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DMLEGALP-#44568-v5 1

HOMESTEAD HOSPITAL

INVESTIGATIONS, CORRECTIVE ACTION,

HEARING, AND APPEAL PLAN MANUAL


Table of Contents

PAGE I. INVESTIGATIONS, CORRECTIVE ACTION, HEARING AND APPEAL PLAN MANUAL ................................................... 5 A. COLLEGIAL INTERVENTION ............................................................ 5 B. INVESTIGATIONS ............................................................................. 6 1. Initial Procedure…………………………………………………… 6 2. Initiation of Investigation………………………………………….. 6 3. Investigative Procedure…………………………………………...7 4. Procedure Thereafter……………………………………………...8 C. PRECAUTIONARY SUSPENSION OF CLINICAL PRIVILEGES .... …. 10 1. Grounds for Precautionary Suspension………………………. 10 2. Medical Executive Committee Procedure……………………. . 10 3. Care of Suspended Member's Patients………………………. . 11 D. AUTOMATIC RELINQUISHMENT/OTHER ACTIONS ..................... 12 1. Failure to Complete Medical Records or Utilize CPOM……...12 2. Action by Government Agency or Insurer .............................. 12 3. Failure to Provide Requested Information…………………….. 13 4. Failure to Attend Special Conference ..................................... 14 5. Procedure for Leave of Absence……………………………….14 6. Disciplinary Suspension……………………………………….... 15 II. HEARING AND APPEAL PROCEDURAL POLICY .................................... 17 A. INITIATION OF HEARING ..................................................................... 17 1. Grounds for Hearing…………………………………………….. 17 2. Events That Are Not Grounds for a Fair Hearing ................... 18 B. THE HEARING ....................................................................................... 19 1. Notice of Recommendation……………………………………. . 19 2. Request for Hearing…………………………………………..… 19 3. Notice of Hearing and Statement of Reasons……………….. . 19


PAGE 4. Witness List……………………………………………………… . 20 5. Hearing Panel and Presiding Officer………………………… 20 6. Counsel .................................................................................. 22 C. PRE-HEARING PROCEDURE ......................................................... 22 1. General Procedures ............................................................... 22 2. Provision of Relevant Information .......................................... 22 3. Pre-Hearing Conference………………………………………...24 4. Stipulations............................................................................. 24 5. Provision of Information to the Hearing Panel ........................ 25 D. THE HEARING ................................................................................. 25 1. Failure to Appear………………………………………………… 25 2. Record of Hearing……………………………………………….. 25 3. Rights of Both Sides and the Hearing Panel .......................... 25 4. Admissibility of Evidence……………………………………….. 26 5. Post-Hearing Proposed Findings and Conclusions…………. . 26 6. Persons to be Present ............................................................ 26 7. Postponements and Extensions………………………………. . 26 8. Presence of Hearing Panel Members .................................... 26 E. HEARING CONCLUSION, DELIBERATIONS AND RECOMMENDATIONS .................................................................... 27 1. Order of Presentation…………………………………………… 27 2. Basis of Recommendation……………………………………… 27 3. Deliberations and Recommendation of the Hearing Panel…27 4. Disposition of Hearing Panel Report…………………………...27 F. APPEAL PROCEDURE ................................................................... 27 1. Time for Appeal…………………………………………………. 27 2. Grounds for Appeal…………………………………………….. 28 3. Time, Place and Notice………………………………………… . 28 4. Nature of Appellate Review……………………………………. 28 5. Appellate Review in the Event of Board Modification or Reversal of Hearing Panel Recommendation…………….29 6. Final Decision of the Board…………………………………….. 29 7. Further Review……………………………………………………29 8. Right to One Hearing and One Appeal Only…………………. 30


PAGE III. AMENDMENTS….. …. …………. . …………………………………………….31

IV. MISCELLANEOUS……………………………………………………………….32

A. CONFIDENTIALITY AND REPORTING………………………………..32

B. PEER REVIEW PROTECTION………………………………………….32

V. ADOPTION………………………………………………………………………...33


INVESTIGATIONS, CORRECTIVE ACTION, HEARING AND APPEAL PLAN MANUAL

ARTICLE I - PART A:COLLEGIAL INTERVENTION

(1) This Policy makes available to Medical Staff leaders and Hospital management, progressive steps, beginning with collegial and educational efforts, to address questions relating to a Member's clinical practice and/or professional conduct. The goal of these collegial and educational alternatives is to arrive at voluntary, responsive actions by the individual to resolve questions that have been raised. (2) Collegial intervention is a part of ongoing and focused professional practice evaluation, performance improvement and peer review. (3) Collegial intervention efforts involve reviewing and following up on questions raised about the clinical practice and/or conduct of Staff Members and pursuing counseling, education, and related steps, including but not limited to the following: (a) advising colleagues of applicable policies, such as policies regarding appropriate behavior, emergency call obligations, implementation and utilization of Hospital systems and technology, and the timely and adequate completion of medical records; (b) proctoring, monitoring, consultation, and letters of guidance; and (c) sharing comparative quality, utilization, and other relevant information, including any variations from clinical protocols or guidelines, in order to assist individuals to conform their practices to appropriate norms. (4) The relevant Medical Staff leader(s) will determine whether it is appropriate to include documentation of collegial intervention efforts in a Member's confidential credentials file. If documentation of collegial efforts is included in a Member's file, the Member will have an opportunity to review it and respond in writing. The response will be maintained in that Member's file along with the original documentation. (5) Collegial intervention efforts are not mandatory, and will be within the discretion of the appropriate Medical Staff leaders and Hospital management. (6) The relevant Medical Staff leader(s), in conjunction with the Chief Executive Officer, may direct that a matter be handled in accordance with another policy (e.g., code of conduct policy, physician health policy, peer review policy). Medical Staff leaders may also direct these matters to the Medical Executive Committee (MEC) for further action.


ARTICLE I - PART B: INVESTIGATIONS

Section 1. Initial Procedure:

(a) Whenever a concern or question has been raised or where collegial efforts have not resolved an issue regarding:

(1) the clinical competence or clinical practice of any Member; (2) the care or treatment of a patient or patients or management of a case by any

Member; (3) the known or suspected violation by any Member of applicable ethical

standards or the Medical Staff Bylaws, Manuals, Rules or Regulations or the Hospital Policies, including, but not limited to the Hospital’s quality assessment, risk management, and utilization review programs; and/or

(4) behavior or conduct on the part of any Member that is considered lower than

the standards of the Hospital or disruptive to the orderly operation of the Hospital or its Medical Staff, including the inability of the Member to work harmoniously with others;

the matter may be referred to the President, a Clinical Service Chief, the Chairperson of the Credentials Committee, the Chief Medical Officer, or the Chief Executive Officer who shall make sufficient inquiry and shall review the matter with at least one other person included on the above list in order to satisfy himself or herself that the concern or question raised is credible. If any of the inquiring individuals set forth in this provision believe the issue is credible, it shall be submitted to the MEC for further review and investigation in accordance with this Article I, Part B. Matters of a severe nature should also be immediately referred to the President.

(b) No action taken pursuant to this Section shall constitute an investigation. Section 2. Initiation of Investigation:

(a) When a concern or question involving clinical competence or behavior/conduct has been referred to or raised by the MEC, that committee shall review the matter and determine whether to conduct an investigation or to direct the matter to be handled pursuant to another policy. In making this determination, the MEC may discuss the matter with the Member concerned. An investigation shall begin only after a formal determination by the MEC.

(b) The MEC will inform the individual that an investigation has begun. Notification

may be delayed if, in the MEC's judgment, informing the individual immediately would compromise the investigation or disrupt the operation of the Hospital or the Medical Staff.


(c) The MEC or the Board may initiate an investigation on their own motion without

preliminary investigation. (d) The President shall promptly notify the Chief Executive Officer of all such requests

and investigations, and shall keep the Chief Executive Officer fully informed of all action taken in connection therewith.

Section 3. Investigative Procedure:

(a) Once a determination has been made to begin an investigation, the MEC shall either investigate the matter itself, or direct the President to appoint an individual or an ad hoc investigating committee (“investigating committee”) to conduct the investigation. This ad hoc investigating committee shall not include partners, associates or relatives of the Member being investigated, but may include individuals not on the Medical Staff. Whenever the question raises concerns about the clinical competence of the Member under review, the investigating committee shall include a peer of the Member (e.g., physician, dentist, psychologist, podiatrist) .

(b) The investigating committee shall have the authority to request and review relevant

documents and interview individuals. Individuals should be counseled regarding the importance of confidentiality. The investigating committee shall also have available to it the full resources of the Medical Staff and the Hospital, as well as the authority to use outside consultants, if needed. An outside consultant or agency may be used whenever a determination is made by the Hospital and the investigating committee that: (1) the clinical expertise needed to conduct the review is not available on the Medical Staff; or (2) the Member under review is likely to raise, or has raised, questions about the objectivity of other Members on the Medical Staff (whether or not such questions have merit); or (3) the Members with the necessary clinical expertise on the Medical Staff would not be able to conduct a review without risk of allegations of bias, even if such allegations are unfounded. Legal counsel for the Hospital will not generally attend the ad hoc investigating committee meetings and deliberations, except the committee may from time to time meet with legal counsel for the Hospital to seek advice and guidance from such counsel regarding appropriate procedures under the Bylaws, Manuals and applicable law.

(c) The investigating committee may also require a physical and/or mental

examination of the Member being investigated by a health care practitioner(s) satisfactory to the committee. The Member shall execute a release allowing (i) the investigating committee (or its representative) to discuss with the health care professional(s) conducting the examination the reasons for the examination; and (ii) the health care professional(s) conducting the examination to discuss and provide documentation of the results of such examination directly to the investigating committee.


(d) The Member being investigated shall have an opportunity to meet with the investigating committee before it makes its report, and a court reporter shall be present at any such meeting. The cost of such court reporter shall be borne by the Hosptial, but copies of the transcript, if desired by the Member shall be at the Member’s expense Prior to this meeting the Member shall be informed of the general nature of the evidence supporting the question being investigated and shall be invited to discuss, explain or refute it. This meeting shall not constitute a hearing, and none of the procedural rules provided in this policy with respect to hearings shall apply. The Member being investigated will not have the right to be represented by legal counsel at this meeting, and no lawyers shall be present at the meeting. A summary of the meeting shall be made by the investigating committee and included with its report to the MEC.

(e) The investigating committee shall make a reasonable effort to complete the

investigation and issue its report within forty five (45) days of the commencement of the investigation, provided that an outside review is not necessary. When an outside review is necessary, the investigating committee shall make a reasonable effort to complete the investigation and issue its report within thirty (30) days of receiving the results of the outside review. These time frames are intended to serve as guidelines and, as such, shall not be deemed to create any right for a Member to have an investigation completed within such time periods. In the event the investigating committee is unable to complete the investigation and issue its report within these time frames, it shall inform the Member of the reasons for the delay and the approximate date on which it expects to complete the investigation.

(f) At the conclusion of the investigation, the investigating committee shall prepare a

report with its findings, conclusions and recommendations. (g) In making its recommendations, the investigating committee shall strive to achieve

a consensus as to what is in the best interests of patient care and the smooth operation of the Hospital, while balancing fairness to the Member, recognizing that fairness does not require that the Member agree with the recommendation. Specifically, the committee may consider:

(1) relevant literature and clinical practice guidelines, as appropriate; (2) all of the opinions and views that were expressed throughout the review,

including report(s) from any outside review(s); (3) any information or explanations provided by the Member under review.

(h) If an individual, subcommittee or ad hoc investigating committee is used, the MEC may accept, modify or reject the recommendation it receives from that committee.

Section 4. Procedure Thereafter:

(a) After reviewing the findings and recommendation(s) of the investigating committee, the MEC shall:


(1) adopt the recommendation of the investigating committee; (2) refer the matter back to the investigating committee for its further investigation

and preparation of responses to specific questions raised by the MEC prior to its final recommendation; or

(3) set forth in its report and recommendation, clear and convincing reasons,

along with supporting information, for its disagreement with the investigating committee’s recommendation, and forward its recommendation and findings to the Board through the Chief Executive Officer.

(b) At the conclusion of the investigation, the MEC may recommend any of the

following or any combination of the following:

(1) the care and/or conduct of the Member was appropriate; (2) no action is justified; (3) a letter of guidance, counsel, warning, or reprimand be issued; (4) conditions for continued appointment be imposed; (5) a requirement for prospective, concurrent, or retrospective monitoring or

consultation be imposed; (6) additional counseling, training, or education be required; (7) Clinical Privileges be reduced or restricted; (8) Clinical Privileges be suspended for a term; (9) Medical Staff appointment and/or Clinical Privileges be revoked; and (10) other recommendations as it deems necessary or appropriate.

(c) Any recommendation by the MEC that would entitle the Member to request a Hearing as provided in Article II of this Manual shall be forwarded to the Chief Executive Officer who shall promptly give Notification to the Member. The Chief Executive Officer shall then hold the recommendation until after the Member has exercised or waived the right to request a hearing, after which time the Chief Executive Officer shall forward the original or revised, if applicable, recommendation of the MEC, together with all supporting information, to the Board.

(d) If the MEC makes a recommendation that does not entitle the individual to request

a hearing, it shall take effect immediately and shall remain in effect until modified by the Board.


(e) In the event the Board modifies the action of the MEC and such modification would entitle the Member to request a hearing in accordance with this policy, the MEC, through the Chief Executive Officer, shall provide the Member with Notification and no final action shall be taken until the Member has exercised or has waived the right to request a hearing.

(f) When applicable, any recommendations or actions that are the result of an

investigation or hearing and appeal should be monitored by the MEC on an ongoing basis through the Hospital’s performance improvement activities or pursuant to the applicable policies regarding conduct, as appropriate.

ARTICLE I - PART C: PRECAUTIONARY SUSPENSION OF CLINICAL PRIVILEGES

Section 1. Grounds for Precautionary Suspension:

(a) Whenever, in their sole discretion, failure to take such action may result in imminent danger to the health and/or safety of any individual, either (i) the President of the Medical Staff, (ii) the Chief Executive Officer, or (iii) the Board Chair, after reviewing the matter with one other person on the above list, shall each have the authority to suspend or restrict all or any portion of the Clinical Privileges of a Member, and/or afford the Member an opportunity to voluntarily refrain from exercising privileges pending an investigation.

(b) A precautionary suspension or restriction can be imposed at any time including, but

not limited to, immediately after the occurrence of an event that causes concern, following a pattern of occurrences that raises concern, or following a recommendation of the MEC that would entitle the Member to request a hearing.

(c) Such precautionary suspension or restriction shall be deemed an interim step in

the Professional Review Activity, but it is not a complete Professional Review Action in and of itself. It shall not imply any final finding of responsibility for the situation that caused the suspension or restriction.

(d) Such precautionary suspension shall become effective immediately upon

imposition, shall be subsequently confirmed in a written letter to the Member, and shall remain in effect unless or until modified by the President of the Medical Staff, the Chief Executive Officer or the Board.

Section 2. Medical Executive Committee Procedure:

(a) Any individual who exercises authority under Section l of this Part C to suspend or restrict Clinical Privileges as a precaution shall immediately report this action to the other individuals having the same authority under that section, who shall take any further action necessary in the matter.


(b) Prior to the imposition of the suspension, or where not practical within 14 days after the imposition of the suspension,the Member may be given an opportunity to meet with the Emergency Suspension Review Committee, which includes the Chief Executive Officer or designee and two or more physicians who are either (i) Officers of the Medical Staff or members of the MEC or (ii) the Chair of the Department,, to discuss the basis for the suspension and confirm that a suspension is necessary. The individual may propose ways other than a precautionary suspension or restriction to protect patients, employees and/or the smooth operation of the Hospital, depending on the circumstances involved.

(c) After considering the matters resulting in the suspension or restriction and the

individual's response, if any, the Emergency Suspension Review Committee shall make a recommendation to the Chief Executive Officer or the Board that the precautionary suspension or restriction should be continued, modified or terminated and shall make a recommendation to the MEC whether it is necessary to commence an investigation.

(d) If the Chief Executive Officer or the Board makes a decision to continue the

suspension, written notice of this decision will be sent to the individual. The notice will include the basis for the decision and that suspensions lasting longer than 30 days must be reported to the National Practitioner Data Bank.

Section 3. Care of Suspended Member’s Patients:

(a) Immediately upon the imposition of a precautionary suspension or restriction, the appropriate Service Chief or, if unavailable, the President, shall assign to another Member with appropriate Clinical Privileges, responsibility for care of the suspended Member’s patients still in the Hospital, or to aid in the implementing of the precautionary restriction, as appropriate. The assignment shall be effective until such time as the patients are discharged. The wishes of the patients shall be considered in the selection of the assigned Member(s).

(b) It shall be the duty of all Members to cooperate with the President, the Service

Chief concerned, the Credentials Committee, the MEC, and the Chief Executive Officer in enforcing all precautionary suspensions or restrictions.


ARTICLE I - PART D: OTHER ACTIONS

Section 1. Failure to Complete Medical Records or Utilize Electronic Medical Record:

The elective and emergency Clinical Privileges of any Member shall be deemed to be automatically relinquished for failure to complete medical records in accordance with applicable Rules and Regulations governing the same, after Notification by the medical records department of such delinquency. Such relinquishment shall continue until all the records of the Member’s patients are no longer delinquent and reinstatement accomplished in accordance with the applicable Rules and Regulations. Failure to complete the medical records that caused relinquishment of Clinical Privileges within sixty (60) calendar days from the relinquishment of such Clinical Privileges shall result in automatic resignation from the Medical Staff. The elective and emergency Clinical Privileges of any Member shall be deemed to be placed on probation for a period of thirty (30) calendar days for failure to utilize the Electronic Medical Record (EMR) after notification by the Hospital of such delinquency. Failure to provide evidence of complete compliance at the end of the thirty (30) day probationary period shall result in an automatic relinquishment of such Clinical Privileges and an automatic resignation from the Medical Staff.

Section 2. Action by Government Agency or Insurer:

(a) Any action taken by any licensing board, professional liability insurance company, court, or government agency regarding any of the matters set forth below must be promptly reported to the Chief Executive Officer by the Member.

(b) A Member's appointment and clinical privileges shall be automatically relinquished

if any of the following occur:

(1) Licensure: Revocation, expiration, suspension, or the placement of conditions or restrictions on a Member's license.

(2) Controlled Substance Authorization: Revocation, expiration, suspension or the

placement of conditions or restrictions on a Member's DEA controlled substance authorization, where applicable (In the case of expiration the President may elect to curtail only ordering of controlled substances).

(3) Insurance Coverage and/or Financial Responsibility: Failure of a Member to

comply with the State of Florida laws governing financial responsibility for physicians, or such other financial responsibility or insurance coverage required by contract with Hospital.

(4) Medicare and Medicaid Participation: Termination, exclusion, or preclusion by

government action from participation in the Medicare/Medicaid or other federal or state health care programs.


(5) Criminal Activity: Indictment, conviction, or a plea of guilty or no contest pertaining to any felony, or to any misdemeanor involving (i) controlled substances; (ii) illegal drugs; (iii) Medicare, Medicaid, or insurance or health care fraud or abuse.

(c) Automatic relinquishment shall take effect immediately upon notice to the Hospital

and continue until the matter is resolved, if applicable. (d) Failure to resolve the underlying matter leading to a Member's clinical privileges

automatically relinquished in accordance with paragraphs (b)(1), (b)(2) or (b)(3) above, within 90 days of the date of relinquishment shall result in automatic resignation from the Medical Staff. If a Member engages in any patient contact after the occurrence of an event that results in automatic relinquishment, without notifying the Hospital of that event, then the relinquishment shall be deemed permanent.

(e) Requests for reinstatement from an automatic relinquishment shall be reviewed by

the relevant Service Chief and either the President of the Medical Staff or the Chief Executive Officer. If both of these individuals makes a favorable recommendation on reinstatement, the Member may immediately resume clinical practice at the Hospital. This determination shall then be forwarded to the Credentials Committee, MEC, and the Board for ratification. If, however, the individual reviewing the request has any questions or concerns, those questions shall be noted and the reinstatement request shall be forwarded to the Credentials Committee, MEC, and Board for review and recommendation.

Section 3. Failure to Provide Requested Information:

If at any time a Member fails to provide requested information pertaining to patient care issues, peer review activities, and/or qualifications for appointment or maintaining Clinical Privileges (including but not limited to information related to automatic relinquishment of privileges and/or physical or mental examination reports as specified elsewhere in this manual) pursuant to a formal request by the Credentials Committee, the MEC, the Board, any other committee engaged in peer review or the Chief Executive Officer, the Member's Clinical Privileges shall be deemed to be voluntarily relinquished until the required information is provided to the satisfaction of the requesting party. For purposes of this section “required information” includes, but is not limited to: (i) physical or mental examination reports as specified elsewhere in this policy; or (ii) information necessary to explain an investigation, Professional Review Action, or resignation from another health care facility or agency.

Section 4. Failure to Attend Special Conference:

(a) Whenever there is an apparent or suspected deviation from standard clinical practice involving any Member, the CEO or the President may require the Member to attend a special conference with Medical Staff leaders and/or with a standing or ad hoc committee of the Medical Staff.


(b) The notice to the Member regarding this conference shall be given by special

notice at least three days prior to the conference and shall inform the Member that attendance at the conference is mandatory.

(c) Failure of the Member to attend the conference shall be reported to the MEC.

Unless excused by the MEC upon a showing of good cause, such failure shall result in automatic relinquishment of all or such portion of the Member's clinical privileges as the MEC may direct. Such relinquishment shall remain in effect until the matter is resolved.

Section 5. Procedure for Leave of Absence:

(a) Members may, for good cause, be granted a leave of absence by the Board for a

definitely stated period of time not to exceed one (1) year (except for military service). Requests for a leave of absence shall be made in writing to the Chairperson of the Credentials Committee, and shall state the beginning and ending dates, if possible, of the requested leave. The Credentials Committee shall consider the request and make a recommendation to the MEC, and the MEC shall make a recommendation for action by the Board. The granting of a leave of absence, or reinstatement, as appropriate, may be conditioned upon the Member's completion of all medical records.

(b) During the leave of absence, the Member shall not exercise any clinical privileges

at the Hospital or be entitled to any of the benefits of Medical Staff Membership. In addition, the Member shall be excused from all Medical Staff responsibilities (e.g., meeting attendance, committee service, emergency service call obligations) during this period.

(c) Members of the Medical Staff must report to the Chief Executive Officer any time

they are away from Medical Staff and/or patient care responsibilities for longer than 30 days, and must provide the reason for such absence and explain whether it is related to their physical or mental health or otherwise related to their ability to care for patients safely and competently. Under such circumstances, the Chief Executive Officer, in consultation with the President of the Medical Staff, may effectuate an automatic leave of absence. The Chief Executive Officer shall also notify the Credentials and MECs of all such requests.

(d) At the conclusion of the leave of absence, the Member may be reinstated, upon

filing a written statement at least thirty (30) days prior to the termination or expiration of the leave with the Chairperson of the Credentials Committee summarizing the professional activities undertaken during the leave of absence. The Member shall also provide such other information as may be requested by the Hospital. Requests for reinstatement shall then be reviewed by the relevant


Service Chief, the Chairperson of the Credentials Committee, the President, and the Chief Executive Officer. If all of these individuals make a favorable recommendation on reinstatement, the Member may immediately resume clinical practice at the Hospital. This determination shall then be forwarded to the Credentials Committee, the MEC, and the Board for ratification. If, however, any of the individuals reviewing the request have any questions or concerns, those questions shall be noted and the reinstatement request shall be forwarded to the Credentials Committee, MEC, and Board for review and recommendation. However, if a request for reinstatement is not granted, for reasons related to clinical competence or professional conduct, the Member shall be entitled to request a hearing and appeal.

(e) If the leave of absence was for health reasons, then the Member must submit a

report from his or her Practitioner indicating that the Member is physically and mentally capable of exercising the Clinical Privileges requested. The Member shall also provide such other information as may be requested by the Credentials Committee at that time. All information shall be forwarded by the Chief Executive Officer to the Credentials Committee. After considering all relevant information, the Credentials Committee shall then make a recommendation regarding reinstatement to the MEC.

(f) Leaves of absence are matters of courtesy, not of right. In the event that it is

determined that a Member has not demonstrated good cause for a leave, or where a request for extension is not granted, the determination shall be final, with no recourse of a hearing and/or appeal.

(g) Unless an extension is granted by the Chief Executive Officer upon

recommendation of the MEC, an absence for longer than the period of time granted shall constitute voluntary resignation of Medical Staff appointment and Clinical Privileges with no recourse of a hearing and/or appeal. Members may be granted a leave of absence for an additional time period, which may exceed one (1) year. Such additional leave must be for good cause and must be approved by the Board. In no event shall a leave of absence exceed two (2) years, including any extensions granted hereunder; and any leave of absence lasting longer than a two-year period shall constitute a voluntary resignation from Medical Staff appointment and Clinical Priviliges.

Section 6. Disciplinary Suspension:

(a) The MEC may, with the approval of the Chief Executive Officer, institute one or more disciplinary suspensions of a Member for a cumulative period not to exceed twenty-nine (29) days in a calendar year. Issuance of a disciplinary suspension will not entitle the Member to the hearing provisions of Article II.

(b) A disciplinary suspension may be instituted only when all of the following criteria

have been met:


(1) When the action that has given rise to the suspension relates to one or more of the following policies of the Medical Staff: completion of medical records or the appropriate utilization of electronic medical records (EMR) (as required pursuant to the Rules and Regulations), practitioner behavior (or disruptive practitioner policy), requirements for the emergency coverage, and/or violations of the Bylaws, Manuals or Rules & Regulations.

(2) When the action(s) have been reviewed by the MEC and only when the MEC

has determined that one or more of the above policies has been violated. (3) When the Member has received at least one (1) written warning within the last

twelve (12) months regarding the conduct in question. Such warning(s) must state the conduct or behavior that is questioned and specify or refer to the applicable policy, and state the consequence of any repeated violation of the policy.

(4) When the affected Member has been offered an opportunity to meet with the

MEC (or a designated committee of the MEC authorized to meet with the Member) to discuss the planned imposition of the disciplinary suspension, he/she will be given at least three days notice of such a meeting and attendance will be mandatory. Failure to appear for a meeting with the MEC will not preclude the MEC from imposing a disciplinary suspension. Failure on the part of the Member to accept the MEC offer of a meeting will constitute a violation of the Bylaws regarding “special meetings” and will not prevent the MEC from issuing the disciplinary suspension.

(c) Disciplinary Suspension and provision for coverage of existing hospitalized

patients:

(1) A disciplinary suspension will take effect after the Member has been given an opportunity to either arrange for his/her patients currently at the Hospital to be cared for by another qualified Member or until he/she has had an opportunity to provide needed care prior to discharge. During this period, the suspended Member will not be permitted to schedule any elective admissions, surgeries, or procedures.

(2) The President of the Medical Staff or Service Chief will determine details of the extent to which the Member may continue to be involved with hospitalized patients prior to the effective date of the disciplinary suspension.


ARTICLE II: HEARING AND APPEAL PROCEDURAL POLICY

ARTICLE II - PART A: INITIATION OF HEARING

Section 1. Grounds for Hearing:

(a) Except as provided for in Section 2 of this Part A, an Applicant to the Active or Associate Staff or a Medical Staff Member shall be entitled to request a hearing whenever one of the following recommendations has been made by the MEC or the Board of Directors:

(1) denial of initial Medical Staff appointment; (2) denial of Medical Staff reappointment; (3) revocation of Medical Staff appointment; (4) denial of requested Clinical Privileges; (5) revocation of Clinical Privileges; (6) suspension of Clinical Privileges for more than (29) twenty nine days (other

than precautionary suspension); (7) imposition of a mandatory concurring consultation requirement, that is, a

requirement that a consultant approve the course of treatment of a patient before Member's Clinical Privileges may be exercised; or

(8) Denial of reinstatement from a leave of absence.

(b) No other recommendations except those enumerated above shall entitle the

Applicant or Member to request a hearing. (c) The Applicant or Member shall also be entitled to request a hearing before the

Board of Directors enters a final decision. In the event the Board of Directors takes any actions set forth above, without a prior similar recommendation of the MEC triggering the Applicant’s or Member’s right to appeal, the Applicant or Member shall have the right to request a hearing.


Section 2. Events Than Are Not Grounds for A Fair Hearing: A Member shall not be entitled to any review of a recommendation or action which is not defined in Article II, Part A, Section 1(a) above, provided that the Member will be entitled to submit a written explanation to be placed into his or her file. Without limitation, hearings are not triggered by the following actions:

(a) Issuance of a letter of guidance, warning, counsel, or reprimand, imposition of a request for continuing education or training, or a chart review requirement;

(b) Failure to comply with Board Certification requirements as defined in the

Credentials Procedure Manual (c) Imposition of conditions, monitoring, or general consultation requirement (i.e.,

the Member must obtain a consult but not get prior approval for the treatment); (d) Deferral of a request for privileges not central or directly related to the

applicant’s prior training and practice, including satisfying Member Utilization Requirements;

(e) Failure to accept or consider an application or reapplication for membership or

Clinical Privileges because the Practitioner has not satisfied the minimum or threshold criteria for such membership or privileges;

(f) Termination of appointment or Clinical Privileges because of either (i) a lack of

need or resources, (ii) employment by the Hospital, or (iii) because of an exclusive contract;

(g) Termination of temporary privileges (h) Automatic or voluntary relinquishment of appointment or privileges; (i) Assignment of a reappointment period that is less than two (2) years; (j) Precautionary suspension; (k) Denial of a request for leave of absence, or for an extension of a leave; (l) Determination that an application or reapplication is incomplete; (m)Termination of appointment or Clinical Privileges in accord with the terms of the

Practitioner’s contract with the Hospital or System; (n) Determination that an application will not be processed due to misstatement or

omission; (o) Decision not to expedite an application;


(p) Limitation or restriction of Privileges during Provisional Staff appointment or a

change in Clinical Privileges that is imposed on all Practitioners who are granted those Privileges;

(q) Extension of the Provisional Staff appointment or failure to grant an extension; (r) Voluntary relinquishment of Clinical Privileges pending obtaining requested

health status examination.

ARTICLE II - PART B: THE HEARING

Section 1. Notice of Recommendation:

When a recommendation is made which, according to this policy entitles an Applicant or Member to a hearing prior to a final decision of the Board of Directors, the Applicant or Member shall promptly be given Notification by the Chief Executive Officer. This Notification shall contain:

(a) a statement of the recommendation made and the general reasons for it; (b) notice that the Applicant or Member has the right to request a hearing on the

recommendation within thirty (30) calendar days of receipt of this notice; and (c) a copy of this Article II setting forth the Applicant or Member’s rights to a

hearing as provided for in this policy. Section 2. Request for Hearing:

An Applicant or Member shall have thirty (30) calendar days following the date of the receipt of such Notification within which to request the hearing. The request shall be by written Notification to the Chief Executive Officer, and shall include the name, address, and telephone number of the Member's counsel, if any. In the event the Applicant or Member does not request a hearing within the time and in the manner required by this policy, the Applicant or Member shall be deemed to have waived the right to the hearing and to have accepted the action involved. That action shall become effective immediately upon final action by the Board of Directors.

Section 3. Notice of Hearing and Statement of Reasons:

(a) The Chief Executive Officer (or an appropriate designee) shall schedule the hearing and shall give Notification to the Applicant or Member who requested the hearing. The Notification shall include:

(1) the time, place and date of the hearing;


(2) a proposed list of witnesses, as known at that time, but which may be modified, who will give testimony or present evidence at the hearing in support of the MEC or the Board of Directors, and a brief summary of the anticipated testimony;

(3) the names of the Hearing Panel members (as set forth below in Section 5(a)(1))

and Presiding Officer or Hearing Officer (as set forth below in Section 5(b)(2)) if known; and

(4) a statement of the specific reasons for the recommendation (the “Statement of

Reasons”), including a list of patient records (if applicable), and information supporting the recommendation. This Statement of Reasons may be revised or amended at any time, even during the hearing, so long as the additional material is relevant to the recommendation or the Applicant or Member's qualifications and the individual has had a sufficient opportunity, up to 30 days, to review and rebut the additional information.

(b) The hearing shall begin as soon as practicable, but no sooner than thirty (30)

calendar days, nor more than sixty (60) calendar days, after receipt of the Notification of the hearing unless an earlier or later hearing date has been specifically agreed to in writing by the parties, or the hearing cannot be reasonably convened.

Section 4. Witness List:

(a) The Applicant or Member requesting the hearing shall provide a written list of the names of the individuals expected to offer testimony or evidence on the Applicant’s or Member’s behalf within fourteen (14) calendar days after receiving Notification of the hearing.

(b) The witness list of either party may, at the discretion of the Presiding Officer or

Hearing Panel Chairperson, be supplemented or amended at any time during the course of the hearing, provided that notice of the change is given to the other party. The Presiding Officer shall have the authority to limit the number of witnesses, as set forth in Section 5(b)(3) of this Article II, Part B, especially character witnesses or witnesses whose testimony is merely cumulative.

Section 5. Hearing Panel and Presiding Officer:

(a) Hearing Panel:

(1) When a hearing is requested, the Chief Executive Officer, acting for the Board of Directors and after considering the recommendations of the President (and that of the Chairperson of the Board of Directors, if the hearing is occasioned by a determination of the Board of Directors) shall appoint a hearing panel which shall be composed of not less than three (3) Members (the "Hearing Panel" or "Panel"). The Hearing Panel shall be composed of: (i) Members who shall not have actively participated in the consideration of the matter involved at any


previous level; (ii) Practitioners not on the Medical Staff; or (iii) any combination of such persons. The Hearing Panel shall not include any Applicant or Member who is in direct economic competition with the Applicant or Member or any individual who is professionally associated with, or related to the Applicant or Member. Knowledge of the matter involved shall not preclude any individual from serving as a member of the Hearing Panel. Employment by, or other contractual arrangement with the Hospital or an affiliate shall not preclude an individual from serving on the Panel. The Panel shall not include any individual who is demonstrated to have an actual bias, prejudice, or conflict of interest that would prevent the individual from fairly and impartially considering the matter.

(2) The Chief Executive Officer shall designate a Presiding Officer.

(b) Presiding Officer:

(1) The Chief Executive Officer may appoint an active or retired attorney at law as Presiding Officer. Such Presiding Officer must not act as a prosecuting officer, or as an advocate for either side at the hearing and is not entitled to vote.

(2) If an attorney has not been appointed to be the Presiding Officer, the Chief Executive Officer will select one of the panel members to serve as the Hearing Panel Chairperson and he or she shall be entitled to one (1) vote.

(3) The Presiding Officer (or Hearing Panel Chairperson) shall:

i. act to ensure that all participants in the hearing have a reasonable opportunity

to be heard and to present oral and documentary evidence subject to reasonable limits on the number of witnesses and duration of direct and cross examination, applicable to both sides, as may be necessary to avoid cumulative or irrelevant testimony or to prevent abuse of the hearing process;

ii. prohibit conduct or presentation of evidence that is cumulative, excessive,

irrelevant, abusive or that causes undue delay; iii. maintain decorum throughout the hearing; iv. determine the order of procedure throughout the hearing; v. have the authority and discretion, in accordance with this policy, to make

rulings on all questions which pertain to matters of procedure and to the admissibility of evidence;

vi. act in such a way that information relevant to the continued appointment or

Clinical Privileges of the Applicant or Member requesting the hearing is considered by the Hearing Panel in formulating its recommendations; and

vii. hear argument by counsel on procedural points outside the presence of the

Hearing Panel unless the Hearing Panel wishes to be present.


(4) The Presiding Officer may be advised by legal counsel to the Hospital with regard to the hearing procedure.

(5) The Presiding Officer may participate in the private deliberations of the Hearing

Panel and be a legal advisor to it.

(c) Objections:

Any objections to any member of the Hearing Panel, or the Hearing Officer or Presiding Officer, shall be made by written Notification, within 10 days of receipt of notice, to the Chief Executive Officer. A copy of such written objections must be provided to the President and must include the basis for the objections. The President shall be given a reasonable opportunity to comment. The Chief Executive Officer shall rule on the objections and give notice to the parties. The Chief Executive Officer may request that the Presiding Officer make a recommendation as to the validity of the objections.

Section 6. Counsel:

The Presiding Officer, Hearing Officer, and counsel for either party may be an attorney at law who is licensed to practice, in good standing, in any state.

ARTICLE II - PART C: PRE-HEARING PROCEDURE

Section 1. General Procedures:

The pre-hearing and hearing processes shall be conducted in an informal manner. Formal rules of evidence or procedure shall not apply.

Section 2. Provision of Relevant Information:

(a) There is no right to discovery in connection with the hearing. However, subject to (i) a stipulation signed by both parties that such documents shall be maintained as confidential and shall not be disclosed or used for any purpose outside of the hearing; and (ii) a written representation from the Member or Applicant that his/her counsel and any expert(s) have executed Business Associate agreements in connection with any patient Protected Health Information contained in any documents, the Applicant or Member requesting the hearing shall be entitled upon specific request to the following:

(1) copies of, or reasonable access to, all patient medical records referred to in the

Statement of Reasons (Part B, Section 3(a)(4)), at the Applicant’s or Member’s expense;


(2) reports of experts relied upon by the MEC or the Board of Directors; (3) copies of relevant minutes (with portions regarding other physicians and

unrelated matters deleted); and (4) copies of any other documents relied upon by the MEC or the Board of Directors

as the Presiding Officer (or Hearing Panel Chairperson) deems appropriate.

The provision of this information is not intended to waive any privilege under the state peer review protection statute.

(b) The Member or Applicant will have no right to discovery beyond the above

information. No information will be provided regarding other practitioners. (c) Prior to the hearing, on dates set by the Presiding Officer (or Hearing Panel

Chairperson) or agreed upon by counsel for both sides, each party shall provide the other party with its proposed exhibits. All objections to documents or witnesses to the extent then reasonably known, shall be submitted to the Presiding Officer (or Hearing Panel Chairperson) in writing in advance of the hearing. The Presiding Officer (or Hearing Panel Chairperson) shall not entertain subsequent objections unless the party offering the objection demonstrates good cause.

(d) Prior to the hearing, on dates set by the Presiding Officer (or Hearing Panel

Chairperson), the Applicant or Member requesting the hearing shall, upon specific request, provide the MEC (or the Board) copies of any expert report or other documents relied upon by the Applicant or Member.

(e) Evidence unrelated to the reasons for the recommendation or to the Member's

qualifications for appointment or the relevant clinical privileges shall be excluded. Specifically, unless character or lack of honesty is a basis for the recommended corrective action, the Applicant or Member may not present evidence of competency or character. In no event may the Applicant or Member present testimony, endorsement or opinions of the Applicant’s or Member’s patients or the patients' families.

(f) Neither the Applicant or Member nor any other person on behalf of the Applicant or

Member, shall contact the Hospital(s) employees whose names appear on the MEC's witness list or in documents provided pursuant to this section concerning the subject matter of the hearing until the Hospital has been notified and has contacted the employees about their willingness to be interviewed. The Hospital will advise the Applicant or Member once it has contacted such employees and confirmed their willingness to meet. Any employee may agree or decline to be interviewed by or on behalf of the Applicant or Member who requested a hearing.

Section 3. Pre-Hearing Conference:


(a) The Presiding Officer (or Hearing Panel Chairperson) will require counsel for the Applicant or Member and for the Hospital’s MEC (or the Board) to participate in a pre-hearing conference for purposes of resolving all procedural questions in advance of the hearing. The Presiding Officer (or Hearing Panel Chairperson) may specifically require that:

(1) all documentary evidence to be submitted by the parties be presented at this

conference; any objections to the documents shall be made at that time and the Presiding Officer (or Hearing Panel Chairperson) shall resolve such objections;

(2) evidence unrelated to the reasons for the unfavorable recommendation or

unrelated to the Applicant’s or Member’s qualifications for appointment or the relevant Clinical Privileges be excluded;

(3) the names of all witnesses and a brief statement of their anticipated testimony be

submitted; (4) the time granted to each witness’s testimony and cross-examination be agreed

upon, or determined by the Presiding Officer (or Hearing Panel Chairperson), in advance; and

(5) witnesses and documentation not provided and agreed upon in advance of the

hearing may be excluded from the hearing, including any objections to exhibits or witnesses.

Section 4. Stipulations:

The parties and counsel, if applicable, shall use their best efforts to develop and agree upon stipulations, so as to provide for a more orderly and efficient hearing by narrowing the issues on which live testimony is reasonably required.

Section 5. Provision of Information to the Hearing Panel:

The following documents will be provided to the Hearing Panel in advance of the hearing: (a) a pre-hearing statement that either party may choose to submit; (b) exhibits offered by the parties following the pre-hearing conference, (without the need for authentication); and (c) stipulations agreed to by the parties.


ARTICLE II - PART D: THE HEARING

Section 1. Failure to Appear:

Failure, without good cause, of the Applicant or Member requesting the hearing to appear and proceed at such a hearing shall be deemed to constitute waiver of the right to a hearing, and the matter shall then be forwarded to the Board for final action.

Section 2. Record of Hearing:

The Hearing Panel shall maintain a record of the hearing by a court reporter present to make a record of the hearing or a recording of the proceedings. The cost of such reporter shall be borne by the Hospital, but copies of the transcript, if desired by the Applicant or Member requesting the hearing, shall be at that Applicant’s or Member’s expense. Oral evidence shall be taken only on oath or affirmation administered by any person designated by such body and entitled to notarize documents in this State.

Section 3. Rights of Both Sides and the Hearing Panel:

(a) At a hearing both sides shall have the following rights, subject to reasonable limits determined by the Presiding Officer (or Hearing Panel Chairperson):

(1) to call and examine witnesses to the extent available; (2) to introduce exhibits; (3) to cross-examine any witness on any matter relevant to the issues raised at the

Hearing and to rebut any evidence; (4) representation by counsel;

(5) to submit a written statement in support of the position advanced by such party at

the close of the hearing; and (6) to submit proposed findings, conclusions, and recommendations to the Hearing

Panel. (b) Any Applicant or Member requesting a hearing who does not testify in his or her own

behalf may be called and examined as if under cross-examination. (c) The Hearing Panel may question the witnesses, call additional witnesses or request

additional documentary evidence.


Section 4. Admissibility of Evidence:

The hearing shall not be conducted according to rules of evidence. Hearsay evidence shall not be excluded merely because it constitutes hearsay. Any relevant evidence shall be admitted if it is the sort of evidence on which responsible persons are accustomed to rely in the conduct of serious affairs, regardless of the admissibility of such evidence in a court of law. The guiding principle will be that the record contains information sufficient to allow the Board to decide whether the Member or Applicant is qualified for appointment and Clinical Privileges.

Section 5. Post-Hearing Proposed Findings and Conclusions:

Each party will have the right to submit a written statement, and the Hearing Panel may request that statements be filed following the close of the hearing.

Section 6. Persons to be Present:

The Hearing shall be restricted to those individuals involved in the proceeding. Administrative personnel may be present as requested by the Chief Executive Officer or the President of the Medical Staff.

Section 7. Postponements and Extensions:

Postponements and extensions of time beyond any time limit set forth in this policy may be requested by anyone but shall be permitted only by the Presiding Officer (or Hearing Panel Chairperson), or the Chief Executive Officer on a showing of good cause.

Section 8. Presence of Hearing Panel Members:

A majority of the Hearing Panel shall be present throughout the hearing. In unusual circumstances when a Hearing Panel member must be absent from any part of the hearing, he or she shall read the entire transcript of the portion of the hearing from which he or she was absent.

ARTICLE II - PART E: HEARING CONCLUSION, DELIBERATIONS AND RECOMMENDATIONS

Section 1. Order of Presentation:

The MEC or the Board of Directors, depending on whose recommendation prompted the hearing initially, shall first present evidence in support of its recommendation. Thereafter, the burden shall shift to the Applicant or Member who requested the hearing.


Section 2. Basis of Recommendation:

(a) Consistent with the burden on an Applicant or Member to demonstrate that he or she satisfies, on a continuing basis, all criteria for initial appointment, reappointment and clinical privileges, the Hearing Panel shall recommend in favor of the MEC (or the Board) unless it finds that the Applicant or Member who requested the hearing has proved by clear and convincing evidence that the recommendation that prompted the hearing was arbitrary, capricious, or not supported by credible evidence.

Section 3. Deliberations and Recommendation of the Hearing Panel:

Within thirty (30) calendar days after final adjournment of the hearing (which may be designated as the time the Hearing Panel receives the hearing transcript or any post-hearing statements, whichever is later), the Hearing Panel shall conduct its deliberations outside the presence of any other person except the Presiding Officer (or Hearing Panel Chairperson), and shall render a recommendation, accompanied by a report, which shall contain a concise statement of the basis for the recommendation.

Section 4. Disposition of Hearing Panel Report:

The Hearing Panel shall deliver its report and recommendation to the Chief Executive Officer. A copy of the Hearing Panel’s report and recommendation shall be sent by the Chief Executive Officer to the Applicant or Member who requested the hearing, and to the MEC for information.

ARTICLE II - PART F: APPEAL PROCEDURE

Section 1. Time for Appeal:

Within twenty (20) calendar days after Notification of the Hearing Panel’s recommendation, either party may appeal the recommendation. The request shall be in writing, and must include a statement(s) of the reasons for appeal and the specific facts or circumstances which justify further review. Such written request shall be delivered to the Chief Executive Officer, either in person or by certified mail, return receipt requested. If such appellate review is not requested in writing within twenty (20) calendar days as provided herein, the parties shall be deemed to have waived the right to an appeal, and the Hearing Panel’s report and recommendation shall be forwarded to the Board of Directors for final action.


Section 2. Grounds for Appeal:

The grounds for appeal shall be limited to the following: (a) there was substantial and material failure by the Hearing Panel to comply with the

Medical Staff Bylaws, Manuals, Rules and Regulations and/or the Hospital’s Policies and procedures during the hearing so as to deny a fair hearing; and/or

(b) the recommendations of the Hearing Panel were made arbitrarily, capriciously or

were not supported by credible evidence.

Section 3. Time, Place and Notice:

Whenever an appeal is requested as set forth in the preceding sections, the Chairperson of the Board of Directors shall schedule and arrange for the appeal. The Applicant or Member shall be given Notification of the time, place and date of the appellate review. The appeal shall be held as soon as the arrangements may reasonably be made taking into account the schedules of all individuals involved.

Section 4. Nature of Appellate Review:

(a) The Chairperson of the Board of Directors shall appoint an Appellate Review Panel composed of not less than three (3) persons, either members of the Board of Directors or others, which may include, but not be limited to reputable persons outside the Hospital, to consider the record upon which the recommendation before it was made, or the Board of Directors may hear the appeal as a whole body.

(b) The Appellate Review Panel may in its discretion accept additional oral or written

evidence subject to the same rights of cross-examination or confrontation provided at the Hearing Panel proceedings. Such additional evidence will be accepted only if the party seeking to admit it can demonstrate that it is new, relevant evidence or that any opportunity to admit it at the hearing was improperly denied, and then only at the discretion of the Appellant Review Panel.

(c) Each party shall have the right to present a written statement in support of its

position on appeal. The party requesting the appeal shall submit a statement first and the other party shall then have ten days to respond. In its sole discretion, the Appellate Review Panel may allow each party’s representative to make oral argument not to exceed thirty (30) minutes.

(d) The Appellate Review Panel shall recommend final action to the Board of Directors.

The Appellate Review Panel may recommend that the Board of Directors affirm, modify or reverse the recommendation of the Hearing Panel or that the matter be


referred back to the Hearing Panel for further consideration or to the appropriate Medical Staff committee for further review.

Section 5. Appellate Review in the Event of Board Modification or Reversal of Hearing Panel Recommendation:

In the event the Board of Directors determines to modify or reverse the recommendation of a Hearing Panel in a matter in which the Applicant or Member did not request appellate review and such action would adversely affect the Applicant or Member, the Board of Directors shall give Notification to the Applicant or Member through the Chief Executive Officer that he or she may appeal the proposed modification or reversal. The Board of Directors shall take no final action until the Applicant or Member has exercised or has waived the procedural rights provided in this Part.

Section 6. Final Decision of the Board:

Within thirty (30) calendar days after receipt of the Appellate Review Panel’s recommendation, the Board of Directors shall render a final decision in writing, including specific reasons, and shall deliver copies thereof to the Applicant or Member and to the chairpersons of the Credentials and MECs by certified mail, return receipt requested. The Board may affirm, modify, or reverse the recommendation of the Appellate Review Panel or, in its discretion, refer the matter for further review and recommendation, or make its own decision based upon the Board's ultimate legal responsibility to grant appointment and Clinical Privileges.

Section 7. Further Review:

Except where the matter is referred for further action and recommendation, the final decision of the Board of Directors following the appeal shall be effective immediately and shall not be subject to further review. If the matter is referred pursuant for further action and recommendation, such recommendation shall be promptly made to the Board of Directors in accordance with the instructions given by the Board of Directors.

Section 8. Right to One Hearing and One Appeal Only:

No Applicant or Member shall be entitled to more than one (1) hearing and one (1) appeal on any matter which may be the subject of an appeal. If the Board of Directors determines to deny initial Medical Staff appointment or Clinical Privileges or reappointment, or to revoke or terminate the Medical Staff appointment and/or Clinical Privileges of a current Member, that Applicant or Member may not apply for Medical Staff appointment or for those Clinical Privileges at the Hospital for a period of five (5) years unless the Board of Directors provides otherwise.


ARTICLE III AMENDMENTS

(a) The Investigations, Corrective Action, Hearing and Appeal Plan Manual may be

amended as set forth in Article VIII of the Medical Staff Bylaws.


ARTICLE IV: MISCELLANEOUS

ARTICLE IV - PART A: CONFIDENTIALITY AND REPORTING

(a) Actions taken and recommendations made pursuant to this policy shall be treated as

confidential in accordance with applicable legal requirements and such policies regarding confidentiality as may be adopted by the Board of Directors. In addition, reports of actions taken pursuant to this policy shall be made by the Chief Executive Officer to such governmental agencies as may be required by law.

(b) All records and other information arising out of or generated as a result of

Professional Review Activities shall be confidential, and each individual or committee member participating in such Professional Review Activities shall agree to make no disclosures of any such information except as authorized, in writing, by the Chief Executive Officer or by legal counsel to the Hospital. Any breach of confidentiality by an individual or committee member may result in a Professional Review Action, and/or may result in appropriate legal action to ensure that confidentiality is preserved, including application to a court of law for injunctive or other relief. The President can remove any committee member if the President reasonably believes that such committee member has breached the confidentiality of any Professional Review Activities. Such removal shall not entitle the committee member to a hearing.

ARTICLE IV - PART B: PEER REVIEW PROTECTION

All minutes, reports, recommendations, communications, and actions made or taken pursuant to this policy are deemed to be covered by the provisions of Florida Statute Sections 395.0193 and 766.101 or the corresponding provisions of any subsequent federal or state statute providing protection to peer review or related activities. Furthermore, the committees and/or panels charged with making reports, findings, recommendations or investigations pursuant to this policy shall be considered to be acting on behalf of the Hospital and its Board of Directors when engaged in such Professional Review Activities and thus shall be deemed to be "professional review bodies" as that term is defined in the Health Care Quality Improvement Act of 1986, as may be amended from time to time.

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