UNIVERSITY OF KENTUCKY UK HEALTHCARE MEDICAL STAFF BYLAWS ADOPTED AND APPROVED OCTOBER 11, 2010 AMENDED AND RESTATED DECEMBER 9, 2019 TABLE OF CONTENTS ARTICLE 1 DEFINITIONS ........................................................................................................... 1 ACGME ............................................................................................................................................. 1 Administration ................................................................................................................................... 1 Board of Trustees or Board ................................................................................................................ 1 Chair .................................................................................................................................................. 1 Chandler Hospital .............................................................................................................................. 1 Children’s Hospital ............................................................................................................................ 2 Chief Clinical Officer ........................................................................................................................ 2 Chief Medical Officer(s) .................................................................................................................... 2 Chief Nurse Executive ....................................................................................................................... 3 Chief Physician Executive ................................................................................................................. 3 CoPs ................................................................................................................................................... 3 Credentials Committee ...................................................................................................................... 3 Executive Vice President for Health Affairs ..................................................................................... 3 Fair Hearing Plan ............................................................................................................................... 4 GSA List ............................................................................................................................................ 4 Good Samaritan Hospital ................................................................................................................... 4 Governance Documents ..................................................................................................................... 4 HCQIA ............................................................................................................................................... 4 Health Professional Staff ................................................................................................................... 4 HIPAA ............................................................................................................................................... 4 Hospital .............................................................................................................................................. 4 Medical Staff...................................................................................................................................... 5 Medical Staff Executive Committee .................................................................................................. 5 Medical Staff Operating Subcommittee ............................................................................................ 5 OIG Sanction Report ......................................................................................................................... 5 Organized Medical Staff .................................................................................................................... 5 Patient Encounter ............................................................................................................................... 5 Peer Review Committee .................................................................................................................... 5 Practitioner ......................................................................................................................................... 5 President of the Medical Staff or President ....................................................................................... 6 Privileging Subcommittee(s) ............................................................................................................. 6 Professional Review Activity ............................................................................................................ 6 Professional Review Action............................................................................................................... 6 Third Party Service ............................................................................................................................ 6 UK HealthCare .................................................................................................................................. 6 University Health Care Committee .................................................................................................... 6 University or UK ............................................................................................................................... 7 Vice President .................................................................................................................................... 7 Vice President for Ambulatory Services ........................................................................................... 7 Vice President for Hospital Operations ............................................................................................. 7 ARTICLE 2 PURPOSE .................................................................................................................. 7 2.1 Medical Staff Purpose............................................................................................................. 7 2.2 Organized Medical Staff Purpose ........................................................................................... 8 2.3 Bylaws Purpose ...................................................................................................................... 9 ARTICLE 3 MEDICAL STAFF MEMBERSHIP ....................................................................... 10 ii 3.1 Nature of Membership .......................................................................................................... 10 3.2 Qualifications for Membership ............................................................................................. 10 3.3 Basic Responsibilities of Medical Staff Membership .......................................................... 12 3.4 Authority of the University Health Care Committee ............................................................ 15 ARTICLE 4 CATEGORIES OF THE MEDICAL STAFF .......................................................... 15 4.1 Categories ............................................................................................................................. 15 4.2 Faculty Appointment ............................................................................................................ 15 4.3 Primary Practice Site; Main Provider Clinical Privileges .................................................... 15 4.4 Organized Medical Staff ....................................................................................................... 16 4.5 Active Faculty ....................................................................................................................... 16 4.6 Active Community................................................................................................................ 17 4.7 Associate ............................................................................................................................... 17 4.8 Courtesy ................................................................................................................................ 18 4.9 University Health .................................................................................................................. 18 4.10 Voluntary .............................................................................................................................. 19 4.11 Clinical Fellow ..................................................................................................................... 19 4.12 Honorary ............................................................................................................................... 19 ARTICLE 5 HEALTH PROFESSIONAL STAFF ...................................................................... 20 5.1 Membership and Identification ............................................................................................. 20 5.2 Clinical Privileges ................................................................................................................. 20 5.3 Application Process .............................................................................................................. 20 5.4 Conditions and Term of Appointment .................................................................................