BYLAWS of THE MEDICAL STAFF of LENOX HILL HOSPITAL NEW YORK Table of Contents PREAMBLE ...................................................................................................................................1 DEFINITIONS ...............................................................................................................................3 ARTICLE I NAME.......................................................................................................................6 ARTICLE II PURPOSES ............................................................................................................7 ARTICLE III MEMBERSHIP ON THE MEDICAL STAFF .................................................8 Section 1. Membership a Privilege ......................................................................... 8 Section 2. Qualifications ......................................................................................... 8 Section 3. Professional Liability Insurance Coverage ............................................ 9 Section 4. Professional and Ethical Standards ...................................................... 10 Section 5. Term of Appointment and Reappointment .......................................... 12 Section 6. Application for Appointment ............................................................... 12 Section 7. The Appointment Process .................................................................... 15 Section 8. The Reappointment Process ................................................................. 18 Section 9. Expedited Credentialing....................................................................... 22 Section 10. Medical Staff Employed by the Hospital or Employed By a Medical Practice Entity With an Exclusive Contract With the Hospital ........... 23 Section 11. Leaves of Absence ............................................................................... 25 Section 12. Exemption from Membership and Privileges Relating to Organ Procurement ......................................................................................... 25 Section 13. Focused Professional Practice Evaluation ........................................... 26 Section 14. Ongoing Professional Practice Evaluation ........................................... 26 ARTICLE IV THE MEDICAL STAFF ...................................................................................27 Section 1. Medical Director .................................................................................. 27 Section 2. Categories Established ......................................................................... 28 Section 3. The Attending Medical Staff ............................................................... 29 Section 4. The Associate Medical Staff ................................................................ 30 Section 5. The Assistant Medical Staff ................................................................. 31 Section 6. The Courtesy Medical Staff ................................................................. 32 - i - 84456 v.1 Section 7. The Consulting Medical Staff .............................................................. 32 Section 8. The Honorary Medical Staff ................................................................ 33 Section 9. The Adjunct Medical Staff................................................................... 33 Section 10. Waiver of Qualifications ...................................................................... 35 ARTICLE V CLINICAL PRIVILEGES OF MEMBERS OF THE MEDICAL STAFF ...36 Section 1. Delineation of Clinical Privileges in General ...................................... 36 Section 2. Clinical Privileges of Dentists ............................................................. 37 Section 3. Clinical Privileges of Podiatrists .......................................................... 37 Section 4. Emergency, Temporary, Visiting Pro Tem & Disaster Privileges....... 37 Section 5. Telemedicine Privileges ....................................................................... 41 ARTICLE VI CORRECTIVE ACTION, SUMMARY SUSPENSION & AUTOMATIC TERMINATION/SUSPENSION ................................................................................................43 Section 1. Minor Infractions ................................................................................. 43 Section 2. Corrective Action ................................................................................. 43 Section 3. Summary Suspension ........................................................................... 45 Section 4. Automatic Suspension ......................................................................... 46 ARTICLE VII HEARING & APPELLATE REVIEW PROCEDURE ................................48 PART A INITIATION OF A HEARING ........................................................48 PART B THE HEARING .................................................................................48 Section 1. Grounds for Hearing ............................................................................ 48 Section 2. Notice of Recommendation or Action ................................................. 49 Section 3. Request for Hearing ............................................................................. 49 Section 4. Notice of Time and Place of Hearing .................................................. 49 Section 5. Statement of Reasons for the Recommendation or Action and List of Witnesses ............................................................................................. 50 Section 6. Composition of Hearing Committee .................................................... 50 Section 7. Failure to Appear ................................................................................. 51 Section 8. Postponements and Extensions ............................................................ 51 PART C HEARING PROCEDURES ..............................................................51 Section 1. Representation...................................................................................... 51 - ii - 84456 v.1 Section 2. The Presiding Officer ........................................................................... 52 Section 3. Record of Hearing ................................................................................ 52 Section 4. Rights of the Parties ............................................................................. 52 Section 5. Admissibility of Evidence.................................................................... 53 Section 6. Official Notice ..................................................................................... 53 Section 7. Basis of Decision ................................................................................. 53 Section 8. Burden of Proof.................................................................................... 54 Section 9. Adjournment and Conclusion .............................................................. 54 Section 10. Hearing Committee Report .................................................................. 54 Section 11. Action on Hearing Committee Report ................................................. 54 Section 12. Notice and Effect of Result .................................................................. 55 PART D APPELLATE REVIEW ....................................................................56 Section 1. Request for Appellate Review ............................................................. 56 Section 2. Grounds for Appeal.............................................................................. 56 Section 3. Notice of Time and Place of Appellate Review................................... 56 Section 4. Appellate Review Body ....................................................................... 56 Section 5. Nature and Procedure of Appellate Review ......................................... 57 Section 6. Action by the Appellate Review Body ................................................ 57 Section 7. Final Decision by the Board of Trustees.............................................. 57 Section 8. Right to One Hearing/Appellate Review ............................................. 58 ARTICLE VIII ALLIED HEALTH PROFESSIONAL STAFF............................................59 Section 1. General Provisions ............................................................................... 59 Section 2. Additional Provisions Regarding the Allied Health Professionals ...... 63 ARTICLE IX MEDICAL BOARD ...........................................................................................64 Section 1. Composition ......................................................................................... 64 Section 2. Procedure for Election of Elected Members of the Medical Board ..... 65 Section 3. Officers of the Medical Board ............................................................. 66 Section 4. Duties and Responsibilities of the President of the Medical Board ..... 67 Section 5. Duties and Responsibilities of the Vice President of the Medical Board .................................................................................................... 68 Section 6. Duties and Responsibilities of the Secretary of the Medical Board .... 68 - iii - 84456 v.1 Section 7. Duties and Responsibilities of the Medical Board ............................... 68 Section 8. Meetings, Quorum and Voting Requirements ..................................... 70 ARTICLE X ORGANIZATION OF CLINICAL DEPARTMENTS,