Medical & Dental Staff Bylaws

MEDICAL AND DENTAL STAFF BYLAWS OF BAYSHORE MEDICAL CENTER A DIVISION OF HMH HOSPITALS CORPORATION April 1, 2018 TABLE OF CONTENTS Page ARTICLE I NAME AND DEFINITION 1.1 NAME ................................................................................................................................ 1 1.2 DEFINITIONS ................................................................................................................... 1 ARTICLE II PURPOSES AND RESPONSIBILITIES 2.1 PURPOSES ........................................................................................................................ 3 2.2 RESPONSIBILITIES ........................................................................................................ 4 2.3 PARTICIPATION IN PERFORMANCE IMPROVEMENT ACTIVITIES .................... 5 2.4 HISTORIES AND PHYSICALS ....................................................................................... 5 ARTICLE III ORGANIZED MEDICAL AND DENTAL STAFF MEMBERSHIP 3.1 NATURE OF MEMBERSHIP .......................................................................................... 6 3.2 BASIC QUALIFICATIONS FOR MEMBERSHIP .......................................................... 6 3.3 SPECIFIC QUALIFICATIONS FOR MEMBERSHIP .................................................... 6 3.4 MEMBERSHIP CONSIDERATIONS .............................................................................. 8 3.5 EFFECT OF OTHER AFFILIATIONS ............................................................................ 9 3.6 NONDISCRIMINATION.................................................................................................. 9 3.7 EMPLOYMENT OR CONTRACT STATUS................................................................... 9 3.8 BASIC RESPONSIBILITIES OF MEMBERSHIP .......................................................... 9 3.9 TERMS OF APPOINTMENT AND REAPPOINTMENT ............................................. 10 3.10 PROVISIONAL STATUS ............................................................................................... 10 3.11 LEAVE OF ABSENCE ................................................................................................... 11 ARTICLE IV CATEGORIES OF THE ORGANIZED MEDICAL AND DENTAL STAFF 4.1 CATEGORIES ................................................................................................................. 12 4.2 THE ACTIVE STAFF ..................................................................................................... 12 4.3 THE CONSULTING STAFF .......................................................................................... 14 4.4 AFFILIATE STAFF ........................................................................................................ 14 4.5 THE TELEMEDICINE STAFF ...................................................................................... 15 -i- TABLE OF CONTENTS (continued) Page 4.6 MEDICAL ASSOCIATES .............................................................................................. 15 4.7 REGIONAL STAFF ........................................................................................................ 16 4.8 THE EMERITUS STAFF ................................................................................................ 16 ARTICLE V PODIATRY STAFF 5.1 QUALIFICATIONS ........................................................................................................ 16 5.2 APPLICATION PROCEDURE AND ASSIGNMENT .................................................. 17 5.3 PREROGATIVES............................................................................................................ 17 5.4 RESPONSIBILITIES ...................................................................................................... 18 5.5 AUTHORITY .................................................................................................................. 18 5.6 PODIATRY STAFF ........................................................................................................ 18 ARTICLE VI ALLIED HEALTH PROFESSIONALS 6.1 RESPONSIBILITIES AND PRIVILEGES ..................................................................... 19 ARTICLE VII APPOINTMENT AND REAPPOINTMENT 7.1 GENERAL RESPONSIBILITY OF ORGANIZED MEDICAL AND DENTAL STAFF.............................................................................................................................. 20 7.2 PRE-APPLICATION FOR INITIAL APPOINTMENT ................................................. 20 7.3 APPLICATION FOR INITIAL APPOINTMENT .......................................................... 21 7.4 ACTION ON COMPLETE APPLICATION .................................................................. 24 7.5 REAPPOINTMENT PROCESS ...................................................................................... 27 7.6 REQUESTS FOR MODIFICATION OF APPOINTMENT ........................................... 29 7.7 ONGOING PROFESSIONAL PRACTICE EVALUATION ......................................... 29 7.8 FOCUSED PROFESSIONAL PRACTICE EVALUATION .......................................... 29 7.9 PRACTITIONER AND ALLIED HEALTH PROFESSIONAL IMPAIRMENT .......... 30 ARTICLE VIII CLINICAL PRIVILEGES 8.1 PRIVILEGES REQUIRED ............................................................................................. 30 8.2 CONFERRAL OF PRIVILEGES .................................................................................... 30 -ii- TABLE OF CONTENTS (continued) Page 8.3 TEMPORARY PRIVILEGES ......................................................................................... 31 8.4 EMERGENCY PRIVILEGES ......................................................................................... 33 8.5 TELEMEDICINE PRIVILEGES .................................................................................... 34 8.6 DISASTER PRIVILEGES .............................................................................................. 34 8.7 HEALTH STATUS ......................................................................................................... 35 8.8 RESIGNATION ............................................................................................................... 36 8.9 MEMBERS WITH ADMINISTRATIVE CONTRACTS............................................... 36 8.10 TREATMENT OF FAMILY MEMBERS ...................................................................... 36 ARTICLE IX CORRECTIVE ACTION 9.1 ROUTINE CORRECTIVE ACTION .............................................................................. 36 9.2 SUMMARY SUSPENSION ............................................................................................ 38 9.3 AUTOMATIC SUSPENSION ........................................................................................ 39 ARTICLE X HEARING AND APPELLATE REVIEW 10.1 RIGHT TO A HEARING AND TO APPELLATE REVIEW ........................................ 39 10.2 NOTICE OF PROPOSED ACTION ............................................................................... 40 10.3 REQUEST FOR A HEARING ........................................................................................ 41 10.4 NOTICE OF HEARING .................................................................................................. 42 10.5 COMPOSITION OF THE FAIR HEARING COMMITTEE ......................................... 42 10.6 PROCEDURAL DUE PROCESS RIGHTS OF THE AFFECTED INDIVIDUAL FOR THE HEARING ...................................................................................................... 43 10.7 CONDUCT OF THE HEARING .................................................................................... 43 10.8 OUTCOME OF HEARING ............................................................................................. 45 10.9 APPELLATE REVIEW................................................................................................... 46 ARTICLE XI DEPARTMENTS, SECTIONS, CLINICAL DIVISIONS AND INSTITUTES 11.1 ORGANIZATION INTO DEPARTMENTS .................................................................. 47 11.2 DESIGNATION .............................................................................................................. 48 11.3 ASSIGNMENT TO DEPARTMENTS, SECTIONS, AND CLINICAL DIVISIONS...................................................................................................................... 48 -iii- TABLE OF CONTENTS (continued) Page 11.4 FUNCTIONS OF DEPARTMENTS ............................................................................... 48 11.5 FUNCTIONS OF SECTIONS ......................................................................................... 49 11.6 FUNCTIONS OF CLINICAL DIVISIONS .................................................................... 49 11.7 INSTITUTES ................................................................................................................... 49 11.8 MEETING ATTENDANCE ............................................................................................ 50 11.9 RULES AND REGULATIONS ...................................................................................... 50 ARTICLE XII OFFICERS 12.1 OFFICERS OF THE ORGANIZED MEDICAL AND DENTAL STAFF ..................... 50 12.2 DEPARTMENT CHAIR ................................................................................................. 55 12.3 DEPARTMENT VICE-CHAIR....................................................................................... 58 12.4 PROGRAM DIRECTOR ................................................................................................

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