.1 FOR ACTION TAKEN ............................................................................................ 64 16.5.2 FOR PROVIDING INFORMATION....................................................................... 65

16.6. ACTIVITIES AND INFORMATION COVERED...................................................... 65 16.6.1 ACTIVITIES............................................................................................................. 65 16.6.2 INFORMATION....................................................................................................... 65

16.7. RELEASES................................................................................................................... 66 16.8. INDEMNIFICATION .................................................................................................. 66

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16.9. CUMULATIVE EFFECT............................................................................................. 66

ARTICLE XVII GENERAL PROVISIONS.............................................................................66 17.1. FORMS......................................................................................................................... 66 17.2. TRANSMITTAL OF REPORTS.................................................................................. 66 17.3. BOARD ACTION ........................................................................................................ 67

ARTICLE XVIII ADOPTION AND AMENDMENT OF MEDICAL STAFF BYLAWS, RULES, REGULATIONS, AND POLICIES .......................................................................67

18.1. BYLAWS...................................................................................................................... 67 18.2. RULES AND REGULATIONS ................................................................................... 67 18.3. EXCLUSIVITY............................................................................................................ 68 18.4. MEDICAL STAFF POLICIES..................................................................................... 68 18.5. SUCCESSOR IN INTEREST/AFFILIATIONS .......................................................... 68

18.5.1 SUCCESSOR IN INTEREST................................................................................... 68 18.5.2 AFFILIATIONS ....................................................................................................... 68

18.6. CONSTRUCTION OF TERMS AND HEADINGS.................................................... 68

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A I

NEW LONDON FAMILY MEDICAL CENTER MEDICAL STAFF BYLAWS

RTICLE PURPOSES OF THE BYLAWS

The Medical Staff of New London Family Medical Center [“Hospital”] is responsible for the

overall quality of clinical services provided in the Hospital and for the ethical and professional practices of its members, and must accept and discharge this responsibility subject to the ultimate authority of the Hospital Board of Directors [“Board”].1 In recognition of its responsibilities to promote quality and to improve the quality of care delivered in the Hospital, the Medical Staff of the Hospital organizes itself for the purpose of self-governance in accordance with these Bylaws.2 These Bylaws provide the professional and legal structure for Medical Staff operations as well as the relationship of the organized Medical Staff with the Board and with Medical Staff members and applicants.3 These Bylaws are intended to be binding on the Hospital, the Medical Staff, its members, Medical Staff applicants, and others holding or requesting clinical privileges in the Hospital.4

1 Wis.Adm.Code H.F.S. § 124.12(2)(a) (“The medical staff shall be responsible to the governing body of the hospital for the quality of all medical care provided patients in the hospital and for the ethical and professional practices of its members.”); JCAHO Standard MS.1.10 (“The hospital has an organized, self-governing medical staff that provides oversight of care, treatment, and services provided by practitioners with privileges, provides for a uniform quality of patient care, treatment, and services, and reports to and is accountable to the governing body.”).

The Medicare Conditions of Participation (“Medicare COPs”) require that the Medical Staff be accountable to the governing body, i.e., the Board, for the quality of medical care provided to patients. 42 C.F.R. § 482.22(b).

2 Bass v. Ambrosius, 185 Wis.2d 879, 520 N.W.2d 625 (Wis.App. 1994) (In order for the bylaws to constitute a contract between the hospital and its medical staff, the bylaws must state that they govern the medical staff.); Wis.Adm.Code H.F.S. § 124.12(2)(a) (“The hospital shall have a medical staff organized under by-laws approved by the governing body.”); JCAHO Standard MS.1.10 (“The hospital has an organized, self-governing medical staff that provides oversight of care, treatment, and services provided by practitioners with privileges, provides for a uniform quality of patient care, treatment, and services, and reports to and is accountable to the governing body.”).

3 Wis.Adm.Code H.F.S. § 124.12(5)(b)(1) (“Medical staff by-laws … shall include a descriptive outline of medical staff organization; … .”); JCAHO Standard MS.1.20 (“Medical staff bylaws address self-governance and accountability to the governing body.”).

4 Bass v. Ambrosius, supra (In order for the bylaws to constitute a contract between the hospital and its medical staff, the hospital must comply with the bylaws; to hold otherwise would be to render them meaningless.); JCAHO Standard MS.1.20 (“Medical staff bylaws address self-governance and accountability to the governing body.”); JCAHO Standard 1.30 (“Neither the organized medical staff nor the governing body may unilaterally amend the medical staff bylaws or rules and regulations.”).

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A I

RTICLE IDEFINITIONS

1. “ACT” means the Health Care Quality Improvement Act of 1986 as amended from time to

time.

2. “BOARD OF DIRECTORS” or “BOARD” means the governing body of the corporation which has the overall responsibility for the conduct of the Medical Staff. The Board is a “professional review body” as such term is defined in the Act.5

3. “CAREGIVER BACKGROUND CHECK LAW” means Section 50.065 of the Wisconsin Statutes as amended from time to time and any state regulations thereunder.

4. “CHIEF EXECUTIVE OFFICER” (“CEO”) means the individual appointed by the Board to act on its behalf in the overall management of the Hospital.

5. “CHIEF OF STAFF” means the chief officer of the Medical Staff elected by members of the Medical Staff; same as the Medical Staff President.

6. “CLINICAL PRIVILEGES” or “PRIVILEGES” means the permission granted to a Practitioner to render specific diagnostic, therapeutic, medical, dental or surgical services.

7. “CRIMINAL CONVICTION” shall include conviction of, or a plea of guilty or nolo contendere for any felony, or any misdemeanor related to the practice of a health care profession, federal health care program fraud or abuse, third-party reimbursement, or controlled substances.

8. “EX OFFICIO” means service as a member of a body by virtue of an office or position held and, unless otherwise expressly provided, means with voting rights.

9. “FEDERAL HEALTH CARE PROGRAM” means Medicare, Medicaid or any other federal or state program providing health benefits which is funded directly or indirectly by the U.S. government.

10. “HOSPITAL” means New London Family Medical Center of New London, Wisconsin. It is the corporate entity which is governed by the Board in accordance with its Articles of Incorporation and Bylaws.

11. “INVESTIGATION” means a process specifically instigated by the MEC to determine the validity, if any, of a concern or complaint raised against a Medical Staff member or individual holding clinical privileges.

5 The Act provides that the governing board of a health care entity is deemed a “professional review body” if it conducts “professional review activity.” Under the NLFMC Medical Staff Bylaws and the Plan, the Board conducts “professional review activity” and, therefore, constitutes a “professional review body” for purposes of the Act. 42 U.S.C. § 11151(11).

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12. “IN GOOD STANDING” means a member of the Medical Staff is currently not under suspension or serving with any limitation of voting or other prerogatives imposed by operation of the Bylaws, Rules and Regulations, or policies of the Medical Staff.

13. “MAJORITY” means a number greater than half of the total.

14. “MEDICAL EXECUTIVE COMMITTEE” or “MEC” means the executive committee of the Medical Staff. The MEC is a “professional review body” as such term is defined in the Act.

15. “MEDICAL STAFF” or “STAFF” means all physicians and dentists who are privileged to attend patients in the Hospital.6 The Medical Staff and the committees through which it acts are each a “professional review body” as such term is defined in the Act.

16. “MEDICAL STAFF PRESIDENT” means the chief officer of the Medical Staff elected by members of the Medical Staff; same as the Chief of Staff.

17. “MEDICAL STAFF YEAR” means the period from January 1 to December 31.

18. “MEDICO-ADMINISTRATIVE OFFICER” means a Practitioner, employed by or otherwise serving the Hospital on a full or part time basis, whose duties include certain responsibilities which are both administrative and clinical in nature. Clinical responsibilities are defined as those involving professional capability as a Practitioner, such as to require the exercise of clinical judgment with respect to patient care and include the supervision of professional activities of Practitioners under his direction.

19. “PHYSICIAN” means an individual with an M.D. or D.O. degree.7

20. “PRACTITIONER” means, unless otherwise expressly limited, any physician, dentist, or podiatrist applying for or exercising clinical privileges in this Hospital.

21. “RULES AND REGULATIONS” or “RULES” refer to the Rules and Regulations of the Medical Staff as adopted by the Medical Staff and approved by the Board, or specific Rules and Regulations adopted by the department and sections and approved by the Executive Committee.

22. “SPECIAL NOTICE” means written notification sent by certified or registered mail, return receipt requested.

23. “HE,” “HIS” and “HIM,” wherever used in these Bylaws, shall refer equally to both sexes. The captions or headings are for convenience only and are not intended to limit or define the scope or effect of any provision of these Bylaws.

6 The Medicare COPs require that the Medical Staff be composed of doctors of medicine or osteopathy, and other practitioners, if permitted, under state law. 42 C.F.R. § 482.22(a).

7 The Medicare COPs require that the Medical Staff be composed of doctors of medicine or osteopathy, and other practitioners, if permitted, under state law. 42 C.F.R. § 482.22(a).

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ARTICLE III

A

NAME The name of this organization is the Medical Staff of New London Family Medical Center.

RTICLE IV

MEDICAL STAFF MEMBERSHIP8 4.1. NATURE OF MEMBERSHIP

Membership on the Medical Staff or the exercise of temporary privileges shall be extended only to Practitioners who continuously meet the qualifications, standards, and requirements set forth in these Bylaws.9 No Practitioner, including an individual in a medical administrative position by virtue of a contract or employment with the Hospital, can admit or provide services to patients in the Hospital unless the Practitioner is a member of the Medical Staff or has been granted temporary privileges in accordance with the procedures set forth in 8.5 and 8.6 of these Bylaws.10 Membership on the Medical Staff confers only such clinical privileges and prerogatives as have been granted in accordance with these Bylaws and the letter of appointment.11

4.1.1 QUALIFICATIONS FOR MEMBERSHIP12

Only Practitioners who meet the following general qualifications are eligible for membership on the Medical Staff: (a) Document their (1) current licensure to practice their profession in the State of

Wisconsin; (2) education, training, and experience; (3) current professional competence and judgment; (4) individual character; and (5) current physical and mental health status (i.e., ability to perform the privileges requested),13 so as to

8 JCAHO Standard MS.1.20 (“Medical staff bylaws address self-governance and accountability to the governing body.”); JCAHO Standard MS.1.20, Elements of Performance 3 (“The medical staff bylaws define the criteria and qualifications for appointment to the medical staff.”).

9 Bass v. Ambrosius, supra (In order for the bylaws to constitute a contract between the hospital and its medical staff, the medical staff is required to continuously meet the qualifications, standards, and requirements set forth in the bylaws.).

10 All medical staff mechanisms apply to contracted or employed staff (i.e., in order to treat patients, a Practitioner must be a member of the medical staff with delineated clinical privileges).

11 Bass v. Ambrosius, supra (In order for the bylaws to constitute a contract between the hospital and its medical staff, an appointment to the medical staff must confer only those privileges provided by the letter of appointment and the bylaws.).

12 The Medicare COPs require that the Bylaws describe the qualifications to be met by the candidate in order to be appointed to the medical staff. 42 C.F.R. § 482.22(c)(4).

13 A Practitioner’s current ability to perform the privileges requested must be evaluated as part of the credentialing process. The Americans with Disabilities Act [ADA], 42 U.S.C. § 12101 et seq., however, prohibits certain types of

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demonstrate to the satisfaction of the Medical Staff that they are professionally and ethically competent, that patients treated by them can expect to receive quality medical care,14 and that they are able to provide a service needed within the Hospital; and

(b) Are determined, on the basis of documented references, (1) to adhere to the ethics of their respective professions; (2) to be able to work cooperatively with others so as not to adversely affect patient care;15 (3) to maintain the confidentiality of all information or records received in the physician-patient relationship and as otherwise required by law; and (4) to be willing to participate in, and properly discharge, all Medical Staff responsibilities; and

(c) Complete a background disclosure form as required by the Caregiver Background Check Law; and

(d) Maintain in force professional liability insurance in not less than the minimum amounts, if any, as from time to time may be jointly determined by the Board and MEC. The MEC, for good cause shown, may waive this requirement with regard to such member as long as such waiver is not granted or withheld on an arbitrary, capricious, or discriminatory basis. In determining whether an individual exception is appropriate, the following may be considered:

(i) Whether the member has applied for the requisite insurance;

(ii) Whether the member has been refused insurance and, if so, the reasons for such refusal; and

(iii) Whether insurance is reasonably available to the member and, if not, the reasons for its unavailability.

discrimination based on physical or mental impairment, and may affect how and when a hospital may ascertain and confirm a Practitioner’s ability to perform the privileges requested. Due to the developing and, therefore, unsettled area of law under the ADA as it applies to the relationship between the medical staff and the hospital, inquiry into the health status of an applicant or member prior to an offer of medical staff membership or reappointment is not recommended. The hospital can reserve, on the membership or reappointment application form and elsewhere, the right to condition an offer of membership or reappointment on the submission of reasonable evidence concerning an applicant or member’s physical and mental health as it relates to his or her current ability to perform the practices for which privileges are requested.

14 Wis.Adm.Code H.F.S. § 124.12(4)(c)(1) (“Criteria for appointment shall include individual character, competence, training, experience, and judgment.”); JCAHO Standard MS.4.10 (“The organized medical staff has a credentialing process that is defined in the bylaws.”); JCAHO Standard MS.4.20 (“There is a process for granting, renewing, or revising setting-specific clinical privileges.”); JCAHO Standard MS.4.40 (“At the time of renewal of privileges, the organized medical staff evaluates individuals for their continued ability to provide quality care, treatment, and services for the privileges requested as defined in the medical staff bylaws.”).

15 The ability to work cooperatively is a relevant qualification only to the extent that patient care may be adversely affected.

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(e) From and after the date of this amendment to the bylaws, June 27, 2006 (Hospital Governing Board ratification date), each physician who has not previously held medical staff privileges at New London Family Medical Center, who initially applies for clinical privileges, hereof must be: (i) Board certified, or (ii) eligible or qualified for Board certification at the time of initial appointment and must become Board certified in his/her practice area or related field, as approved by MEC, within five (5) years after the initial request for clinical privileges is approved by the Hospital Governing Board.

4.1.2 EFFECT OF OTHER AFFILIATIONS

No Practitioner shall be entitled to membership on the Medical Staff or to exercise clinical privileges merely because that individual is licensed to practice in this or in any other state, is certified by any clinical board, is a member of any professional organization, or because that individual had, or presently has, Medical Staff membership or privileges at another health care facility or in another practice setting.

4.1.3 NONDISCRIMINATION16

No aspect of Medical Staff membership or particular clinical privileges shall be denied on the basis of sex, race, age, creed, color, national origin, disability, sexual orientation, or any other bases protected by law.

4.2. GENERAL RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP

With certain exceptions delineated in Article V for the courtesy, consulting, and honorary staff, the ongoing responsibilities of each member of the Medical Staff include:

(a) Providing patients with the quality of care meeting the professional standards of the Medical Staff of this Hospital;

(b) Abiding by the Medical Staff Bylaws, Medical Staff Rules and Regulations, and policies and standards of the Medical Staff and the Hospital;

(c) Discharging in a responsible and cooperative manner such reasonable responsibilities and assignments imposed upon the member by virtue of Medical Staff membership, including committee assignment;

(d) Preparing and completing in a timely fashion the medical and other required records for all the patients whom the member admits or, in any way, provides care for, in the Hospital;

(e) Abiding by the ethical principles of the member’s profession;

16 JCAHO Standard LD.1.30 (“The hospital complies with applicable law and regulation.”).

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(f) Working cooperatively with members, nurses, hospital administration, and others so as not to adversely affect patient care;

(g) Making appropriate arrangements for coverage of that member’s patients as determined by the Medical Staff;

(h) Refusing to engage in improper inducements for patient referral;

(i) Participating in continuing education programs as determined by the Medical Staff;

(j) Participating in such emergency service coverage or consultation as may be determined by the Medical Staff; and

(k) Discharging such other Medical Staff obligations as may be lawfully established from time to time by the Medical Staff or MEC.

4.3. HARASSMENT PROHIBITED

Harassment by a Medical Staff member against any individual (i.e., against another Medical Staff member, house staff, hospital employee, or patient) on the basis of race, religion, color, national origin, ancestry, physical disability, mental disability, medical disability, marital status, gender, or sexual orientation shall not be tolerated.

Sexual harassment includes unwelcome advances, requests for sexual favors, and any other verbal, visual, or physical conduct of a sexual nature when (1) submission to or rejection of this conduct by an individual is used as a factor in decisions affecting hiring, evaluation, retention, promotion, or other aspects of employment; or (2) this conduct substantially interferes with the individual’s employment or creates an intimidating, hostile, or offensive work environment. Sexual harassment also includes conduct which indicates that employment and/or employment benefits are conditioned upon acquiescence in sexual activities.

All allegations of sexual harassment shall be immediately investigated by the medical staff and, if confirmed, will result in appropriate corrective action, from reprimands up to and including termination of medical staff privileges or membership, if warranted by the facts.

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4.4. DIVISION OF FEES PROHIBITED

The division of fees between Medical Staff members is prohibited.17

RTICLE VCATEGORIES OF MEMBERSHIP18

5.1. CATEGORIES

All appointments and reappointments to the Medical Staff shall be as approved by the Board upon recommendation of the MEC19 and shall be to one of the following categories: active,20 associate, courtesy, consulting, and honorary.21

5.2. ACTIVE MEDICAL STAFF

5.2.1 QUALIFICATIONS22

The Active Medical Staff shall consist of Physicians and Dentists who regularly attend, admit, or are otherwise involved in the diagnosis and treatment of patients at the Hospital and who:

17 Wis.Adm.Code H.F.S. § 124.12(5)(b)(5) (“Medical staff by-laws … shall include …[a] definite and specific statement forbidding the practice of the division of fees between medical staff members.”).

18 JCAHO Standard MS.1.10 (“The hospital has an organized, self-governing medical staff that provides oversight of care, treatment, and services provided by practitioners with privileges, provides for a uniform quality of patient care, treatment, and services, and reports to and is accountable to the governing body”.). Categories of membership are implicit in this standard.

Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2). 19 The Medicare COPs require that the Medical Staff make recommendations to the Board on the appointment of medical staff candidates. 42 C.F.R. § 482.22(a)(2).

20 Wis.Adm.Code H.F.S. § 124.12(3)(a) (“Regardless of any other categories of medical staff having privileges in the hospital, a hospital shall have an active staff which performs all the organizational duties pertaining to the medial staff. Active staff membership shall be limited to individuals who are currently licensed to practice medicine, podiatric medicine, and dentistry. These individuals may be granted membership in accordance with the medical staff by-laws and rules, and in accordance with the by-laws of the hospital. A majority of the members of the active staff shall be physicians.”).

21 Wis.Adm.Code H.F.S. § 124.12(3)(b) (“The medical staff may include one or more categories defined in the medical staff by-laws in addition to the active staff.”); Wis.Adm.Code H.F.S. § 124.12(4)(b)(2) (“The medical staff may include one or more categories of medical staff defined in the medical staff by-laws in addition to the active staff, but this in no way modifies the duties and responsibilities of the active staff.”); Wis.Adm.Code H.F.S. § 124.12(5)(b)(2) (“The medical staff by-laws and rules shall include a statement … of the duties and privileges of each category of medical staff.”).

22 Medicare COPs require that the Bylaws describe the qualifications to be met by the candidate in order to be appointed to the medical staff. 42 C.F.R. § 482.22(c)(4).

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(a) Meet the general qualifications for appointment to the Medical Staff set forth in Section 4.1.1; and

(b) Regularly attend, admit or are otherwise involved in the care of at least twelve (12) patients at the Hospital per year or, in the case of dentists, regularly attend, admit or are otherwise involved in the care of at least four (4) patients per year; and

(c) Have satisfactorily served on the Associate Medical Staff for a period of at least one (1) year.

Podiatrists shall not be eligible for the Active Medical Staff category.

5.2.2 PREROGATIVES23

The prerogatives of an Active Medical Staff member shall be to:

(a) Admit patients without limitation, unless otherwise provided in the Medical Staff Rules and Regulations, and exercise such clinical privileges as are granted pursuant to Article VIII, and

(b) Vote on all matters presented at general and special meetings of the Medical Staff and of the department and committees to which the member is appointed; and

(c) Hold office in this Medical Staff organization and in the departments and committees to which the member is appointed.

5.2.3 RESPONSIBILITIES24

Each member of the Active Medical Staff shall:

(a) Fulfill the general responsibilities of Medical Staff membership set forth in Section 4.2; and

(b) Satisfy the requirements set forth in Article XV for attendance at meetings of the Medical Staff and of the department and committees to which the member is appointed.

5.3. ASSOCIATE MEDICAL STAFF

5.3.1 QUALIFICATIONS25

23 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

24 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

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The Associate Medical Staff shall consist of Physicians and Dentists who:

(a) Meet the general qualifications for appointment to the Medical Staff set forth in Section 4.1.1; and

(b) Regularly attend, admit or are otherwise involved in the care of at least twelve (12) patients at the Hospital per year or, in the case of dentists, regularly attend, admit or are otherwise involved in the care of at least four (4) patients per year; and

(c) Following their initial appointment to the Medical Staff are being considered for advancement to the Active Medical Staff and will, in the ordinary course of events, be promoted to Active Medical Staff status after serving not more than one (1) year on the Associate Medical Staff.

Podiatrists shall not be eligible for the Associate Medical Staff category.

5.3.2 PREROGATIVES26

The prerogatives of an Associate Medical Staff member shall be to:

(a) Admit patients without limitation, unless otherwise provided in the Medical Staff Rules and Regulations, and exercise such clinical privileges as are granted pursuant to Article VIII; and

(b) Vote on all matters presented at general and special meetings of the Medical Staff and of the department and committees to which the member is appointed.

Associate Medical Staff members are not eligible to hold office in this Medical Staff organization.

5.3.3 RESPONSIBILITIES27

Each member of the Associate Medical Staff shall:

(a) Fulfill the general responsibilities of Medical Staff membership set forth in Section 4.2; and

25 Medicare COPs require that the Bylaws describe the qualifications to be met by the candidate in order to be appointed to the medical staff. 42 C.F.R. § 482.22(c)(4).

26 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

27 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

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(b) Satisfy the requirements set forth in Article XV for attendance at meetings of the Medical Staff and of the department and committees to which the member is appointed.

Failure to fulfill those responsibilities shall be grounds for denial of advancement to the Active Medical Staff or denial of reappointment to the Medical Staff. In either case, the member shall be afforded all rights provided in Article X and in the Fair Hearing Plan (the “Plan”).

5.4. COURTESY MEDICAL STAFF

5.4.1 QUALIFICATIONS28

The Courtesy Medical Staff shall consist of Physicians and Dentists who wish to admit or attend to a limited number of patients in the Hospital and who:

(a) Meet the general qualifications for appointment to the Medical Staff set forth in Section 4.1.1; and

(b) Render patient care services at the Hospital at the request of any member of the Active or Associate Medical Staff; and

(c) Admit or attend not more than four (4) patients at the Hospital per calendar year.

5.4.2 PREROGATIVES29

The prerogatives of a Courtesy Medical Staff member shall be to:

(a) Admit patients and exercise such clinical privileges as are granted pursuant to Article VIII within the limitations provided in Section 5.4.1(c), except that at times of full Hospital occupancy or a shortage of Hospital beds or other facilities, as determined by the CEO, the elective patient admissions of Courtesy Staff members shall be subordinate to those of Active and Associate Staff members; and

(b) Attend meetings of the Medical Staff and the Hospital, including open committee and department meetings and educational programs, but shall have no right to vote at such meetings; and

(c) Serve on Medical Staff committees with the right to vote if such right is specified at the time of appointment to the committee.

28 Medicare COPs require that the Bylaws describe the qualifications to be met by the candidate in order to be appointed to the medical staff. 42 C.F.R. § 482.22(c)(4).

29 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

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Courtesy Medical Staff members are not eligible to hold office in this Medical Staff organization.

5.4.3 RESPONSIBILITIES30

Each member of the Courtesy Medical Staff shall fulfill the general responsibilities of Medical Staff membership set forth in Section 4.2

5.5. CONSULTING MEDICAL STAFF

5.5.1 QUALIFICATIONS31

The Consulting Medical Staff shall consist of Practitioners who certified specialists and have distinguished themselves as authorities in their areas of specialization who can provide services to the Hospital or Medical Staff, which are not otherwise offered by current Members, and who:

(a) Meet the general qualifications for Medical Staff appointment set forth in Section 4.1.1; and

(b) Render patient care services at the Hospital at the request of any member of the Active or Associate Medical Staff; and

(c) Admit or attend not more than 11 patients per year or 33 percent (%) of the Practitioner’s total annual admissions, whichever is greater, at the Hospital.

Podiatrists are eligible only for the Consulting Staff category. 5.5.2 PREROGATIVES32

The prerogatives of a Consulting Medical Staff member shall be to:

(a) Admit patients and exercise such clinical privileges as are granted pursuant to Article VIII within the limitations provided in Section 5.5.1(c); and

(b) Attend meetings of the Medical Staff and the Hospital, including open committee and department meetings and educational programs, but shall have no right to vote at such meetings; and

30 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

31 Medicare COPs require that the Bylaws describe the qualifications to be met by the candidate in order to be appointed to the medical staff. 42 C.F.R. § 482.22(c)(4).

32 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

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(c) Serve on Medical Staff committees with the right to vote if such right is specified at the time of appointment to the committee.

Consulting Medical Staff members are not eligible to hold office in this Medical Staff organization.

5.5.3 RESPONSIBILITIES33

Each member of the Consulting Medical Staff shall fulfill the general responsibilities of Medical Staff membership set forth in Section 4.2

5.6. HONORARY MEDICAL STAFF

5.6.1 QUALIFICATIONS34

The Honorary Medical Staff shall consist of Practitioners who do not actively practice in the Hospital, but are deemed deserving of membership by virtue of their outstanding reputation, noteworthy contributions to the health and medical sciences, or their previous longstanding service to the Hospital, and who continue to exemplify high standards of professional and ethical conduct.

5.6.2 PREROGATIVES35

Honorary Medical Staff members shall be entitled to attend meetings of the Medical Staff and the Hospital, including open committee and department meetings and educational programs, but shall have no right to vote at such meetings.

Honorary Medical Staff members are not eligible to hold office in this Medical Staff organization or to admit patients or exercise clinical privileges.

5.6.3 RESPONSIBILITIES36

Pursuant to Sections 4.2(b) and 4.2(e), each member of the Honorary Medical Staff shall abide by:

33 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)2).

34 Medicare COPs require that the Bylaws describe the qualifications to be met by the candidate in order to be appointed to the medical staff. 42 C.F.R. § 482.22(c)(4).

35 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

36 Medicare COPs require that the Bylaws state the duties and privileges of each category of the medical staff. 42 C.F.R. § 482.22(c)(2).

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(a) The Medical Staff Bylaws and Rules and Regulations, and the policies and standards of the Medical Staff and the Hospital; and

(b) The ethical principles of the member’s profession.

5.7. LIMITATION OF PREROGATIVES

The prerogatives set forth under each membership category are general in nature and may be subject to limitation by special conditions attached to a Practitioner’s Staff membership, other sections of these Bylaws, the Medical Staff Rules and Regulations, or Medical Staff or Hospital policies.

5.8. WAIVER OF QUALIFICATIONS

The Board, in its discretion, may waive any qualification established for a particular Medical Staff category with regard to a Practitioner after consultation with the MEC upon determination that such waiver will serve the best interests of patient care in the Hospital.

5.9. MODIFICATION OF MEMBERSHIP CATEGORY

On its own initiative, upon recommendation of the credentials committee, pursuant to a request by a member, or upon direction of the Board, the MEC may recommend a change in the Medical Staff category of a member consistent with the requirements of these Bylaws. The National Practitioner Data Bank must be queried for recommendations or requests for category upgrade.

RTICLE VI3

PROCEDURES FOR CREDENTIALING 6.1. GENERAL PROCEDURE

The credentialing process provides the basis for making decisions regarding (1) initial appointment, modification, and reappointment to membership on the Medical Staff, and (2) initial granting, renewal, and modification of clinical privileges to Practitioners. The Medical Staff, through its designated committees and officers, shall investigate and consider each submitted application, collect relevant data, verify and evaluate the results, and make recommendations to the Board on each applicant’s request to provide patient care, treatment, and services.

37 JCAHO Standard MS.4.10 (“The organized medical staff has a credentialing process that is defined in the bylaws.”); JCAHO Standard MS.4.20 (“There is a process for granting, renewing, or revising setting-specific clinical privileges.”); JCAHO Standard MS.4.40 (“At the time of renewal of privileges, the organized medical staff evaluates individuals for their continued ability to provide quality care, treatment, and services for the privileges requested as defined in the medical staff bylaws.”); JCAHO Standard MS.4.60 (“The organized medical staff provides oversight for the quality of care, treatment, and services by recommending members for appointment to the medical staff.”).

Medicare COPs require that the Medical Staff examine the credentials of candidates and make recommendations to the governing body on the appointment of medical staff candidates. 42 C.F.R. § 482.22(a)(2).

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6.2. APPLICATION

6.2.1 FORM

Each application must be in (a) writing, (b) submitted on the prescribed form, and (c) signed by the applicant. When an applicant requests an application form, the applicant shall be given a copy of, or access to, a copy of the Medical Staff Bylaws, the Staff Rules and Regulations, the Hospital corporate Bylaws, and summaries of other Hospital and Staff policies relating to clinical practice in the Hospital.

6.2.2 CONTENT

The application shall include:

(a) Acknowledgement and Agreement: A statement that the applicant has received (or has had access to) and read the Bylaws, Rules and Regulations of the Medical Staff, and that the applicant agrees to be bound by the terms thereof if the applicant is appointed and/or granted clinical privileges.38

(b) Requests: The Staff category and clinical privileges for which the applicant wishes to be considered.

(c) References: The names of at least three (3) persons who have recently worked with the applicant and directly observed the applicant’s professional performance over a reasonable period of time and who can and will provide reliable information regarding the applicant’s current clinical ability, ethical character, and ability to work with others.

(d) Professional Sanctions: Information as to whether any of the following have ever been or are in the process of being denied, revoked, suspended, reduced, not renewed, or voluntarily relinquished:

(i) Staff appointment status of clinical privileges at any other hospital or health care institution;

(ii) Membership/fellowship in local, state or national professional organizations;

(iii) Specialty Board certification/eligibility;

(iv) License to practice any profession in any jurisdiction;

(v) Bureau of Narcotics and Dangerous Drug Number.

38 Bass v. Ambrosius, supra (In order for the bylaws to constitute a contract between the hospital and its medical staff, an applicant for appointment must submit a signed application acknowledging that he or she would agree to read and become familiar with the bylaws and be bound by them.).

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If any such actions ever occurred or are pending, the particulars shall be included.

(e) Notification of Release and Immunity Provisions: Statements notifying the applicant of the scope and extent of the authorization, confidentiality, immunity and release provisions of Section 6.3 and Article XVI.

(f) Administrative Remedies: A statement whereby the applicant agrees that, when an adverse decision is made with respect to the applicant’s Staff appointment, Staff status, and/or clinical privileges, the applicant will exhaust the administrative remedies afforded by these Bylaws before resorting to formal legal action.

6.3. EFFECT OF APPLICATION

By applying for clinical privileges and appointment to membership on the Medical Staff, each applicant:

(a) Signifies the applicant’s willingness to appear for interviews in regard to the applicant’s application;

(b) Authorizes Hospital representatives to consult with others who have been associated with the applicant and/or who may have information bearing on the applicant’s competence and qualifications;

(c) Consents to Hospital representatives inspecting all records and documents that may be material to an evaluation of the applicant’s professional qualifications and competence to carry out the clinical privileges the applicant requests, of the applicant’s physical and mental health status,39 and of the applicant’s professional ethical qualifications;40

(d) Releases from any liability all Hospital representatives for their acts performed in good faith and without malice in connection with evaluating the applicant and the applicant’s credentials;

39 A Practitioner’s current ability to perform the privileges requested must be evaluated as part of the credentialing process. The Americans with Disabilities Act [ADA], 42 U.S.C. § 12101 et seq., however, prohibits certain types of discrimination based on physical or mental impairment, and may affect how and when a hospital may ascertain and confirm a Practitioner’s ability to perform the privileges requested. Due to the developing and, therefore, unsettled area of law under the ADA as it applies to the relationship between the medical staff and the hospital, inquiry into the health status of an applicant or member prior to an offer of medical staff membership or reappointment is not recommended. The hospital can reserve, on the membership or reappointment application form and elsewhere, the right to condition an offer of membership or reappointment on the submission of reasonable evidence concerning an applicant or member’s physical and mental health as it relates to his or her current ability to perform the practices for which privileges are requested.

40 Wis.Adm.Code H.F.S. § 124.12(4)(c)(1) (“Criteria for appointment shall include individual character, competence, training, experience, and judgment.”).

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(e) Releases from any liability all individuals and organizations who provide information, including otherwise privileged or confidential information, to Hospital representatives in good faith concerning the applicant’s competence, professional ethics, character, physical and mental health status, and other qualifications for Staff appointment and clinical privileges;

(f) Authorizes and consents to the Physician Evaluation Committee and Hospital representatives providing other Hospitals, medical associations, licensing Boards, and other organizations concerned with provider performance and the quality and efficiency of patient care with any information relevant to such matters that the Hospital may have concerning the applicant, and release members of the Physician Evaluation Committee and Hospital representatives from liability for such actions, provided that such actions are done in good faith and without malice.

For purposes of this Section, the term “Hospital representative” includes the Board, its directors and committees; the CEO or his designee; the Medical Staff organization and all Medical Staff members, departments and committees which have responsibility for collecting or evaluating the applicant’s credentials or acting upon the applicant’s application; and any authorized representative of any of the foregoing.

6.4. PROCESSING THE APPLICATION

6.4.1 APPLICANT’S BURDEN

The applicant shall have the burden of producing adequate information for a proper evaluation of his experience, background, training, ability, and physical and mental health status, and of resolving any doubts about these or any of the other qualifications specified in Section 4.1.1.

6.4.2 VERIFICATION AND EVALUATION OF APPLICATION

The applicant shall deliver a completed application to the CEO, who shall, in timely fashion, seek to collect, verify, and evaluate the licensure, qualification evidence, and references submitted. The CEO shall promptly notify the applicant of any problems with the application and it shall then be the applicant’s obligation to obtain the required information. When collection, verification, and evaluation is accomplished, the CEO shall transmit the application and all supporting materials to the Credentials Committee.

6.5. CREDENTIALS COMMITTEE ACTION

The Credentials Committee shall review the application, evaluate and verify the supporting documentation and recommendations, and such other information available to it that may be relevant to consideration of the applicant’s qualifications for the Staff category and clinical privileges requested. The Credentials Committee may elect to interview the applicant and seek additional information. As soon as practicable, the Credentials Committee shall transmit to the MEC on the prescribed form, a written report and recommendations as to Staff appointment, and

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if appointment is recommended, as to Staff category and clinical privileges to be granted and any special conditions to be attached to the appointment. The Credentials Committee may also recommend that the MEC defer action on the application.

As part of its review and verification process, the Credentials Committee shall include the investigation required by the Caregiver Background Check Law. If the information obtained as required under the Caregiver Background Check Law shows the applicant to be disqualified for Medical Staff membership, the application shall be automatically denied. Such denial shall not entitle the applicant to hearing and appeal rights described in Article X and in the Plan.

The reason for each recommendation shall be stated and supported by reference to the completed application and all other documentation considered by the Committee, all of which shall be transmitted with the report. Any minority views shall also be reduced to writing, supported by reasons and references, and transmitted with the majority report.

Practitioners who diagnose or treat patients via telemedicine link are subject to the credentialing and privileging processes of the organization that receives the telemedicine service.

6.6. EFFECT OF MEDICAL EXECUTIVE COMMITTEE ACTION

At its next regular meeting after receipt of the Credentials’ Committee report and recommendation, or as soon thereafter as is practicable, the MEC shall consider the report and any other relevant information. The MEC may request additional information, return the matter to the Credentials Committee for further investigation, and/or elect to interview the applicant. The MEC shall immediately then forward to the President of the Medical Staff for transmittal to the Board a written report and recommendation as to medical staff appointment, and if appointment is recommended, as to membership category, clinical privileges to be granted, and any special conditions to be attached to the appointment. The Committee may also defer action on the application. The reasons for each recommendation shall be stated. The following procedures shall apply with respect to action on the application:

(a) DEFERRAL: Action by the MEC to defer the application for further consideration must be followed up within 21 days with a subsequent recommendation for appointment with specified clinical privileges, or for rejection of Staff appointment.

(b) FAVORABLE RECOMMENDATION: When the recommendation of the MEC is favorable to the applicant, the CEO shall promptly forward it together with all supporting documentation, to the Board. For the purposes of this Section 6.6, “all supporting documentation” includes the application form and its accompanying information and the reports and recommendations of the Credentials Committee and minority views.

(c) ADVERSE RECOMMENDATION: When the recommendation of the MEC is adverse to the applicant, the CEO shall immediately so inform the applicant by special notice, and the applicant shall be entitled to the procedural rights as

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provided in Article X and in the Plan. For the purpose of this Section 6.6, an “adverse recommendation” by the MEC is as defined in Section 10.2.3.

6.7. BOARD ACTION

The Board may accept the recommendation of the MEC, in whole or in part, or it may refer the matter back to the MEC for further recommendation, stating the purpose for such referral and setting a reasonable time limit for making a subsequent recommendation. The following procedures shall apply with respect to action on the application:

6.7.1 FAVORABLE RECOMMENDATION

If the MEC issues a favorable recommendation, the Board shall affirm the recommendation of the MEC if the MEC’s decision is supported by substantial evidence. (a) If the Board concurs in that recommendation, the decision of the Board shall be

deemed final action.

(b) If the tentative final action of the Board is unfavorable, the CEO shall give the applicant written notice of the tentative adverse recommendation, as defined in Section 10.2.3, and the applicant shall be entitled to the procedural rights set forth in Article X and in the Plan. If the procedural rights are waived by the applicant, the decision of the Board shall be deemed final action.

(c) If the MEC and the Board concur in that recommendation, the positive decision shall be ratified by the Board at its next regularly scheduled meeting. The ratification by the Board shall be deemed final. If the MEC’s decision is adverse to the applicant, or the Board fails to ratify the MEC’s decision, the matter shall be referred back to the MEC for evaluation, stating the reasons for such referral and establishing a time limit within which a subsequent recommendation shall be made.

6.7.2 ADVERSE RECOMMENDATION

In the event the recommendation of the MEC, or any significant part of it, is unfavorable to the applicant, the procedural rights in Article X shall apply. (a) If the procedural rights are waived by the applicant, the recommendations of the

MEC shall be forwarded to the Board for final action. The Board shall affirm the recommendation of the MEC if the MEC’s decision is supported by substantial evidence.

(b) If the applicant requests a hearing following the adverse MEC recommendation pursuant to Section 10.2.1, or an adverse Board tentative final action pursuant to Section 10.2.2, the Board shall take final action only after the applicant has exhausted all procedural rights as established by Article X and in the Plan. After exhaustion of the procedures set forth in Article X, the Board shall make a final

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decision and shall affirm the decision of the MEC, if the MEC’s decision is supported by substantial evidence following a fair procedure. The Board’s decision shall be in writing and shall specify the reasons for the action taken.

(c) Whenever the Board’s proposed decision will be contrary to the MEC’s recommendation, the Board shall submit the matter to a joint conference of equal numbers of Medical Staff members and Board members for review and recommendation before making its final decision and giving notice of final decision required by Section 6.7.3.

6.7.3 NOTICE OF FINAL DECISION

(a) Notice of the final decision shall be given through the CEO, to the Chair of the MEC and the Credentials Committee, and to the applicant by special notice.

(b) A decision and notice to appoint or reappoint shall include, if applicable: (1) the Staff category to which the applicant is appointed; (2) the clinical privileges granted; and (3) any special conditions attached to the appointment.

6.7.4 DENIAL FOR HOSPITAL’S INABILITY TO ACCOMMODATE

A recommendation by the MEC or a decision by the Board to deny Staff appointment, Staff category assignment, or particular clinical privileges, either:

(a) on the basis of the Hospital’s present inability, as supported by documented

evidence, to provide adequate facilities, supportive services, or patient load for the applicant and the applicant’s patients, or

(b) on the basis of inconsistency with the Hospital’s written plan of development, including the mix of patient care services to be provided, as currently being implemented

shall be considered adverse in nature and shall entitle the applicant to the procedural rights as provided in Article X and in the Plan.

Upon written request by the applicant to the CEO, the application shall be kept in a pending status for the next succeeding three (3) years. If, during this period, the Hospital finds it possible to accept Staff applications for clinical privileges and appointment to membership on the Medical Staff for which the applicant is eligible, and there is no obligation to applicants with prior pending status, the CEO shall promptly so inform the applicant by special notice. Within ninety (90) days of receipt of such notice, the applicant shall provide, in writing on the prescribed form, such supplemental information as is required to update all elements of his original application. Thereafter, the procedure provided in Section 6.4 for initial appointments and requests for clinical privileges shall apply.

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6.7.5 REAPPLICATION AFTER ADVERSE APPOINTMENT DECISION

An applicant who has received an adverse final decision regarding appointment or granting of clinical privileges shall not be eligible to reapply to the Medical Staff for appointment for a period of one (1) year. Any such reapplication shall be processed as an initial application, and the applicant shall submit such additional information as the Staff or the Board may require to demonstrate that the basis for the earlier adverse action no longer exists.

6.8. TIMELY PROCESSING OF APPLICATIONS

Applications for Staff appointments shall be considered in a timely manner by all persons and committees required by these Bylaws to act thereon. The following maximum time periods provide guidelines for routine processing of applications, although special circumstances may warrant exceptions to the guidelines:

(a) Within 30 days after receipt of the initial application, the CEO of the Medical Staff shall transmit the application, verification of application information, and all supporting documentation to the Credentials Committee.

(b) Within 30 days, the Credentials Committee shall review, evaluate, and provide its written recommendation to the MEC.

(c) Within 30 days, the MEC shall review, evaluate, and provide its written recommendation to the Board.

(d) The Board shall then take final action on the application at its next regular meeting following receipt of the MEC’s written recommendation.

The time periods specified herein are to assist those named in accomplishing their tasks and shall not be deemed to create any right of a Practitioner to have an application processed within those periods.

6.9. REAPPOINTMENT AND REQUESTS FOR MODIFICATION OF APPOINTMENT STATUS OR CLINICAL PRIVILEGES41

6.9.1 APPLICATION:

(a) The CEO shall, at least 60 days prior to the expiration date of the present Staff appointment of each Medical Staff member, shall mail or deliver a Reappointment Application form to each Staff member. Each Staff member who desires reappointment shall, at least 30 days prior to their Staff appointment expiration date, send a completed Reappointment Application form to the CEO. The reapplication form shall include all information necessary to update and evaluate

41 Medicare COPs require that the Bylaws determine the privileges to be granted to individual practitioners and a procedure for applying the criteria.

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the qualifications of the member including, but not limited to, the matters set forth in Section 4.1.1 and Section 6.2, as well as other relevant matters. Upon receipt of the reapplication form, the information shall be processed as set forth in Section 6.4.

(b) A Medical Staff member who seeks a modification of Staff status or clinical privileges may submit such a request, either in connection with reappointment or at any other time, by submitting a written application to the CEO on the prescribed form. This request shall be processed in substantially the same manner as provided in Article VII for reappointment. Such application may not be filed within 3 months of the time a prior such request has been denied.

6.9.2 EFFECT OF APPLICATION

The effect of an application for reappointment or modification of Staff status or clinical privileges is the same as that set forth in Section 6.3.

6.9.3 STANDARDS AND PROCEDURE FOR REVIEW

When a Staff member submits an application for reappointment for the first time, and every two (2) years thereafter, or when the member submits an application for modification of Staff status or clinical privileges, the member shall be subject to an in-depth review generally following the procedures set forth in Section 6.4 through Section 6.7.

6.9.4 BASIS FOR RECOMMENDATIONS

Each recommendation concerning the reappointment of a Staff member and the renewal of clinical privileges to be granted upon reappointment shall be based upon documented evidence of such member’s professional ability and clinical judgment in the treatment of patients, professional ethics, discharge of Staff obligations, compliance with the Medical Staff Bylaws, Rules and Regulations, cooperation with Hospital personnel, other Practitioners, and patients, and other matters bearing on the member’s ability and willingness to contribute to quality patient care in the Hospital.

6.9.5 TIME PERIODS FOR PROCESSING

Transmittal of the interval information form to a Staff appointee and his return of it shall be carried out in accordance with Section 6.9.1. Thereafter and except for good cause, each person, department and committee required by these Bylaws to act thereon shall complete such action in timely fashion so that all reports and recommendations concerning the reappointment of a Staff member shall have been transmitted to the MEC for its consideration and action pursuant to Section 6.6 and to the Board for its action pursuant to Section 6.7, all prior to the expiration date of the Staff appointment of the member being considered for reappointment. If the processing has not been completed by the expiration date of the appointment and the MEC determines that patient care would be adversely affected if the Staff member were required to cease practicing in the

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Hospital until the reappointment process is completed, the MEC will recommend that the CEO grant interim appointment and clinical privileges until such time as the processing is completed. In making this determination, the CEO shall consult with the President of the Medical Staff. Such interim appointment shall not be deemed to create a right for the Staff appointee to be automatically reappointed for the coming term. 6.9.6 FAILURE TO FILE REAPPOINTMENT APPLICATION

Failure, without good cause, to timely return a completed application for reappointment shall result in the automatic suspension of the member’s admitting privileges and the expiration of other practice privileges and prerogatives at the end of the current staff appointment, unless otherwise extended by the MEC with the approval of the Board. If the member fails to submit a completed application for reappointment, the member shall be deemed to have resigned membership in the Medical Staff. In the event membership terminates for the reasons set forth herein, the member shall be entitled to the procedures set forth in Article X and the Plan.

6.10. LEAVE OF ABSENCE

6.10.1 LEAVE STATUS

A Medical Staff member may obtain a voluntary leave of absence from the Staff upon submitting a written request to the MEC and the CEO stating the approximate period of leave desired, which may not exceed four (4) years. During the period of the leave, the Staff member shall not exercise clinical privileges at the Hospital, and membership prerogatives and responsibilities shall be suspended. The obligation to pay dues, if any, shall continue, unless waived by the MEC.

6.10.2 TERMINATION OF LEAVE

At least 90 days prior to the termination of the leave of absence, or at any earlier time, the Medical Staff member may request reinstatement of the member’s privileges and prerogatives by submitting to the CEO for transmittal to the MEC, the following: (1) a written notice to that effect, (2) a summary of the Staff member’s activities during the leave, and, (3) if on leave for more than one (1) year, a completed Reappointment Application form. The MEC shall make a recommendation to the Board concerning the reinstatement of the Staff member’s privileges and prerogatives. Thereafter, the procedure provided in Sections 6.7 through 6.8 shall be followed.

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ARTICLE VII

6.10.3 FAILURE TO REQUEST REINSTATEMENT

Failure, without good cause, to request reinstatement or to provide a requested summary of activities after a leave of absence, as above described, shall be deemed a voluntary resignation from the Staff and shall result in automatic termination of Staff appointment, privileges, and prerogatives.

A Staff member whose appointment, privileges, and prerogatives is so terminated shall be entitled to the procedural rights provided in Article X and in the Plan for the sole purpose of determining whether the failure to request reinstatement was unintentional or excusable, or otherwise. A request for Medical Staff appointment subsequently received from a Staff member so terminated shall be submitted and processed in the manner specified for applications for initial appointments.

MEDICAL STAFF APPOINTMENT, REAPPOINTMENT, AND REQUEST FOR MODIFICATION OF STAFF APPOINTMENT42 43

7.1. GENERAL PROCEDURE

The Medical Staff, through its designated committees and officers, shall investigate and consider each application for appointment or reappointment to the Staff and each request for modification of Staff appointment status, and shall adopt and transmit recommendations thereon to the Board.

All applications for initial appointment, reappointment, and requests for modification of Staff appointment shall be processed pursuant to the procedures outlined in Article VI.

7.2. DURATION OF APPOINTMENT

7.2.1 INITIAL APPOINTMENT AND MODIFICATIONS OF MEDICAL STAFF APPOINTMENT

All initial appointments and all modifications of appointment status pursuant to Article VI shall be for one (1) year.

7.2.2 REAPPOINTMENTS

Reappointments to any category of the Medical Staff shall be for a period of not more than two (2) years.

42 The Medicare COPs require that the Medical Staff periodically conduct appraisals of its members. 42 C.F.R. § 482.22(a)(2).

43 Medicare COPs require that the Medical Staff examine the credentials of candidates and make recommendations to the governing body on the appointment of medical staff candidates. 42 C.F.R. § 482.22(a)(2).

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ARTICLE VIII

7.3. PROCTORING REQUIREMENT

7.3.1 FOR INITIAL APPOINTMENTS

Except as otherwise determined by the Board, all initial appointments to any category of the Staff shall be subject to a period of proctoring. Each initial appointee’s performance shall be observed by the President of the Medical Staff or his designee, to determine the appointee’s eligibility for continued Staff appointment in the Staff category to which the appointee was initially appointed. An initial appointee shall remain subject to proctoring until the appointee has furnished to the Credentials Committee and to the CEO a statement signed by the President of the Medical Staff, or his designee, that the appointee meets all of the qualifications, has discharged all of the responsibilities, and has not exceeded or abused the prerogatives of the Staff category to which the appointee was appointed.

7.3.2 FOR MODIFICATIONS OF APPOINTMENT STATUS

The MEC may recommend to the Board that a change in Staff category of a current Staff member, pursuant to Section 6.9 be made subject to proctoring in accordance with the procedures outlined in Section 7.3.1.

7.3.3 TERM OF PROCTORING PERIOD

A proctoring period for initial appointment or for a modification of appointment status shall extend for no more than six (6) months unless extended for an additional period by the MEC and the Board. If an initial appointee fails, within that period, to furnish the statement required in Section 7.3.1, the Staff appointment, as applicable, shall automatically terminate. The initial appointee or Staff member so affected shall be given special notice of such termination and shall be entitled to the procedural rights afforded in Article X and in the Plan.

7.4. REQUESTS FOR MODIFICATION OF APPOINTMENT STATUS

A Staff member may, either in connection with reappointment or at any other time, request modification of the member’s Staff category by submitting a written application to the CEO on the prescribed form. Such application shall be processed pursuant to the procedures outlined in Section 6.9 for reappointment.

DETERMINATION OF CLINICAL PRIVILEGES44 8.1. EXERCISE OF CLINICAL PRIVILEGES

44 JCAHO Standard MS.4.20 (“There is a process for granting, renewing, or revising setting-specific clinical privileges.”).

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A Practitioner or other professional providing direct clinical services at this Hospital by virtue of Medical Staff appointment, or as provided for in Sections 8.5 and 8.6, shall be entitled to exercise only those clinical privileges specifically granted by the Board. Said privileges and services must be within the scope of the license, certificate or other legal credentials authorizing him to practice in the State of Wisconsin and consistent with any restrictions thereon.

8.2. DELINEATION OF PRIVILEGES IN GENERAL

8.2.1 REQUESTS

Each application for Medical Staff membership must contain a request for the specific clinical privileges desired by the applicant. A request by a Staff member pursuant to Section 8.2.4 for a modification of privileges must be supported by documentation of additional training and/or experience which supports the request.

8.2.2 BASIS FOR CLINICAL PRIVILEGES DETERMINATION

Requests for clinical privileges shall be evaluated on the basis of the Practitioner’s education, training, experience, ability, competence, and judgment. The basis for privileges determinations to be made in connection with periodic reappointment or otherwise shall include observed clinical performance and the documented results of the patient care audit and other quality review, evaluation and monitoring activities required by these Bylaws and the Hospital corporate Bylaws to be conducted at the Hospital. Privileges determinations shall also be based on pertinent information concerning clinical performance obtained from other sources, especially other institutions and health care settings where a Practitioner exercises clinical privileges. This information shall be added to and maintained in the Medical Staff file established for a Staff member.

8.2.3 PROCEDURES FOR APPLYING FOR CLINICAL PRIVILEGES AND FOR RENEWAL OF CLINICAL PRIVILEGES45

The Medical Staff, through its designated committees and officers, shall investigate and consider each application requesting initial clinical privileges or renewal of clinical privileges, and shall adopt and transmit recommendations thereon to the Board. All applications for initial granting of clinical privileges or renewal of clinical privileges shall be processed pursuant to the procedures outlined in Article VI.

8.2.4 REQUESTS FOR MODIFICATION OF CLINICAL PRIVILEGES

A Staff member may, either in connection with renewal of clinical privileges or at any other time, request a modification of his clinical privileges by submitting a written application to the CEO on the prescribed form. Such application shall be processed pursuant to the procedures outlined in Section 6.9 for modification of clinical privileges.

45 JCAHO Standard MS.4.40 (“At the time of renewal of privileges, the organized medical staff evaluates individuals for the their continued ability to provide quality care, treatment, and services for the privileges requested as defined in the medical staff bylaws.”).

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8.2.5 DURATION OF CLINICAL PRIVILEGES

All initial privileges granted, renewed, and modified pursuant to Article VI, shall be for a period of one (1) year.

8.2.6 FINAL AUTHORITY

The Board has final authority for granting, renewing, modifying, or denying privileges.

8.3. PROCTORING REQUIREMENT

8.3.1 INITIAL GRANTING OF CLINICAL PRIVILEGES

Except as otherwise determined by the Board, all granting of clinical privileges shall be subject to a proctoring period. Each initial appointee’s performance shall be observed by the President of the Medical Staff or designee, to determine his eligibility for continuing to exercise the clinical privileges initially granted. An initial appointee shall remain subject to observation until the appointee has furnished to the Credentials Committee or the MEC and to the CEO a statement signed by the President of the Medical Staff or his designee, that the appointee meets all of the qualifications, has discharged all of the responsibilities, and has not exceeded or abused the prerogatives of the clinical privileges which the appointee has been granted.

8.3.2 MODIFICATION OF CLINICAL PRIVILEGES

The MEC may recommend to the Board that a change in clinical privileges for a current Staff member, pursuant to Section 6.9, be made subject to proctoring in accordance with procedures similar to those outlined in Section 8.3.1. 8.3.3 TERM OF PROCTORING PERIOD

The proctoring period for initial granting of clinical privileges or for a modification of clinical privilege status shall extend for no more than six (6) months, unless extended for an additional period by the MEC, and the Board. If an initial appointee fails within that period to furnish the statement required in Section 8.3.1, his clinical privileges, as applicable, shall automatically terminate. The Staff appointee so affected shall be given special notice of such termination and shall be entitled to the procedural rights afforded in Article X and in the Plan.

8.4. SPECIAL CONDITIONS FOR DENTAL AND PODIATRIC PRIVILEGES

Requests for clinical privileges from dentists and podiatrists shall be processed in the manner specified in Section 8.2. Surgical procedures performed by dentists and podiatrists shall be under the overall supervision of the medical advisor for the department of surgery or an appropriately qualified designee. All dental and podiatric patients shall receive the same basic medical appraisal as patients admitted to other surgical services. A physician member of the Medical Staff shall be responsible for the care of any medical problem that may be present at the

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time of admission or may arise during hospitalization, and also shall determine the risk, effect, and appropriateness of the proposed surgical procedure on the total health status of the patient. 8.5. TEMPORARY PRIVILEGES46

8.5.1 CIRCUMSTANCES

Upon the written recommendation of the President of the Medical Staff, the CEO may grant temporary privileges in the following circumstances:

(a) To Meet An Important Patient Care, Treatment, or Service Need

(i) Care of Specific Patients: Upon receipt of a written request for specific temporary privileges, an appropriately licensed Practitioner of documented competence who is not an applicant for appointment to the Staff may be granted temporary privileges for the care of one (1) or more specific patients. Such privileges shall be exercised in accordance with the conditions specified in Section 8.5.2 and shall be restricted to the treatment of not more than four (4) patients in any one (1) year by any Practitioner, after which such Practitioner shall be required to apply for appointment to the Medical Staff before being allowed to attend to additional patients.

(ii) Locum Tenens: Upon receipt of a written request for specific temporary privileges, an appropriately licensed Practitioner of documented competence who is serving as a locum tenens for a member of the Medical Staff may, without applying for appointment to the Staff, be granted temporary privileges for an initial period of 30 days. Such privileges may be renewed for two (2) successive periods of 30 days but not to exceed his services as locum tenens, shall be limited to treatment of the patients of the Practitioner for whom he is serving as locum tenens, and shall be exercised in accordance with the conditions specified in Section 8.5.2. The Practitioner serving as a locum tenens shall not be entitled to admit his own patients to the Hospital.

(b) Completed Pending Application for New Medical Staff Membership

Temporary clinical privileges may be granted to an applicant while that applicant’s completed application for new Medical Staff membership and privileges is awaiting review and approval of the MEC and the Board, provided that the procedure described in Article VI has been completed, and that the applicant has no current or previously successful challenge to professional licensure or registration, involuntary termination of medical staff membership at

46 JCAHO Standard MS.4.100 (“Under certain circumstances, temporary clinical privileges may be granted for a limited period of time.”).

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any other organization, involuntary limitation, reduction, denial or loss of clinical privileges, or other matter of concern to which his application gives rise. Temporary privileges for new applicants may not exceed 120 days.

8.5.2 CONDITIONS

Temporary privileges shall be granted only when the information available reasonably supports a favorable determination regarding the requesting Practitioner’s qualifications, ability, and judgment to exercise the privileges requested. Special requirements of consultation and reporting may be imposed by the President of the Medical Staff or his designee responsible for supervision of a Practitioner granted temporary privileges. Before temporary privileges are granted, the Practitioner must acknowledge in writing that he has received, or been given access to, and read the Medical Staff Bylaws and Rules and Regulations and that he agrees to be bound by them in all matters relating to his temporary privileges.

8.5.3 TERMINATION

On the discovery of any information or the occurrence of any event of a nature which raises question about a Practitioner’s professional qualifications or ability to exercise any or all of the temporary privileges granted, the CEO or the President of the Medical Staff may terminate any or all of such Practitioner’s temporary privileges, provided that where the life or well-being of a patient is determined to be endangered by continued treatment by the Practitioner, the termination may be effected by any person entitled to impose summary suspensions under Article IX. In the event of any such termination, the Practitioner’s patients then in the Hospital shall be assigned to another Practitioner by the President of the Medical Staff or his designee responsible for the Practitioner’s supervision. The wishes of the patient shall be considered, where feasible, in choosing a substitute Practitioner.

8.5.4 RIGHTS OF THE PRACTITIONER WITH TEMPORARY PRIVILEGES

A Practitioner shall not be entitled to the procedural rights afforded by Article X and the Plan if his request for temporary privileges is refused, or because all or any portion of his temporary privileges are terminated or suspended.

8.6. EMERGENCY PRIVILEGES

For the purpose of this Section, an “emergency” is defined as a condition in which serious or permanent harm would result to a patient, or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger. In an emergency, any Practitioner, to the degree permitted by his license and regardless of Staff status or clinical privileges, shall be permitted to provide, and shall be assisted by Hospital personnel in providing, any type of patient care necessary to save the life of, or prevent serious harm to, a patient.

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A

RTICLE IXCORRECTIVE ACTION47

9.1. ROUTINE CORRECTIVE ACTION

9.1.1 CRITERIA FOR INITIATION

Whenever a Practitioner with clinical privileges shall engage in, make, or exhibit acts, statements, demeanor, or professional conduct, either within or outside of the Hospital, and the same is or is reasonably likely to be, detrimental to patient safety or to the delivery of good patient care or, is or is reasonably likely to be, disruptive to Hospital operations, corrective action against such Practitioner may be initiated by (1) the MEC or any member thereof; (2) the CEO; or (3) the Board or any officer of the Board.

9.1.2 REQUESTS AND NOTICES

All requests for corrective action shall be in writing, submitted to the MEC, signed by the person(s) submitting the request, and supported by reference to the specific activities or conduct which constitute the grounds for the request. The chair of the MEC shall promptly notify the CEO and the Practitioner who is the subject of the request in writing of all requests for corrective action received by the MEC and shall forward a copy of the request and all supporting documents submitted with the request to the Practitioner by certified mail, return receipt requested, or by personal service. The MEC shall continue to keep the CEO and the Practitioner who is the subject of the request fully informed of all action taken in conjunction therewith.

In addition, the MEC Chair shall notify the Practitioner who is the subject of the request within ten (10) days of the receipt of the request, and the Practitioner and his counsel shall be permitted to inspect the request and all supporting documents and other materials, and to submit a response thereto along with any supporting documents or other materials. The response and supporting documents or other materials shall be included and maintained in the Hospital records.

9.1.3 INVESTIGATION

After deliberation, the MEC may either act on the request or direct that investigation concerning the grounds for the request for corrective action be undertaken. The MEC may conduct such investigation itself or may assign the investigation to an officer or committee of the Medical Staff. This investigative process shall not be deemed a “hearing” as that term is defined in Article X and in the Plan, but shall include consultation with the Practitioner involved.

47 Wis.Adm.Code H.F.S. § 124.12(2)(b) (“The medical staff bylaws shall prescribe disciplinary procedures for infraction of hospital and medical staff policies by members of the medical staff. There shall be evidence that the disciplinary procedures are applied where appropriate.”).

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If the investigation is undertaken by a group or individual other than the MEC, such group or individual shall forward a written report of the investigation to the MEC as soon as is practicable but not later than 30 days after the assignment to investigate is made. The MEC may at any time within its discretion, and shall at the request of the Board (or of the Executive or Professional Relations Committee thereof), terminate the investigative process and proceed with action as provided in Section 9.1.4 below.

9.1.4 MEC ACTION

As soon as is practicable after the conclusion of the investigative process, if any, but in any event within 45 days after receipt of the request for corrective action unless deferred pursuant to Section 9.1.5 the MEC shall take action upon such request. Such action may include, without limitations:

(a) Recommending rejection of the request for corrective action.

(b) Recommending a warning, a letter of admonition, or a letter of reprimand.

(c) Recommending terms of probation or individual requirements of consultation or proctoring.

(d) Recommending reduction, suspension, or revocation of clinical privileges.

(e) Recommending reduction of Staff category or limitation of any Staff prerogatives directly related to the Practitioner’s delivery of patient care.

(f) Recommending suspension or revocation of Staff appointment.

9.1.5 DEFERRAL

If additional time is needed to complete the investigative process, the MEC may defer action on the request, but only upon the written consent of the affected Practitioner. A subsequent recommendation for any one (1) or more of the actions provided in Sections 9.1.4(a) through 9.1.4(f) above must be made within fifteen (15) days of the deferral and no longer than 60 days from the receipt of request for corrective action.

9.1.6 PROCEDURAL RIGHTS

Any recommendation by the MEC pursuant to Section 9.1.4(c), 9.1.4(d), 9.1.4(e), 9.1.4(f), or any combination of such actions, shall entitle the Practitioner to the procedural rights as provided in Article X and in the Plan.

9.1.7 OTHER ACTION

(a) If the MEC’s recommended action is to reject the request for corrective action, such recommendation together with all supporting documentation, shall be transmitted to the Board. Thereafter, the procedure to be followed shall be as provided in Sections 6.7.1, 6.7.2(c), and 6.7.3 as applicable.

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(b) If the MEC’s recommended action is a warning, admonition or reprimand, such recommendation together with all supporting documentation, shall be transmitted to the Board. Board action to adopt such MEC recommendation without substantive modification shall conclude the matter and notice of final decision shall be given as provided in Section 6.7.3.

If the Board’s proposed action will modify substantively the MEC’s recommendation, the provisions of Section 6.7.2(c) shall be followed. If the Board’s action is adverse to the applicant as defined in Section 10.2.3 the CEO shall promptly so inform the Practitioner by special notice, and he shall be entitled to the procedural rights as provided in Article X and in the Plan.

(c) If, in the Board’s determination, the MEC fails to act in timely fashion in processing and recommending action on the request for corrective action the Board (or an appropriate committee thereof) may, after notifying the MEC, take action on its own initiative. If such action is favorable, it shall become effective as the final decision of the Board. If such action is adverse as defined in Section 10.2.3, the CEO shall promptly so inform the Practitioner by special notice, and he shall be entitled to the procedural rights as provided in Article X and in the Plan.

9.2. SUMMARY SUSPENSION

9.2.1 CRITERIA FOR INITIATION

Whenever a Practitioner’s conduct requires that immediate action be taken to protect the life of any patient(s) or to reduce the substantial likelihood of immediate injury or damage to the health or safety of any patient, employee or other person present in the Hospital, either the President of the Medical Staff or the CEO or designee, the Executive Committee of either the Medical Staff or the Board, or the Board (or an appropriate committee thereof) shall have the authority to summarily suspend the Medical Staff appointment status or all or any portion of the clinical privileges of such Practitioner.

Such summary suspension shall become effective immediately upon imposition, and the CEO shall immediately give special notice of the suspension to the Practitioner. In the event of any such suspension, the care of the Practitioner’s patients in the Hospital shall be assigned to a substitute Practitioner by President of the Medical Staff or designee. The wishes of the patient shall be considered, where feasible, in choosing a substitute Practitioner.

9.2.2 MEC ACTION

As soon as possible after such summary suspension, a meeting of the MEC shall be convened to review and consider the action taken. The MEC may modify, continue or terminate the terms of the summary suspension.

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9.2.3 PROCEDURAL RIGHTS

Unless the MEC immediately terminates the suspension and ceases all further corrective action, the Practitioner shall be entitled to the procedural rights as provided in Article X and in the Plan.

9.2.4 OTHER ACTION

If the MEC’s action pursuant to Section 9.2.2 is to terminate the suspension and to cease all further corrective action, such action shall be transmitted immediately, together with all supporting documentation, to the Board. Thereafter, the procedure to be followed shall be as provided in Sections 6.7.1, 6.7.2(c) and 6.7.3 as applicable. The terms of the summary suspension as originally imposed shall remain in effect pending a final decision by the Board.

9.3. AUTOMATIC SUSPENSION

9.3.1 LICENSE

(a) REVOCATION: Whenever a Practitioner’s license authorizing him to practice in this State is revoked, his Staff appointment and clinical privileges shall be immediately and automatically revoked.

(b) RESTRICTION: Whenever a Practitioner’s license is limited or restricted by the applicable licensing authority, those clinical privileges which he has been granted that are within the scope of said limitation or restriction shall be immediately and automatically revoked.

(c) SUSPENSION: Whenever a Practitioner’s license is suspended, his Staff appointment and clinical privileges shall be automatically suspended effective upon and for at least the term of the suspension. Further action on the matter shall proceed pursuant to Section 9.3.3.

(d) PROBATION: Whenever a Staff member is placed on probation by the applicable licensing authority, his voting, office-holding, and teaching prerogatives and responsibilities, if any, shall be automatically suspended effective upon and for at least the term of the probation. Further action on the matter shall proceed pursuant to Section 9.3.3.

9.3.2 BUREAU OF NARCOTICS AND DANGEROUS DRUGS (BNDD) NUMBER

(a) REVOCATION: Whenever a Practitioner’s BNDD number is revoked, he shall immediately and automatically be divested at least of his right to prescribe medications covered by the number. Further action on the matter shall proceed pursuant to Section 9.3.3.

(b) SUSPENSION: Whenever a Practitioner’s BNDD number is suspended, he shall be divested at least of his right to prescribe medications covered by the number

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effective upon and for at least the term of the suspension. Further action on the matter shall proceed pursuant to Section 9.3.3.

(c) PROBATION: Whenever a Practitioner is placed on probation insofar as the use of his BNDD number is concerned, further action on the matter shall proceed pursuant to Section 9.3.3.

9.3.3 MEC DELIBERATION

As soon as practicable after action is taken as described in Sections 9.3.1(c) or 9.3.1(d), or in Sections 9.3.2(a), 9.3.2(b) or 9.3.2(c), the MEC shall convene to review and consider the facts under which such action was taken. The MEC may then recommend such further corrective action as is appropriate to the facts disclosed in its investigation, including limitation of prerogatives. Thereafter when the matter involves a Practitioner, the procedure to be followed shall be provided in Sections 9.1.6 and 9.1.7, as applicable.

9.3.4 FAILURE TO SATISFY SPECIAL ATTENDANCE REQUIREMENT

A Practitioner who fails to satisfy the requirements of Section 15.7.3 shall automatically be suspended from exercising all or such portion of his clinical privileges in accordance with the provisions of said Section 15.7.3.

9.3.5 MEDICAL RECORDS

For failure to complete medical records in timely fashion as specified in the current Rules and Regulations, a Practitioner’s clinical privileges (except with respect to his patients already in the Hospital) and his rights to admit patients and to consult with respect to patients shall, after written warning of delinquency, be automatically suspended and shall remain suspended until medical records are completed.

9.3.6 NOTICE

The President of the Medical Staff shall promptly transmit notice of any suspension under this Section 9.3 to the CEO, who shall promptly notify the affected Practitioner, in writing, of the suspension and the grounds therefor.

RTICLE XINTERVIEWS, HEARINGS AND APPELLATE REVIEW

10.1. INTERVIEWS

When the MEC other relevant Staff committee, or the Board of any appropriate committee thereof receives or is considering initiating an adverse recommendation concerning a Practitioner, the Practitioner may be afforded an interview. The interview shall not constitute a hearing, shall be preliminary in nature, and shall not be conducted according to the procedural rules provided with respect to hearings. The Practitioner shall be informed of the general nature

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of the circumstances and may present information relevant thereto. A record of the findings of such interview shall be made.

10.2. HEARINGS AND APPELLATE REVIEW

10.2.1 ADVERSE MEC RECOMMENDATION

A Practitioner against whom an adverse recommended action has been made by the MEC, as defined in Section 10.2.3, shall promptly be given special notice of such recommendation in accordance with the terms of the Plan. Upon receipt of such special notice, the Practitioner shall be entitled, upon request, to a hearing before an ad hoc hearing committee of the Medical Staff. If the recommendation of the MEC following such hearing is still adverse to the Practitioner, the Practitioner shall then be entitled, upon request, to an appellate review by the Board before a final decision is rendered.48

10.2.2 ADVERSE BOARD ACTION

A Practitioner against whom an adverse action has been taken by the Board, as defined in Section 10.2.3 below, shall promptly be given special notice of such action in accordance with the provisions of the Plan. Upon receipt of such special notice, the Practitioner shall be entitled, upon request, to a hearing by an ad hoc hearing committee appointed by the Board. If the action by the Board following such hearing is still adverse to the Practitioner, the Practitioner shall then be entitled, upon request, to an appellate review by the Board before a final decision is rendered.49

10.2.3 ADVERSE ACTIONS OR RECOMMENDED ACTIONS DEFINED

(a) The following actions or recommended actions shall, if deemed adverse pursuant to Section (b) below, entitle the Practitioner affected thereby to a hearing, upon his timely request for the same:

(i) Denial of initial Medical Staff appointment.

(ii) Denial of Medical Staff reappointment.

(iii) Suspension of Medical Staff membership.

(iv) Revocation of Medical Staff membership.

(v) Denial of requested advancement in Medical Staff category.

48 This paragraph was revised to specify that a Practitioner is entitled to receive special notice of adverse recommendations by the MEC. This revision was made to make the Bylaws more consistent with the provisions in the Plan.

49 This paragraph was revised to specify that a Practitioner is entitled to receive special notice of adverse actions by the Board. This was revision was made to make the Bylaws more consistent with the provisions in the Plan.

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(vi) Involuntary reduction in Medical Staff category.

(vii) Limitation of the right to admit patients.

(viii) Denial of requested department/service/section affiliation.

(ix) Denial of requested clinical privileges.

(x) Involuntary reduction in clinical privileges.

(xi) Condition of continuation of privileges—proctoring.

(xii) Suspension of clinical privileges.

(xiii) Termination of clinical privileges.

(xiv) Terms of probation.

(xv) Individual application of, or individual change in mandatory consultation requirement.

(b) An action or recommended action listed in Section 10.2.3(a) above shall be deemed adverse only when it has been:

(i) Recommended by the MEC; or

(ii) Taken by the Board contrary to a favorable recommendation by the MEC under circumstances where no right to a hearing existed; or

(iii) Taken by the Board on its own initiative without benefit of a prior recommendation by the MEC.

10.2.4 PROCEDURE AND PROCESS

All hearings and appellate reviews shall be in accordance with the procedure and safeguards set forth in the Plan. An AHP’s scope of practice may be terminated at will by the Board or a committee of the Board, upon recommendation of the department advisor or chairman of the MEC. Such termination is not covered by the Plan. However, the AHP shall have the right, upon request of the supervisory Practitioner, to appear before the Executive Committee before the Board’s final decision is made.

10.2.5 EXCEPTIONS

Neither the issuance of a warning, a letter of admonition, a letter of reprimand, nor the denial, termination or reduction of temporary privileges, nor any other actions except those specified in Section 10.2.3 shall give rise to any right to a hearing or appellate review, unless such actions were taken in response to the events described in Sections 9.3.1(a) and 9.3.1(b).

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10.3. REMOVAL FROM OFFICE OF MEDICO-ADMINISTRATIVE OFFICER

Removal from office of a medico-administrative officer shall not affect his Staff appointment status or clinical privileges, unless otherwise provided in such officer’s employment agreement, contract or other arrangement, if any. If his appointment status or clinical privileges are adversely affected in a direct manner by the removal in any of the respects listed in Section 10.2.3, and

(a) The employment agreement, contract or other arrangement is silent on procedural rights, then such officer shall be entitled to the procedural rights provided in Article X and in the Plan; or

(b) The employment agreement, contract or other arrangement includes a provision on procedural rights, then the terms as provided therein shall be followed.

If there is no employment agreement, contract or other arrangement, adverse action with respect to the officer’s Staff appointment status and/or clinical privileges must be initiated and processed in accordance with Article VI.

RTICLE XALLIED HEALTH PROFESSIONALS50

11.1. DEFINITIONS

Allied Health Professionals” [AHPs] means categories of health care professionals, other than physicians, podiatrists, and dentists, who are approved by the Board and hold a license, certificate, or other legal credential, as required by Wisconsin law, to provide certain professional services. AHPs are neither employees of the Hospital nor eligible for Medical Staff membership pursuant to these Bylaws, but have been granted a scope of practice to provide certain clinical services. Such AHPs shall include, but are not limited to, clinical psychologists (Ph.D.), bacteriologists, chemists, clinical pharmacologists, dental auxiliaries, nurse physiologist, and qualified therapists (i.e., occupational, physical, respiratory)

“Scope of practice” means the permission granted to AHPs to provide specified patient care services within the AHP’s qualifications and scope of practice.

50 Wis.Adm.Code H.F.S. § 124.12(4)(c)(6) (“If categories of hospital staff membership are established for allied health personnel not employed by the hospital, the necessary qualifications, privileges, and rights shall be delineated in accordance with the medical staff by-laws.”).

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11.2. QUALIFICATIONS

Only AHPs who meet the following qualifications are eligible for a scope of practice in the Hospital:

(a) Hold a license, certificate, or other legal credential in a category of AHPs which the Board has identified as eligible to apply for a scope of practice; and

(b) Document their experience, background, training, current competence, judgment; and current physical and mental health status (i.e., ability to perform the specified patient care services requested) with sufficient adequacy to demonstrate that patients treated by them will receive care of the generally recognized professional level of quality established by the Medical Staff, and that they are able to provide a service needed within the Hospital; and

(c) Are determined, on the basis of documented references, (1) to adhere to the ethics of their respective professions; (2) to be able to work cooperatively with others so as not to adversely affect patient care;51 and (3) to be willing to commit to and regularly assist the Medical Staff in fulfilling its patient care obligations within the area of the AHPs professional competence and credentials; and

(d) Agree to comply with all Medical Staff and Department bylaws, rules and regulations, and protocols to the extent applicable to AHPs; and

(e) Complete a background disclosure form as required by the Caregiver Background Check Law; and

(f) Maintain in force professional liability insurance with a suitable insurer in not less than the minimum amounts, if any, as from time to time may be jointly determined by the Board and the MEC.

11.3. CATEGORIES OF AHPS ELIGIBLE TO APPLY FOR SCOPE OF PRACTICE

The categories of AHPs, based on occupation or profession, which shall be eligible to apply for AHP membership and for a scope of practice in the Hospital and the corresponding prerogatives, terms, and conditions for each such AHP category, including any particular qualifications, shall be designated by the Board, upon the recommendation of the MEC. Such designations shall be set forth in the Medical Staff Rules and Regulations and shall be reviewed by the Board, within its discretion, as necessary, or upon the recommendation of the MEC.

11.4. PROCEDURE FOR GRANTING SCOPE OF PRACTICE

An application for a scope of practice for an AHP shall be submitted and processed in the same manner as provided in Article VIII for clinical privileges, provided that the Credentials

51 The ability to work cooperatively with others is a relevant qualification only to the extent that patient care may be adversely affected.

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Committee and the MEC need not take action on any such application until requested to so act by the chair of the Department to which the AHP is requesting assignment. An AHP shall be assigned to the clinical department appropriate to the AHP’s professional training and subject to the same terms and conditions as specified in Sections 6.9, 7.2, and 7.3 for Medical Staff appointments.

The Medical Staff shall perform the same investigation, evaluation, and recommendation functions set forth in Article VI in connection with any AHP who seeks a scope of practice in any Department of the Hospital.

An AHP may, subject to any licensure requirements or other legal limitations, exercise independent judgment within the areas of his professional competence, and may participate directly in the medical management of patients under the supervision of a Practitioner who has been accorded privileges to provide such care and who has ultimate responsibility for the patient’s care. The Medical Staff shall, through credentialing, develop and set forth criteria that determine which clinical procedures, treatments, medical, surgical or psychiatric conditions require consultation with or management by a Practitioner. The patient’s condition will be managed accordingly.

11.5. PREROGATIVES

The prerogatives of an AHP shall be to:

(a) Provide specified patient care services under the supervision of an active physician member of the Medical Staff who has been granted specific privileges to supervise and direct the exercise of a scope of practice by the same category of AHPs. AHP services, including writing orders, must be consistent with the scope of practice granted to the AHP and within the scope of the AHP’s license, certificate, or other legal credential (except as otherwise expressly provided by resolution of the department approved by the MEC and the Board) and consistent with the limitations stated in Section 7.4;

(b) Serve on Medical Staff, Department, and Hospital committees;

(c) Attend meetings of the Medical Staff and Department to which the AHP is assigned, and attend Medical Staff and Hospital education programs in his or her field of practice; and

(d) Exercise such other prerogatives as shall, by resolution or written policy duly adopted by the Medical Staff or any of its departments or committees and approved by the MEC and the Board, be accorded to all AHPs collectively or to any specific category of AHPs.

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11.6. RESPONSIBILITIES

Each AHP shall:

(a) Retain appropriate responsibility within the AHP’s area of professional competence for the care of each patient in the Hospital for whom he or she is providing services;

(b) Participate, as appropriate, in patient care audit and other quality review, evaluation, and monitoring activities required of AHPs, in supervising initial AHP appointees of his or her same occupation or profession during the observation period, and in discharging such other responsibilities and functions, as may be required by the Medical Staff from time to time; and

(c) Satisfy the requirements set forth in Article XV for attendance at meetings of the Medical Staff and of the department and committees of which the AHP is a member.

11.7. CORRECTIVE ACTION, FAIR HEARING AND APPEAL PROCEDURES

Corrective action and fair hearing and appeal procedures involving an AHP shall proceed in accordance with the procedures and rights outlined in Article IX and Article X, respectively, and the Plan. Hospital policies and procedures shall determine the manner of final processing.

RTICLE XIOFFICERS

12.1. OFFICERS OF THE MEDICAL STAFF

12.1.1 IDENTIFICATION

The officers of the Medical Staff shall be the President, Vice President, and Secretary-Treasurer.52

12.1.2 DUTIES OF OFFICERS

52 Wis.Adm.Code H.F.S. § 124.12(6)(a) (“The medical staff shall have the numbers and kinds of officers necessary for the governance of the staff.”); JCAHO Standard MS.1.10 (“The hospital has an organized, self-governing medical staff that provides oversight of care, treatment, and services provided by practitioners with privileges, provides for a uniform quality of patient care, treatment, and services, and reports to and is accountable to the governing body.”). JCAHO Standard MS.1.10, Elements of Performance 1 (“The organized medical staff is self-governing, as referenced in the bullets defining self governance on page M-8,” which include provisions for the selection and removal of medical staff officers.).

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12.1.3 PRESIDENT

The President shall serve as the chief elected officer of the Medical Staff President of the Medical Staff and shall:

(a) Interact with the Board and CEO in matters of mutual concern involving the Hospital;

(b) Aid in coordinating the activities and concerns of the Hospital administration and of the nursing and other patient care services with those of the Medical Staff.

(c) Enforce the Medical Staff Bylaws, Rules and Regulations, implementing sanctions where indicated, and promoting compliance with procedural safeguards in all instances where corrective action has been requested or initiated;

(d) Call, preside at, and be responsible for the agenda of all general meetings of the Medical Staff;

(e) Serve as chair of the MEC and as an ex-officio, non-voting member of all other Staff committees;

(f) Serve as an ex-officio, non-voting member of the Board; report on Medical Staff activities to the Board and the CEO; and represent the opinions, policies, concerns, needs and grievances of the Medical Staff;

(g) Communicate the Board’s Corporate Compliance Programs to the Medical Staff, to ensure the Medical Staff’s participation and compliance;

(h) Communicate the plans and policies of the Board to the Medical Staff and report to the Board on the performance and maintenance of quality with respect to the responsibility of the Medical Staff to provide medical care; and

(i) Serve as a spokesperson for the Medical Staff in external professional and public relations, and before licensing and accreditation agencies.

12.1.4 VICE PRESIDENT

The Vice President shall:

(a) Assume all duties and authority of the President in the President’s absence or inability to perform his or her duties;

(b) Automatically succeed the President, should that office become vacant for any reason during the President’s term of office;

(c) Assume responsibility for review and revision of the Bylaws;

(d) Serve on the MEC;

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(e) Perform such additional duties as may be assigned by the President, the MEC, or the Board.

12.1.5 SECRETARY-TREASURER

The Secretary-Treasurer shall:

(a) Serve on the MEC and as an ex-officio, non-voting member of all other Staff committees;

(b) Give proper notice of all Staff meetings on order of the appropriate authority.

(c) Keep accurate and complete minutes of all MEC and Medical Staff meetings;

(d) Receive, account for, and safeguard any funds that may be collected in the form of Staff dues, assessments, or application fees; and

(e) Perform such other duties as ordinarily pertain to such office or as may be assigned by the President or the MEC.

12.1.6 QUALIFICATIONS

Only those members of the Active Medical Staff53 who satisfy each of the following criteria shall be eligible to serve as Medical Staff officers:

(a) Good Standing. Officers must be and remain voting members in good standing at all times during their term of office. Failure to maintain such status shall immediately create a vacancy in the office involved.

(b) No Pending Professional Review Actions. Officers may not have adverse recommendations or actions pending against their Medical Staff membership or clinical privileges.

(c) Conflict of Interest. Officers may not be presently serving as a corporate officer at another hospital.

(d) Medical Staff Participation. Officers must have constructively participated in Medical Staff affairs, including peer review activities.

(e) Committee Participation. Officers must have actively served on Medical Staff committees or held previous Medical Staff leadership roles at this Hospital or at another hospital.

53 Wis.Adm.Code H.F.S. § 124.12(6)(b) (“Officers shall be members of the active staff and shall be elected by the active staff, unless this is precluded by the hospital bylaws.”).

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Each Officer must possess the above qualifications when nominated or appointed and maintain such qualifications during his or her term.

12.1.7 NOMINATIONS54

(a) BY NOMINATING COMMITTEE: The Medical Staff Officer Nominating Committee shall consist of three (3) members of the Medical appointed by the MEC, and the Hospital CEO, who shall serve as an ex-officio, non-voting member. The Committee shall convene seventy-five (75) days prior to the annual meeting and submit to the Staff secretary one (1) or more qualified nominees for each office. The names of such nominees shall be reported to the voting members of the Staff at least sixty (60) days prior to the annual meeting at a Medical Staff meeting.

(b) BY PETITION: Nominations for Medical Staff officers may also be made by petition signed by at least twenty percent (20%) of the members of the Active Medical Staff and filed with the Staff secretary at least fifteen (15) days prior to the annual meeting. As soon as reasonably practicable, the names of these nominees shall be reported to the voting members of the Staff at a Medical Staff meeting.

(c) BY OTHER MEANS: If, before the election, any of the individuals nominated for an office pursuant to Section 12.1.7(a) or (b) shall refuse, be disqualified from, or otherwise be unable to accept, the nomination, the Nominating Committee shall submit one (1) or more substitute nominees at the annual meeting. Nominations from the floor at the annual meeting will be recognized if the nominee is present and consents.

12.1.8 ELECTION55

Officers shall be elected at the odd numbered year’s annual meeting of the Medical Staff. Only Medical Staff members accorded the prerogative to vote for Medical Staff officers under Article V shall be eligible to vote.56 Voting shall be by written ballot. The ballots will be delivered to voting Medical Staff members by a representative of Administration 30-45 days prior to the annual meeting. Written ballots shall be returned to the Quality Coordinator or designee prior to the annual meeting and tallied by the current secretary of Medical Staff. Voting by proxy is not permitted. All ballots are to be signed by the voter

54 JCAHO Standard MS.1.20 (“Medical staff bylaws address self governance and accountability to the governing body.”); JCAHO Standard MS.1.20, Elements of Performance 10 (“The medical staff bylaws include a description of the … method of selecting and removing officers.”).

55 JCAHO Standard MS.1.20 (“Medical staff bylaws address self governance and accountability to the governing body.”); JCAHO Standard MS.1.20, Elements of Performance 10 (“The medical staff bylaws include a description of the … method of selecting and removing officers.”).

56 Wis.Adm.Code H.F.S. § 124.12(6)(b) (“Officers shall be members of the active staff and shall be elected by the active staff, unless this is precluded by the hospital bylaws.”).

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and are confidential, viewed only by the secretary of Medical Staff and disposed of by the secretary of Medical Staff after approved by the Medical Staff. A nominee shall be elected upon receiving a majority of the valid votes cast. If no candidate for the office receives a majority vote on the first ballot, a runoff election shall be held promptly between the two candidates receiving the highest number of votes.

12.1.9 TERM OF ELECTED OFFICE

Each officer shall assume office immediately following the meeting where final election results are obtained, and serve until the next regularly scheduled election or until a successor is elected, unless that officer shall sooner resign or be removed from office. All officers may be re-elected.

12.1.10 REMOVAL OF ELECTED OFFICERS57

Except as otherwise provided, removal of a Medical Staff officer may be initiated by the Board acting upon its own initiative or by a 66 percent (%) vote of Medical Staff members eligible to vote for Staff officers. Removal may be based only upon failure to perform the duties of the position held as described in these Bylaws. If a Staff officer is deemed a medico-administrative officer, his removal shall be accomplished pursuant to Section 10.3.

12.1.11VACANCIES IN ELECTED OFFICE

Vacancies in office occur upon the death or disability, resignation, or removal of the officer, or such officer’s loss of Medical Staff membership. If there is a vacancy in the office of the president, the vice president shall serve out the remaining term. A vacancy in the office of the vice president shall be filled by a special election conducted as soon after the vacancy occurs as is reasonably practicable in accordance with the procedures set forth in Sections 12.1.7 and 12.1.8. A vacancy in the office of Secretary/Treasurer shall be filled by the MEC until the next election.

12.1.12OFFICER STIPEND

Stipends will be paid on an annual basis following completion of the year. Stipends will be determined at the January meeting. For the full stipend to be paid, the officer must attend at least 75% of scheduled Medical Staff and Committee meetings, in addition to duties out-lined in 12.1.2. The stipend will be paid out of the Medical Staff Annual dues.

A complete or partial withhold of the stipend as per the New London Family Medical Center Board of Directors may occur if it is noted by the CEO or another Medical Staff officer that the minimum responsibilities were not met. This will be determined by the Board of Directors at the next meeting following completion of the year of service.

57 JCAHO Standard MS.1.20 (“Medical staff bylaws address self governance and accountability to the governing body.”); JCAHO Standard MS.1.20, Elements of Performance 10 (“The medical staff bylaws include a description of the … method of selecting and removing officers.”).

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ARTICLE XIII

DEPARTMENTS AND ADVISORS 13.1. FORMATION, MERGER, OR ELIMINATION OF DEPARTMENTS

A Medical Staff department can be formed, merged, or eliminated only after a determination by the MEC of the appropriateness of the action based on consideration of its effects on the quality of care in the Hospital. 13.2. DEPARTMENT ADVISORS58

(a) QUALIFICATIONS: Each Department advisor shall be (1) a member of the Active Staff and of the Department of which he or she is the advisor; (2) qualified to serve as advisor by training and experience;59 and (3) willing and able to faithfully discharge the functions of the position.60

(b) SELECTION AND APPOINTMENT: The advisor of each Department shall be appointed by the President of the Medical Staff after consultation with the outgoing department advisor and appropriate members of the Medical Staff.

(c) TERM OF OFFICE: An advisor shall serve a two- (2) year minimum term commencing with his appointment. Removal of an advisor may be initiated by either the Board acting upon its own initiative, the President of the Medical Staff, or a 67 percent (%) vote of Staff members eligible to vote for Staff officers. If an advisor is deemed a medico-administrative officer, his removal shall be accomplished pursuant to Section 10.3.

(d) SCOPE OF AUTHORITY: Each advisor shall be responsible for:

(i) The administration of the Department;

(ii) The quality of patient care provided by the Department and the conduct of quality assessment and improvement activities for which that Department is responsible;

58 JCAHO Standard MS.1.20 (“Medical staff bylaws address self governance and accountability to the governing body.”); JCAHO Standard MS.1.20, Element of Performance 8 (“When medical departments exist, the qualifications and roles and responsibilities of the medical department chair are defined in the medical staff bylaws … .”).

59 JCAHO Standard MS.1.20, Element of Performance 8 (Qualifications for a department chair include “[c]ertification by an appropriate specialty board or affirmatively established comparable competence through the credentialing process.”).

60 Wis.Adm.Code H.F.S. § 124.12(9)(b) (“Each service shall have a chief appointed in accordance with the medical staff bylaws. The chief of service shall be a member of the service and be qualified by training and experience to serve as chief of service.”).

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(iii) Making recommendations to the MEC and the Board concerning the qualifications and privileges of the members of the Department;61

(iv) Making recommendations to Hospital Administration regarding the planning of hospital facilities, equipment, routine procedures, and any other matters concerning patient care;

(v) Arranging and implementing inpatient programs, including organizing, engaging in educational activities, and supervising and evaluating the clinical work;

(vi) Enforcing Medical Staff Bylaws and Rules and Regulations within the Department;

(vii) Formulating rules and policies for the Department;

(viii) Cooperating with the hospital’s administrative staff on purchase of supplies and equipment;

(ix) Maintaining the quality of medical records;

(x) Representing the Department in a medical advisory capacity to the Board and Hospital Administration;62

(xi) Serving on the MEC, and providing recommendations on the overall clinical policies of the Hospital and his area of responsibility;

(xii) Ensuring implementation within the Department actions taken by the MEC and by the Board with regard to the professional activities of the Medical Staff; and

(xiii) Performing such other duties commensurate with his position as may from time to time be assigned by the President of the Staff, the MEC, or the Board.63

RTICLE XIVCOMMITTEES AND FUNCTIONS

61 JCAHO Standard MS.4.20 (“There is a process for granting, renewing, or revising setting-specific clinical privileges.”); JCAHO Standard MS.4.20, Element of Performance 8 (“When department chairpersons exist, the chairperson participates in the evaluation of practitioners practicing within the department.”).

62 Wis.Adm.Code § H.F.S. 124.12(9)(b)(1)-(10).

63 JCAHO Standard 1.20 (“Medical staff bylaws address self governance and accountability to the governing body.”); JCAHO Standard 1.20, Element of Performance 8 (The bylaws must define the qualifications, roles, and responsibilities of clinical department chairs delineated in this EOP.).

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14.1. DESIGNATION AND SUBSTITUTION

Medical Staff committees shall include but not be limited to, the Medical Staff meeting as a committee of the whole, meetings of Departments, meetings of committees established under this Article, and meetings of other standing, special, or ad hoc committees created by the MEC or by Departments to perform the Staff functions listed in Section 14.3 and elsewhere in these Bylaws.64 The MEC may, by resolution subject to approval by the Board, establish a Staff committee to perform one or more of the Staff functions. Those functions requiring Staff participation, rather than direct Staff responsibility, may be discharged by Medical Staff representation on Hospital committees established to perform such functions.

Whenever these Bylaws require that a function be performed by, or that a report or recommendation be submitted to:

(a) A named Medical Staff committee but no such committee shall exist, the MEC shall perform such function or receive such report or recommendation or shall assign the functions of such committee to a new or existing committee of the Staff or the Staff as a whole.

(b) The MEC, but a standing or special committee has been formed to perform the function, the committee so formed shall act in accordance with the authority delegated to it.

14.2. MEDICAL EXECUTIVE COMMITTEE

14.2.1 COMPOSITION65

The MEC shall consist of ten (10) members, with the voting majority being Active Medical Staff physician members.66 The Committee shall consist of the three-(3) Medical Staff officers, the immediate past President of the Medical Staff, five (5)

64 Wis.Adm.Code H.F.S. § 124.12(8) (“The medical staff shall have an executive committee to coordinate the activities and general policies of the various departments, act for the staff as a whole under limitations that may be imposed by the staff, and receive and act upon the reports of all other medical staff committees.”).

65 JCAHO Standard MS 1.40 (“There is a medical staff executive committee.”); JCAHO Standard MS.1.20 (“Medical staff bylaws address self governance and accountability to the governing body.”), Elements of Performance 9, (“The medical staff executive committee includes physicians and may include other LIPs.”), 10 (“The medical staff bylaws include a description of the executive committee’s function, size, composition, and method of selecting and removing officers.”), and 11 (“The medical staff bylaws empower the medical staff executive committee to act for the organized medical staff between meetings of the organized medical staff.”).

Medicare COPs require that a majority of the members of the MEC consist of doctors of medicine or osteopathy. 42 C.F.R. § 482.22(b)(2). Note that the NLFMC Bylaws define “Physician” as an individual with an M.D. or D.O. (doctor of osteopathy).

66 JCAHO Standard MS.1.40 (“There is a medical staff executive committee.”), Elements of Performance 4 (“The majority of voting medical staff executive committee members is fully licensed physicians actively practicing in the hospital.”).

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advisors of departments, and the Hospital CEO.67 If the immediate past President is not eligible to serve, another physician shall be appointed by the Chair of the MEC, subject to ratification by the Medical Staff, acting as an executive committee of the whole.

14.2.2 DUTIES68

The duties of the MEC, and the Medical Staff when functioning as an Executive Committee of the whole, shall include, but not be limited to:

(a) Representing and acting on behalf of the Medical Staff between Medical Staff meetings, subject to such limitations as may be imposed by these Bylaws;69

(b) Coordinating and implementing the professional and organizational activities of and policies of the Medical Staff;

(c) Receiving and acting upon reports and recommendations from Medical Staff departments, committees, and assigned activity groups;70

(d) Recommending actions to the Board on medical-administrative and Hospital management matters;

(e) Establishing and adopting policies relative to the structure of the Medical Staff, the mechanisms to review credentials and delineate individual clinical privileges, the granting of individual staff memberships and privileges, the organization of quality assurance and improvement activities and mechanisms of the Medical

67 JCAHO Standard MS.1.40 (“There is a medical staff executive committee.”), Elements of Performance 2 (“The CEO of the hospital or his or her designee attends each executive committee meeting on an ex officio basis, with or without a vote.”).

68 Wis.Adm.Code H.F.S. § 124.12(8)(b) (“The medical staff shall have an executive committee to coordinate the activities and general policies of the various departments, act for the staff as a whole under limitations that may be imposed by the staff, and receive and act upon the reports of all other medical staff committees.”); JCAHO Standard MS.1.40 (“There is a medical staff executive committee.”), Elements of Performance 8, 9, 10, 11, and 12 (“The medical staff executive committee makes recommendations, as defined in the medical staff bylaws, directly to the governing body on at least the following: (8) the organized medical staff’s structure, (9) the process used to review credentials and delineate privileges, (10) the delineation of privileges for each practitioner privileged through the medical staff process, (11) medical Staff membership, and (12) the executive committee reviews and acts on reports of medical staff committees, departments, and other assigned activity groups.”).

69 JCAHO Standard MS.1.20 (“Medical staff bylaws address self governance and accountability to the governing body.”); JCAHO Standard MS.1.20, Elements of Performance 11 (“The medical staff bylaws empower the medical staff executive committee to act for the organized medical staff between meetings of the organized medical staff.”); JCAHO Standard MS.1.40 (“There is a medical staff executive committee.”); JCAHO Standard MS.1.40, Elements of Performance 5 (“The medical staff executive committee acts on behalf of the organized medical staff between medical staff meetings.”).

70 JCAHO Standard MS.1.40 (“There is a medical staff executive committee.”); JCAHO Standard MS.1.40, Elements of Performance 12 (“The executive committee reviews and acts upon reports of medical staff committees, departments, and other assigned activity groups.”).

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Staff, the termination of Medical Staff membership and fair hearing procedures, needed changes to Medical Staff Bylaws, and other matters relevant to the operation of an organized Medical Staff;71

(f) Evaluating the medical care rendered to patients in the Hospital;

(g) Participating in the development of all Medical Staff policy, practice, and planning;

(h) Reviewing the qualifications, credentials, performance, and professional competence and character of Medical Staff applicants and members, and making recommendations to the Board regarding Medical Staff appointments and reappointments, clinical privileges,72 and corrective action;

(i) Adopting such Medical Staff Rules and Regulations as may be necessary for the proper conduct of the Staff consistent with these Bylaws;

(j) Taking reasonable steps to promote ethical conduct and competent clinical performance by all Medical Staff members, including initiating and participating in corrective or review measures when warranted;

(k) Taking reasonable steps to develop continuing education activities and programs for the Medical Staff;

(l) Designating such committees as may be appropriate or necessary in carrying out the duties and responsibilities of the Medical Staff and approving or rejecting appointment to those committees by the President of the Medical Staff;

(m) Appointing such special or ad hoc committees as may be appropriate or necessary to assist the MEC in carrying out its duties and responsibilities and those of the Medical Staff;

(n) Assisting in obtaining and maintaining Hospital accreditation;

71 JCAHO Standard MS.1.40 (“There is a medical staff executive committee.”); JCAHO Standard MS.1.40, Elements of Performance 6 (“The medical staff executive committee has a mechanism to recommend medical staff membership termination.”), 8 (“The medical staff executive committee makes recommendations, as defined in the medical staff bylaws, directly to the governing body on … [t]he organized medical staff’s structure.”), and 9 (“The medical staff executive committee makes recommendations, as defined in the medical staff bylaws, directly to the governing body on … [t]he process used to review credentials and delineate privileges.”); JCAHO Standard MS.3.10 (“The organized medical staff has a leadership role in hospital performance improvement activities to improve quality of care, treatment, and services and patient safety.”); JCAHO Standard MS.3.20 (“The organized medical staff participates in the measurement, assessment, and improvement of other processes.”).

72 JCAHO Standard MS.1.40 (“There is a medical staff executive committee.”); JCAHO Standard MS.1.40, Elements of Performance 10 (“The medical staff executive committee makes recommendations … directly to the governing body on … the delineation of privileges for each practitioner privileged through the medical staff process.”).

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(o) Reporting appropriate matters and making recommendations to the Medical Staff at regular meetings;

(p) Reporting appropriate matters and making recommendations to the Board at regular meetings; and

(q) Participating in identifying community health needs and in establishing Hospital goals and implementing programs to meet those needs.

14.2.3 MEETINGS

The MEC shall meet on alternate months to the full Medical Staff meetings, the latter of which are held bi-monthly, beginning in January of each calendar year. The MEC shall maintain a record of its proceedings and actions.

14.3. STAFF FUNCTIONS

Provision shall be made in these Bylaws or by resolution of the MEC approved by the Board, either through assignment to Department advisors, Staff committees, Staff officers, or interdisciplinary Hospital committees, for the effective performance of the Staff functions listed below and further described in Section 14.4, of all other Staff functions required by these Bylaws, and of such other Staff functions as the MEC or the Board shall reasonably require. Staff functions shall include, but not be limited to the following:

(a) Conduct, coordinate, and review quality assessment and improvement activities;

(b) Conduct, coordinate, and review utilization review activities;

(c) Conduct, coordinate and review credentials investigations and recommendations regarding Staff appointment and grants of clinical privileges and specified services;

(d) Respond to requests for information from other health care institutions about Practitioners who are or were, at one time, members of the Medical Staff seeking appointment and privileges at the other institution;

(e) Monitor and evaluate care provided in and develop clinical policy for special care areas, such as intensive or coronary care unit, patient care support services, such as respiratory therapy, physical medicine and anesthesia; and emergency, outpatient, and other ambulatory care services;

(f) Provide continuing education opportunities responsive to quality assessment and improvement activities, clinical developments, and other perceived needs, and supervise the Hospital’s professional library services;

(g) Review the completeness, timeliness, and clinical pertinence of patient medical and related records;

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(h) Develop and maintain surveillance over drug utilization policies and practices;

(i) Prevent, investigate, and control nosocomial infections and monitor the Hospital’s infection control program;

(j) Plan for response to fire and other disasters, for Hospital growth and development, and for the provision of services required to meet the needs of the community;

(k) Direct Staff organizational activities, including Staff Bylaws review and revision, Staff officer and committee nominations, liaison with the Board and Hospital administration, and review and maintenance of Hospital accreditation; and

(l) Coordinate the care provided by Practitioners with the care provided by the nursing service and with the activities of other Hospital patient care and administrative services.

14.4. DESCRIPTION OF FUNCTIONS

14.4.1 QUALITY ASSESSMENT AND IMPROVEMENT FUNCTION

The purpose of the quality assessment and improvement function is to monitor and evaluate the quality of patient care and the ancillary services in the Hospital on an ongoing basis, and to promote the most effective and efficient use of available health facilities and services consistent with patient needs and professionally recognized standards of health care.73 The duties involved in the quality assessment and improvement function shall include:

(a) Adopting, subject to the approval of the MEC and the Board, specific programs and procedures for monitoring, reviewing, evaluating, and maintaining the quality, effectiveness, and efficiency of patient care within the Hospital, including mechanisms for at least the following:

(i) Establishing written objective criteria to be used in quality assessment and improvement activities;

(ii) Assessing Medical Staff performance and practice in relation to the criteria using peer review organization data, medical records, hospital information systems, and other data sources;

(iii) Identifying and evaluating patient care problems and the factors that contribute to each problem, and corresponding opportunities for improving patient care;

73 Wis.Adm.Code H.F.S. § 124.10(1).

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(iv) Initiating changes that improve the quality and appropriateness of care and promote more efficient use of facilities and services; and

(v) Documenting monitoring and evaluation activities, including indicating how the results of these activities have been used to institute changes to improve the quality and appropriateness of care and to promote more efficient use of facilities and services.

(b) Review and act upon, on a regular basis, factors affecting the quality, effectiveness, and efficiency of patient care provided in the Hospital.

(c) Coordinating the findings, actions, and results of department, committee, and Staff activities related to quality assessment and improvement, utilization review, continuing education, medical records review, and other activities designed to monitor and evaluate patient care.

(d) Reporting to the MEC, monthly, and to the CEO and the Board, as needed, on the overall quality, effectiveness, and efficiency of patient care provided in the Hospital. Such reporting shall encompass department, committee, and Staff quality assessment and improvement, utilization review, and other patient care-related monitoring and evaluation activities, and shall include the findings, actions, and results of such activities and, where indicated, recommendations for change.

14.4.2 UTILIZATION REVIEW FUNCTION74

The purpose of the utilization review function is to ensure that resources and facilities are utilized effectively to provide quality patient care and safety.75 The duties involved in the utilization review function shall include:

(a) Conducting utilization review studies designed to evaluate the appropriateness of admissions to the Hospital, lengths of stay, discharge practices, use of medical and hospital services, and other factors that may contribute to the effective utilization of services;

(b) Developing a utilization review plan for the Hospital, subject to approval by the MEC, Hospital Administration, and the Board; and76

74 Wis.Adm.Code H.F.S. § 124.11(1)(c) provides that “[t]he medical staff is responsible for performance of utilization review,” while “[t]he chief executive officer and hospital administrative staff shall ensure that the plan is effectively implemented.” Conduct of utilization review by the medical staff is governed by Wis.Adm.Code H.F.S. § 124.11(2).

75 Wis.Adm.Code H.F.S. § 124.11(1)(a).

76 Wis.Adm.Code H.F.S. § 124.11(1)(c)(“The plan shall be approved by the medical staff, administration and governing body.”).

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(c) Maintaining a record of all activities relating to utilization review functions and submitting periodic reports concerning those activities and recommendations for the utilization of resources and facilities commensurate with quality patient care and safety, as needed, to the MEC and the Board.77

14.4.3 CREDENTIALS FUNCTION

The purpose of the credentials function is to develop and implement a system by which the Medical Staff selects its members and delineates their clinical privileges, and make recommendations to the Medical Staff and the Board for membership and privileges based on the evaluation of each applicant.78 The duties involved in the credentials function shall include:

(a) Reviewing and evaluating the qualifications of each applicant applying for initial appointment, reappointment, or modification of appointment to the Medical Staff and for clinical privileges, and, in connection therewith, obtaining and considering the recommendations of the appropriate departments; and

(b) Reviewing and evaluating the qualifications of each AHP applying to perform specified services and, in connection therewith, to obtain and consider the recommendations of the appropriate departments; and

(c) Submitting required reports and information, in accordance with Article VI, Article VII, and Article VIII, on the qualifications of each applicant applying for Medical Staff appointment or particular clinical privileges, and of each AHP applying to perform specified services. Such reports shall include recommendations with regard to appointment, category, department affiliation, clinical privileges, AHP specified services, and any special conditions; and

(d) Investigating, evaluating, and reporting on matters regarding the qualifications, conduct, professional character or competence of any applicant, Staff member, or AHP, in order to maintain and improve the quality of medical care rendered by the Staff or AHPs, referred by:

(i) The President of the Medical Staff;

(ii) The MEC; or

(iii) Those individuals or entities responsible, respectively, for the functions described in this Article; and

77 Wis.Adm.Code H.F.S. § 124.11(3) (“Records shall be kept of hospital utilization review activities and findings. Regular reports shall be made to the executive committee of the medical staff and to the governing body. Recommendations relevant to hospital operations and administration shall be reported to administration.”).

78 Wis.Adm.Code H.F.S. § 124.12(4)(b)(1) (“To select its members and delineate their privileges, the hospital medical staff shall have a system, based on definite workable standards, for evaluation of each applicant by a credentials committee which makes recommendations to the medical staff and to the governing body.”).

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(e) Submitting periodic reports to the MEC on the status of pending applications, including specific reasons for any unreasonable delay in processing an application or request.

14.4.4 PEER REVIEW FUNCTION

The purpose of peer review or professional review activity is to measure, assess, and improve the performance of the Medical Staff members and to communicate with the Hospital its findings, conclusions, and recommendations for action to improve care provided by any Practitioner or AHP. The duties involved in the peer review function shall include:

(a) Setting priorities for correcting problems;

(b) Referring priority problems for assessment and corrective action to appropriate Hospital departments, divisions or committees;

(c) Collecting and organizing information pertaining to the competence and professional conduct of a Practitioner or AHP and forwarding a record of its recommendations to the credentials function as required; and

(d) Performing such other tasks necessary to integrate the quality assessment and improvement, utilization review, and credentials functions of the Medical Staff.

14.4.5 PHYSICIAN EVALUATION FUNCTION

The purpose of the physician evaluation function is to develop and implement a system for responding to requests for information from other health care institutions about Practitioners who are members of the Medical Staff seeking membership and privileges at the other institution. The function shall be performed by an Officer of the Medical Staff and the CEO. 14.4.6 CONTINUING MEDICAL EDUCATION FUNCTION

The purpose of the continuing medical education function is to organize continuing medical education programs and supervise the Hospital’s professional library services. The duties involved in the continuing medical education function shall include:

(a) Planning, implementing, and coordinating ongoing clinical and scientific educational programs for the Medical Staff, which shall include:

(i) Identifying the educational needs of the Medical Staff;

(ii) Formulating clear statements of objectives for each program;

(iii) Assessing the effectiveness of each program;

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(iv) Choosing appropriate teaching methods and knowledgeable faculty for each program; and

(v) Documenting staff attendance at each program.

(b) Establishing liaison with the quality assurance and other patient care-related monitoring and evaluation activities of the Hospital to be apprised of problem areas in patient care, which may be addressed by a specific continuing medical education activity;

(c) Maintaining close liaison with other Hospital, Medical Staff, and Department committees concerned with patient care;

(d) Making recommendations to the MEC regarding the Hospital and Staff’s needs for professional library services; and

(e) Maintaining a record of all activities relating to continuing medical education functions and submitting periodic reports concerning these activities, as needed, to the MEC, with an emphasis on their relationship to findings and recommendations arising from quality assurance and other patient care-related activities.

(f) Ensuring that all members of the Medical Staff are properly licensed and meet the annual continuing education requirements for licensure.

14.4.7 MEDICAL RECORDS FUNCTION

The purpose of the medical records function is to oversee all matters and practices related to medical records in the Hospital. The duties involved the medical records function shall include:

(a) Reviewing and evaluating medical records, or a representative sample, to determine whether they:

(i) Properly describe the condition and diagnosis, the progress of the patient during hospitalization and at the time of discharge, the therapy provided and results thereof, and adequate identification of individuals responsible for orders given and treatment provided; and

(ii) Are sufficiently complete at all times to facilitate continuity of care and communications between individuals providing patient care services in the Hospital.

(b) Reviewing and making recommendations for Medical Staff and Hospital policies, rules and regulations relating to medical records, including medical records completion, forms and formats, filing, indexing, storage, destruction, availability, and methods of enforcement; and

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(c) Acting upon recommendations from the MEC, the departments, and other committees responsible for patient care audit and other quality review, evaluation and monitoring activities relative to medical records related matters; and

(d) Providing liaison with Hospital administration and medical records professionals in the employ of the Hospital on matters relating to medical records practice; and

(e) Maintaining a record of all activities relating to medical records functions and submitting periodic reports and recommendations concerning those activities, as needed, to the MEC.

14.4.8 PHARMACY AND THERAPEUTICS FUNCTION

The purpose of the pharmacy and therapeutics function is to develop and maintain surveillance over drug utilization. The duties of the pharmacy and therapeutics function shall include:

(a) Assisting in the formulation of professional policies and practices regarding the evaluation, appraisal, selection, procurement, storage, distribution, use, safety procedures, and all other matters relating to drugs in the Hospital;

(b) Advising the Medical Staff and the Hospital’s pharmaceutical department on matters pertaining to the choice of available drugs;

(c) Making recommendations concerning drugs to be stocked on the nursing unit floors and by other services;

(d) Periodically developing and reviewing a formulary or drug list for use in the Hospital;

(e) Evaluating clinical data concerning new drugs or preparations requested for use in the Hospital;

(f) Establishing standards concerning the use and control of investigational drugs and of research in the use of recognized drugs;

(g) Maintaining a record of all activities relating to pharmacy and therapeutics functions and submitting periodic reports and recommendations to the MEC concerning those activities, as needed;

(h) Developing proposed policies and procedures for, and continuously evaluating the appropriateness of blood and blood products usage, including the screening, distribution, handling and administration and monitoring of blood and blood components’ effects on patients;

(i) Reviewing untoward drug reactions; and

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(j) Performing such other duties as may be assigned by the President of the Medical Staff or the MEC.

14.4.9 INFECTION CONTROL FUNCTION79

The purpose of the infection control function is to develop and carry out surveillance and investigation of Hospital-acquired infections and implement measures designed to reduce these infections to the extent possible.80 The duties of the infection control function shall include:

(a) Establishing techniques and systems for discovering and isolating infections in the Hospital;

(b) Establishing written infection control policies and procedures which govern the use of aseptic techniques and procedures in all areas of the Hospital;

(c) Establishing a control method for the sterilization of supplies and solutions and a written policy requiring identification of sterile items and specifying time periods for the reprocessing of sterile items;

(d) Establishing policies specifying when individuals with specified infections or contagious conditions shall be relieved from or reassigned duties, including a requirement that these individuals remain relieved or reassigned until there is evidence that the disease or condition no longer poses a significant threat to others;

(e) Reviewing on as-needed basis, and no less than annually, infection control policies, procedures, systems, and techniques, and make recommendations to the Board and the MEC for changes thereto;81 and

(f) Reviewing all related matters referred by the Board, the MEC, departmental advisors, the Medical Staff president, the CEO, and Medical Staff committees.

79 Wis.Adm.Code H.F.S. § 124.08(2) permits the establishment of an infection control committee by either the governing body of the hospital or the medical staff. Membership on such a committee must be drawn from the medical and nursing staffs, the laboratory service, and the hospital administrative staff. Wis.Adm. Code H.F.S. § 124.08(2)(b).

80 Wis.Adm. Code H.F.S. § 124.08(2)(a) states the purpose of an infection control committee.

81 Wis.Adm. Code H.F.S. § 124.08(2)(c) states the committee’s responsibilities, all of which are set forth in Section 12.4.7 (a)-(e) above.

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14.4.10 NOMINATING FUNCTION

The purpose of the nominating function is to present to the Medical Staff qualified candidates for elective positions in the Medical Staff organization. The duties of the nominating function shall include:

(a) Consulting with members of the Staff and Hospital administration concerning the qualifications and acceptability of prospective nominees;

(b) Submitting, at the appropriate times as provided in these Bylaws, one (1) or more nominations for:

(i) Each elective office of the Staff to be filled; and

(ii) Such other elective positions as may be required by these Bylaws.

14.5. PARTICIPATION OF INTERDISCIPLINARY HOSPITAL COMMITTEES

Staff functions and responsibilities relating to liaison with the Board and the Hospital administration, Hospital accreditation, disaster planning, facility and services planning, and financial management shall be discharged by the appointment of Medical Staff members to such Hospital function.

14.6. COMMITTEES OF THE STAFF

14.6.1 COMPOSITION AND APPOINTMENT

A Staff committee established to perform one or more of the Staff functions required by these Bylaws shall be composed of appointees to the Active and Associate Staffs and may include, where appropriate, AHPs and representation from Hospital administration, nursing service, medical records service, pharmaceutical service, social service, and other such Hospital departments as are appropriate to the function(s) to be discharged. Unless otherwise specifically provided, the Medical Staff members shall be appointed to committees by the President of the Medical Staff and the administrative Staff members shall be appointed by the CEO. Each committee shall, with the approval of the MEC, select its chairman and secretary where they are not provided for in these Bylaws. The President of the Medical Staff and the CEO, or their respective designees, shall serve as ex officio, non-voting members on all committees, unless otherwise expressly provided.

14.6.2 TERM AND PRIOR REMOVAL

Unless otherwise specifically provided, a Medical Staff committee member (other than one serving ex-officio) shall continue as such until the end of the member’s normal period of Staff appointment and until the member’s successor is elected or appointed, unless the member shall sooner resign or be removed from the committee. A Medical Staff committee member, other than one serving ex-officio, may be removed by a majority vote of the MEC. An administrative Staff committee member shall serve for a term equivalent to that of a Medical Staff committee member and until the member’s

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A

successor is elected or appointed, unless the member shall sooner resign or be removed from the committee. An administrative Staff committee member may be removed by action of the CEO.

14.6.3 VACANCIES

Unless otherwise specifically provided, vacancies on any Staff committee shall be filled in the same manner in which original appointment to such committee is made.

14.6.4 MEETINGS

A Staff committee established to perform one or more Staff functions required by these Bylaws shall meet as often as is necessary to discharge its assigned duties, at least quarterly.

RTICLE XVMEETINGS82

15.1. MEETINGS

15.1.1 ANNUAL MEETINGS

The annual meeting of the Medical Staff shall be held in January of each year, on a date to be determined by MEC, at which time officers will be elected when his/her term is due to expire, in addition to conducting other business. Notice of this meeting shall be given to the members at least five (5) days, but no more than ten (10) days, prior to the meeting.

15.1.2 REGULAR MEETINGS

Regular meetings of the Medical Staff shall be held bimonthly, except that the annual meeting shall constitute the regular meeting during the month in which it occurs. The date, place, and time of the regular meetings shall be determined by the MEC and at least five (5) days, but no more than ten (10) day’s notice given to Staff members prior to the meeting.

15.1.3 ORDER OF BUSINESS AND AGENDA

The order of business at a regular meeting shall be determined by the President of the Medical Staff. The agenda shall include at least the following:

(a) Reading and acceptance of the minutes of the last regular and all special meetings held since the last regular meeting;

82 Wis.Adm.Code H.F.S. § 124.12(5)(b)(7) (“Medical staff by-laws and rules shall include provision for regular meetings of the medical staff.”); Wis.Adm.Code H.F.S. § 124.12(7)(a) (“The number and frequency of medical staff meetings shall be determined by the active staff and clearly stated in the by-laws.); Wis.Adm.Code H.F.S. § 124.12(7)(c) (“Full medical staff meetings shall be held to conduct the general business of the medical staff and to review the significant findings identified through the quality assurance program.”).

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(b) Administrative reports from the CEO, the President of the Medical Staff, Departments, and committees;

(c) Election of officers and representatives to Medical Staff and Hospital committees, when required by these Bylaws;

(d) Reports by responsible officers, committees and departments on the overall results of patient care audit and other quality review, evaluation, and monitoring activities of the Medical Staff and on the fulfillment of other required Staff functions;

(e) Old business; and

(f) New business.

15.1.4 SPECIAL MEETINGS

Special meetings of the Medical Staff may be called at any time by the Board, the President of the Medical Staff, the MEC, or upon the written request of not less than one-third (1/3) of the members of the active Medical Staff. The individual or body calling or requesting the special meeting shall state the purpose of the meeting in writing. The meeting shall be scheduled by the MEC within thirty days after the receipt of the request and notice given the members of the Staff at least five (5) days but no more than ten (10) days prior to the meeting, which includes the stated purpose of the meeting. No business shall be transacted at any special meeting except that stated in the meeting notice.

15.2. COMMITTEE AND DEPARTMENT MEETINGS

15.2.1 REGULAR MEETINGS

Committees and departments may, by resolution, establish the times for the holding of regular meetings. No notice other than resolution is required. The frequency of such meetings shall be as required by these Bylaws.

15.2.2 SPECIAL MEETINGS

A special meeting of any committee or department may be called by the chair thereof, the Board, the President of the Medical Staff, or upon written request of one-third (1/3) of the current members of the committee or department eligible to vote. No business shall be transacted at any special meeting except that stated in the meeting notice.

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15.3. NOTICE OF MEETINGS

Written notice stating the place, day, and time of any regular or special Staff meeting, or any regular committee or department meeting not held pursuant to resolution, or any special committee or department meeting shall be delivered or mailed to each person entitled to be present at such meeting not less than five (5) days nor more than ten (10) days before the date of such meeting. Notice of department or committee meetings may be given orally. If mailed, the notice of the meeting shall be deemed delivered 72 hours after deposited, postage prepaid, in the United States mail addressed to each person entitled to such notice at his address as it appears in the Hospital records. 15.4. QUORUM

15.4.1 REGULAR STAFF MEETINGS

The presence of 33 percent (%) of the total voting members of the Active Medical Staff at any regular or special meeting shall constitute a quorum for all purposes except the amendment of these Bylaws.

15.4.2 DEPARTMENT AND COMMITTEE MEETINGS

Fifty percent (50%) of the voting members of a department or committee, but not less than two (2) members, shall constitute a quorum at any meeting of such department or committee.

15.5. MANNER OF ACTION

Except as otherwise specified, the action of a 2/3 majority of the members present and voting at a meeting at which quorum is present shall be the action of the group. Action may be taken without a meeting by a department or committee if it is acknowledged by a writing setting forth the action so taken which is signed by a majority of the members entitled to vote.

15.6. MINUTES

Minutes of all meetings shall be prepared and retained by the secretary of the meeting, and shall include a record of the attendance of members and the vote taken on each matter.83 A copy of the minutes shall be signed by the presiding officer, approved by the attendees, forwarded to the MEC, and made available to the Medical Staff.

15.7. ATTENDANCE REQUIREMENTS84

83 Wis.Adm.Code H.F.S. § 124.12(7)(d) (“Adequate minutes shall be kept that are sufficient to document for those members who did not attend the meeting the general nature of the business conducted, the decisions reached, and the findings and recommendations of the medical staff.”).

84 Wis.Adm.Code H.F.S. § 124.12(7)(b) (“Attendance requirements for each individual member shall be clearly stated in the by-laws of the medical staff.”); Wis.Adm.Code H.F.S. § 124.12(7)(b) (“Attendance records shall be kept of medical staff meetings.”).

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15.7.1 REGULAR ATTENDANCE

Each member of a Medical Staff category required to attend meetings under Article V shall be required to attend:

(a) The annual Medical Staff meeting; and

(b) At least two-thirds (2/3) of all other regular Medical Staff meetings duly convened pursuant to these Bylaws; and

(c) At least 60 percent (%) of all meetings of each department and committee to which the member is assigned.

(d)

15.7.2 ABSENCE FROM MEETINGS

Any member who is compelled to be absent from any Medical Staff, department or committee meeting shall promptly provide to the regular presiding officer thereof the reason for such absence. Unless excused for good cause by the presiding officer, failure to meet the attendance requirements may be grounds for corrective action specified in Section 9.1.4 and/or removal from such department or committee. Reinstatement of a member whose Medical Staff membership has been revoked due to unexcused absences from meetings shall be made only on written application processed in the same manner as an application for initial appointment to the Medical Staff.

15.7.3 SPECIAL ATTENDANCE

At the discretion of the chair or presiding officer, when a member’s practice or conduct is scheduled for discussion at a regular department or committee meeting, the member may be requested to attend. If a suspected deviation from standard clinical practice is involved, notice shall be given at least five (5) days prior to the meeting and shall include the time and place of the meeting, a general statement of the issue(s) involved, and a statement that the member’s appearance is mandatory. Failure of the member to appear at any meeting to which notice was given shall, unless excused by the MEC upon a showing of good cause, result in an automatic suspension of all or such portion of the member’s clinical privileges as the MEC may direct. Such suspension shall remain in effect until the matter is resolved by subsequent action of the MEC or the Board, including corrective action, if necessary.

RTICLE XVCONFIDENTIALITY, IMMUNITY AND RELEASES

16.1. SPECIAL DEFINITIONS

For the purpose of this Article, the following definitions shall apply:

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(a) INFORMATION means record of proceedings, minutes, records, reports, memoranda, statements, recommendations, data, and other disclosure whether made in writing or orally relating to any of the subject matters specified in Section 16.6.2.

(b) MALICE means dissemination of a knowing falsehood or of information with a reckless disregard for whether or not it is true or false.

(c) REPRESENTATIVE means any director or committee of the Board; a CEO or his designee; a Medical Staff, organization and any member, officer, department or committee thereof; and any individual authorized by any of the foregoing to perform specific information gathering or disseminating functions for the purpose of credentialing.

(d) THIRD PARTIES means both individuals and organizations providing information to any representative.

16.2. AUTHORIZATIONS AND CONDITIONS

By applying for, or exercising, clinical privileges or, in the case of an AHP, providing specified patient care services, within this Hospital, a Practitioner:

(a) Authorizes representatives of the Hospital and the Medical Staff to solicit, provide, and act upon information bearing upon, or reasonably believed to bear upon, the Practitioner’s professional ability and qualifications;

(b) Authorizes individuals and organizations to provide information concerning the Practitioner to the Medical Staff;

(c) Agrees to be bound by the provisions of this Article and to waive all legal claims against any representative of the Medical Staff or the Hospital who would be immune from liability under Section 16.5 of this Article; and

(d) Acknowledges that the provisions of this Article are express conditions to an application for and acceptance of Medical Staff membership, the continuation of such membership, and/or the exercise of clinical privileges or, in the case of an AHP, the provision of specified patient services at this Hospital.

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16.3. CONFIDENTIALITY OF INFORMATION

16.3.1 GENERAL

Records and proceedings of all medical staff committees having the responsibility of evaluation and improvement of quality of care provided in this Hospital, including, but not limited to, meetings of the Medical Staff meeting as a committee of the whole, meetings of departments, meetings of committees established pursuant to Article XIV, and meetings of special or ad hoc committees created by the MEC or by departments and including information regarding any member or applicant to this Medical Staff provided by representatives and third parties shall, to the fullest extent permitted by law, be maintained as confidential. Access to such records shall be limited to duly appointed officers and committees of the medical staff for the sole purpose of discharging medical staff responsibilities and subject to the requirement that confidentiality be maintained. Information which is disclosed to the Board or its appointed representatives in order that the Board may discharge its lawful obligation and responsibilities shall be maintained by the Board as confidential.

A Practitioner’s credentialing information shall be maintained in a single, member-specific file to preserve confidentiality and promote inclusion of the information in credentialing processes, and shall not be made part of any patient’s records or the general Hospital records. Information contained in the credentials file of any Practitioner may be disclosed with the Practitioner’s consent, or to any medical staff or professional licensing board, or as required by law.

16.4. BREACH OF CONFIDENTIALITY

As effective peer review and consideration of the qualifications of Medical Staff members and applicants to perform specific procedures must be based on free and candid discussions, any breach of confidentiality of the discussions or deliberations of Medical Staff departments or committees, except in conjunction with other hospital, professional society, or licensing authority, is outside appropriate standards of conduct for this Medical Staff, violates the Medical Staff Bylaws, and will be deemed disruptive to Hospital operations. If it is determined that such a breach has occurred, the MEC may undertake such corrective action as it deems appropriate.

16.5. IMMUNITY FROM LIABILITY

16.5.1 FOR ACTION TAKEN

Each representative of the Medical Staff and the Hospital shall be immune, to the fullest extent provided by law, from liability to a Practitioner for damages or other relief for any action taken or statements or recommendations made within the scope of duties exercised as a representative of the Medical Staff or the Hospital.

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16.5.2 FOR PROVIDING INFORMATION

Each representative of the Medical Staff and the Hospital and all third parties shall be immune, to the fullest extent provided by law, from liability to a Practitioner for damages or other relief by reason of providing information to a representative of the Medical Staff or the Hospital or to any other health care facility or organization, concerning such individual who is, or has been, an applicant to or member of the Staff or who did, or does, exercise clinical privileges or provide specified services at this Hospital.

16.6. ACTIVITIES AND INFORMATION COVERED

16.6.1 ACTIVITIES

The confidentiality and immunity provided by this Article shall apply to all acts, communications, reports, recommendations or disclosures performed or made in connection with this or any other health care facility’s or organization’s activities concerning, but not limited to:

(a) Application for appointment, reappointment, clinical privileges or specified services;

(b) Corrective action;

(c) Hearings and appellate reviews;

(d) Quality assessment and improvement activities;

(e) Utilization reviews;

(f) Other department, committee, Medical Staff, or Hospital activities related to monitoring and maintaining quality patient care and appropriate professional conduct; and

(g) Queries and reports concerning the National Practitioner Data Bank, peer review, the Wisconsin Medical Examining Board, and similar queries and reports.

16.6.2 INFORMATION

The acts, communications, reports, recommendations, disclosures, and other information referred to in this Article may relate to a Practitioner’s professional qualifications, clinical ability, judgment, character, physical and mental health, professional ethics, or any other matter that might directly or indirectly affect patient care.

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16.7. RELEASES

Each Practitioner shall, upon request of the Medical Staff or the Hospital, execute general and specific releases in accordance with the express provisions and general intent of this Article. Execution of such releases shall not be deemed a prerequisite to the effectiveness of this Article.

16.8. INDEMNIFICATION

The Hospital shall defend, or assume the costs incurred for defense and, pay any settlements, judgments, and damages on behalf of any member of the Medical Staff arising out of service on any Hospital or Medical Staff committee or assisting in peer or professional review or quality assessment and improvement activities involving care provided at the Hospital, including review of AHPs, so long as the member of the Medical Staff acted in good faith.85 16.9. CUMULATIVE EFFECT

Provisions in the Bylaws and in application forms for appointment, reappointment, and clinical privileges relating to authorizations by a Practitioner to provide or obtain information about the Practitioner, the confidentiality of that information, and immunities from liability with regard to the provision or obtainment of such information shall be in addition to other protections provided by law and not in limitation thereof and, in the event of a conflict, the applicable law shall be controlling.

RTICLE XVIGENERAL PROVISIONS

17.1. FORMS

Any forms required by these Bylaws for use in connection with Medical Staff appointments, reappointments, delineation of clinical privileges, corrective action, notices, recommendations, reports, or other matters shall be subject to adoption by the Board after considering the recommendation of the MEC.

17.2. TRANSMITTAL OF REPORTS

Whenever these Bylaws require the Medical Staff to transmit reports, documents or other information to the Board, such reports, documents or other information shall be deemed so transmitted when delivered to the CEO, generally by the President of the Medical Staff, unless otherwise specified.

85 Wis.Stat. § 146.37 affords immunity to individuals from civil liability when peer review is conducted in good faith. It also expressly provides for a presumption of good faith.

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17.3. BOARD ACTION

Whenever these Bylaws require or authorize action by the Board, such action may be taken by a committee of the Board to which the Board has delegated the responsibility and authority to act for it with regard to the particular subject matter, activity, or function.

RTICLE XVIIADOPTION AND AMENDMENT OF MEDICAL STAFF BYLAWS, RULES,

REGULATIONS, AND POLICIES 18.1. BYLAWS86

The Medical Staff is responsible for adopting and amending Medical Staff Bylaws every four years or less as required by changes in regulatory standards. Bylaws shall be adopted or amended after notice of the proposed action, including text of the proposed revisions, has been given in writing at least twenty (20) days prior to the meeting at which such action is proposed. Adoption or amendment shall require a two-thirds (2/3) majority vote of the regular active Staff members present and voting at any regular or special meeting of the Staff at which a quorum is present, or by written ballot. The adoption or amendment of Bylaws by the Medical Staff shall become effective when approved by the Board, which approval shall not be unreasonably withheld or delayed.87 Amendments to the Bylaws will be distributed in writing to Medical Staff members and other individuals holding clinical privileges in a timely and effective manner. 18.2. RULES AND REGULATIONS

The MEC is responsible for recommending to the Medical Staff the adoption and amendment of such Rules and Regulations as may be necessary to implement the general principles set forth in these Bylaws. The Rules and Regulations shall be part of the Bylaws and shall, more specifically, govern the conduct of Medical Staff organizational activities, the level of practice required of each Practitioner or AHP, and protocols for clinical practice issues. The Rules and Regulations may be adopted or amended without prior notice by 2/3 majority vote of the regular active Staff members present and voting at any regular meeting of the Staff at which a quorum is present, or at any special meeting with prior notice, by a majority vote of those present and eligible to vote. Changes to the Rules and Regulations shall become effective when approved by the Board, which approval shall not be unreasonably withheld or delayed. Amendments to the Rules and Regulations will be distributed in writing to Medical Staff members and other individuals holding clinical privileges in a timely and effective manner.

86 JCAHO Standard MS.1.20 (“Medical staff bylaws address self-governance and accountability to the governing body.”), Elements of Performance 1 (“The medical staff develops medical staff bylaws.”), 4 (“The medical staff bylaws are adopted and amended by the medical staff.”) and 5 (“The governing body approves and complies with the medical staff bylaws.”).

87 Medicare COPs require that Medical Staff operate under Bylaws approved by the Board. 42 C.F.R. § 482.22. Medicare COPs also require that Medical Staff be organized in a manner approved by the Board. 42 C.F.R. § 482.22(b)(1).

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18.3. EXCLUSIVITY

The mechanisms described in this Article shall be the sole methods for the adoption and amendment of the Medical Staff Bylaws and Rules and Regulations. The recommendations of the Medical Staff shall be considered by the Board as part of the approval process. The unilateral amendment of the Bylaws and Rules and Regulations by either the Medical Staff or the Board is prohibited.88

18.4. MEDICAL STAFF POLICIES

The MEC shall review, develop, and adopt policies that will be binding on the Medical Staff and its members and those holding clinical privileges. Such policies must be consistent with the Medical Staff Bylaws and Rules and Regulations. Only policies adopted by the MEC are binding on the Medical Staff and its members. Amendments to Medical Staff policies will be distributed in writing to Medical Staff members and other individuals holding clinical privileges in a timely and effective manner.

18.5. SUCCESSOR IN INTEREST/AFFILIATIONS

18.5.1 SUCCESSOR IN INTEREST

These Bylaws, and the clinical privileges accorded to individual Staff members under these Bylaws, are binding upon the Hospital and Medical Staff of any successor in interest in this Hospital.

18.5.2 AFFILIATIONS

The Hospital’s affiliation with other hospitals, health care systems, or other similar entities shall not, in and of itself, affect these Bylaws.

18.6. CONSTRUCTION OF TERMS AND HEADINGS

The captions or headings in these Bylaws are for convenience only and are not intended to limit or define the scope of or affect any provision of these Bylaws. Words used in these Bylaws shall be read as the masculine or feminine gender and as the singular and plural, as the context requires.

The revised version adopted by the Active Medical Staff on April 11, 2007

Paul Hoell, M.D. Donn Fuhrmann, M.D. President, Medical Staff Secretary, Medical Staff

88 JCAHO Standard MS.1.30 (“Neither the organized medical staff nor the governing body may unilaterally amend the medical staff bylaws or rules and regulations.”).

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The revised version adopted by the Governing Body on April 24, 2007

Kerry L. Griebenow Nate Leider Chairman of the Board of Directors Secretary of the Board of Directors

MN203599_1.DOC