SUBJECT: Ebola Virus Disease Exposure Policy

INDEX: MS3-8 EFFECTIVE: 06/04/15 Page 1 of 2 SUPERSEDES: New

POLICY STATEMENT: The purpose of the Medical Staff Ebola Virus Disease Exposure Policy is to further patient care and safety through protocols and processes in the event a Member of the Medical Staff or Allied Health Professionals Staff (Credentialed Member) has been or may have been exposed to the Ebola Virus Disease or is returning from an area where there is an Ebola Virus Disease outbreak or where a quarantine has been imposed because of Ebola Virus Disease.

RULES:

A. NOTICE. All Credentialed Members shall promptly notify the Medical Executive Committee (MEC) as well the Medical Staff Office of the following:

1. Any plans to travel to an area in which there is an active outbreak of Ebola, or where quarantine has been imposed with regard to Ebola; 2. The return from any place where there has been an active outbreak of Ebola Virus Disease or where quarantine has been imposed with regard to Ebola; and 3. Any direct or indirect exposure to Ebola.

B. ASSESSMENT. Upon so notifying the MEC and Medical Staff Office, the Credentialed Member shall make himself/herself readily available for an immediate assessment by a physician(s) and shall cooperate fully with such assessment. The cost of the assessment shall be borne by the Credentialed Member. The assessment will include determining if the Credentialed Member carries the Ebola Virus Disease, or has the potential to carry the Ebola Virus Disease. The Credentialed Member shall execute all consents necessary to allow the MEC and Medical Staff Office access to the results of such assessment.

C. ACTIVITY PENDING ASSESSMENT. Prior to and pending the completion of such assessment, the Credentialed Member shall refrain from coming onto the grounds of Hendrick Medical Center or any affiliates of Hendrick Medical Center.

D. POST ASSESSMENT ACTIVITES. The Credentialed Member shall abide by all instructions/recommendations/restrictions of the assessing physician(s) and/or MEC, which may include but are not limited to one or more of the following:

1. Refrain from all patient care activities for a period of up to 21 days; 2. Refrain from coming onto the grounds of Hendrick Medical Center or any affiliates of Hendrick Medical Center for a period of up to 21 days; 3. Comply with all monitoring/observation protocols imposed by the assessing physician(s) or the MEC; INDEX: MS3-8 EFFECTIVE: 06/04/15 Page 2 of 2 SUPERSEDES: New

4. If it is determined that the Credentialed Member has been infected by the Ebola Virus Disease, such Credentialed Member shall comply with all guidelines as promulgated by the Centers for Disease with regard to Ebola Virus Disease exposure by healthcare workers; and 5. Comply with all other applicable infectious disease guidelines, local, state or national.

Any restrictions on clinical practice imposed under this Policy shall be considered a non-adverse corrective action under the Medical Staff Bylaws and shall not entitle the Credentialed Member to a hearing.

A failure to abide by this Policy or any instructions/recommendations/restrictions imposed under this policy may subject the Credentialed Member to disciplinary action under the Medical Staff Bylaws, including a permanent loss of membership and privileges.

Recommended by Medical Executive Committee: 04/30/15 Approved by the Board of Trustees: 06/04/15

Initially Approved: 06/04/15 Amended: Reviewed: