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BYLAWS OF THE MEDICAL STAFF - Aspirus Medical Staff

VIEWS: 0 PAGES: 91

									                       ASPIRUS WAUSAU HOSPITAL, INC.
                       Passion for excellence. Compassion for people.




ONBASE POLICY ID:     10379                       P&P REF : NEW
                                                  REPLACES:
POLICY STATUS : FINAL                             DOCUMENT TYPE: Policy
EFFECTIVE DATE: 3/31/11                           PROPOSED BY: Administration
REVISION DATE:                                    RESPONSIBLE DEPT: Provider Support Services
                                                  Class: AWH-DS-Admin

VERSION HISTORY: 3/31/2011, 06/25/08
Update approvals: Quality Review” 3/25/2011; MED: 3/30/2011; Accountability: 3/31/2011; BOD: 3/31/2011.
Committee/Department APPROVALS: Board of Directors: 6/25/08, Medical Staff: 06/25/08.


SUBJECT: MEDICAL STAFF BYLAWS


PURPOSE:
The benefits of membership on the staff may be obtained by individual practitioners and the
obligations of staff membership may be fulfilled.

AREAS AFFECTED/STAKEHOLDERS:
Medical Staff
Board of Directors
MEDICAL STAFF BYLAWS




                              Aspirus Wausau Hospital
                                   Wausau, Wisconsin

           Revised: 8/87; 6/88; 2/89; 2/90; 6/90; 11/90;
           2/91; 6/91; 6/92; 6/93; 9/93; 6/94; 6/97; 6/98;
          6/99; 2/00; 7/00; 10/01; 4/02; 6/03; 1/04; 6/04;
                        3/05; 7/06; 2/07; 6/07; 7/08; 3/11
                                         TABLE OF CONTENTS
                                        MEDICAL STAFF BYLAWS

ORGANIZATIONAL CHART ........................................................................................... x
PREAMBLE .................................................................................................................... 1
DEFINITIONS                                                                                                                   1

ARTICLE I: NAME                                                                                                                       3

ARTICLE II: PURPOSES AND RESPONSIBILITIES                                                                                             3

         2.1       PURPOSES ......................................................................................................... 3

         2.2       RESPONSIBILITIES ............................................................................................ 4
                   2.2-1 Accountability ........................................................................................... 4
                   2.2-2 Recommendation to Board ....................................................................... 5
                   2.2-3 Quality/Utilization Management ................................................................ 5
                   2.2-4 Corrective Action ...................................................................................... 5
                   2.2-5 Compliance with Bylaws, Rules and Regulations ..................................... 5
                   2.2-6 Identification of Needs and Goals ............................................................. 5
                   2.2-7 Authority ................................................................................................... 5

ARTICLE III: MEDICAL STAFF MEMBERSHIP                                                                                                 5

         3.1       NATURE OF MEDICAL STAFF MEMBERSHIP................................................... 5

         3.2       BASIC QUALIFICATIONS FOR MEMBERSHIP .................................................. 6
                   3.2-1 Basic Qualifications .................................................................................. 6
                   3.2-2 Effect of Other Affiliations ......................................................................... 7
                   3.2-3 Nondiscrimination ..................................................................................... 7
                   3.2-4 Administrative and Medico-Administrative Officers ................................... 7

         3.3       BASIC RESPONSIBILITIES OF INDIVIDUAL STAFF MEMBERSHIP ................. 7

         3.4       DURATION OF APPOINTMENT ......................................................................... 9
                   3.4-1 Duration of Initial Appointments and Modifications ................................... 9

         3.5       PROFESSIONAL PRACTICE EVALUATION ....................................................... 9

         3.6       CONTRACT PHYSICIANS ................................................................................ 10

         3.7       LEAVE OF ABSENCE ....................................................................................... 10
                   3.7-1 Leave Status .......................................................................................... 10
                   3.7-2 Termination of Leave.............................................................................. 10

         3.8       RESIGNATION .................................................................................................. 11

ARTICLE IV: CATEGORIES OF THE MEDICAL STAFF                                                                                         11



                                                                  i
     4.1   ACTIVE STAFF ................................................................................................. 11
           4.1-1 Qualifications.......................................................................................... 11
           4.1-2 Prerogatives ........................................................................................... 12
           4.1-3 Responsibilities ...................................................................................... 12

     4.2   COURTESY STAFF........................................................................................... 12
           4.2-1 Qualifications.......................................................................................... 12
           4.2-2 Prerogatives ........................................................................................... 13
           4.2-3 Responsibilities ...................................................................................... 13

     4.3   AFFILIATE STAFF ............................................................................................. 13
           4.3-1 Qualifications.......................................................................................... 13
           4.3-2 Prerogatives ........................................................................................... 14
           4.3-3 Responsibilities ...................................................................................... 14

     4.4   HONORARY STAFF .......................................................................................... 15
           4.4-1 Qualifications.......................................................................................... 15
           4.4-2 Prerogatives ........................................................................................... 15

     4.5   RESIDENTS ...................................................................................................... 15
           4.5-1 Resident Supervision.............................................................................. 15

     4.6   LIMITATIONS OF PREROGATIVES ................................................................. 16

     4.7   WAIVER OF QUALIFICATIONS ........................................................................ 16

ARTICLE V: ALLIED HEALTH PRACTITIONERS                                                                                        16

     5.1   GRANTING OF SCOPE OF PRACTICE ............................................................ 16
           5.1-1 Definition ................................................................................................ 16

     5.2   RECONSIDERATION OF SCOPE OF PRACTICE SERVICES ......................... 17

ARTICLE VI: PROCEDURES FOR APPOINTMENT AND REAPPOINTMENT                                                                      17

     6.1   GENERAL PROCEDURE .................................................................................. 17

     6.2   APPLICATION FOR INITIAL APPOINTMENT ................................................... 17
           6.2-1 Application Form .................................................................................... 17
           6.2-2 Content .................................................................................................. 18
           6.2-3 Application Processing Fee .................................................................... 18
           6.2-4 ............................................................................................................... 18

     6.3   EFFECTS OF APPLICATION ............................................................................ 18

     6.4   PROCESSING THE APPLICATION .................................................................. 19
           6.4-1 Applicant’s Burden ................................................................................. 19
           6.4-2 Verification of Information....................................................................... 19
           6.4-3 Department Action.................................................................................. 19


                                                           ii
           6.4-4     Bylaws/Credentials Committee Action .................................................... 20
           6.4-5     Medical Executive Committee Action...................................................... 20
           6.4-6     Effect of Medical Executive Committee Action ....................................... 20
           6.4-7     Board Action........................................................................................... 21
           6.4-8     Conflict Resolution ................................................................................. 22
           6.4-9     Notice of Final Decision .......................................................................... 22
           6.4-10    Reapplication After Adverse Appointment Decision ................................ 22
           6.4-11    Time Period for Processing .................................................................... 22

     6.5   REAPPOINTMENT PROCESS .......................................................................... 23
           6.5-1 Information Form for Reappointment ...................................................... 23
           6.5-2 Verification of Information....................................................................... 23
           6.5-3 Department Action.................................................................................. 23
           6.5-4 Bylaws/Credentials Committee Action .................................................... 23
           6.5-5 Medical Executive Committee Action...................................................... 24
           6.5-6 Final Processing and Board Action......................................................... 24
           6.5-7 Basis for Recommendation .................................................................... 24
           6.5-8 Time Periods for Processing .................................................................. 24

     6.6   REQUESTS FOR MODIFICATIONS OF TERMS OF APPOINTMENTS ........... 24
           6.6-1 Request Status Modification ................................................................... 24
           6.6-2 Request New Privileges ......................................................................... 25

ARTICLE VII: DETERMINATION OF CLINICAL PRIVILEGES                                                                          25

     7.1   EXERCISE OF PRIVILEGES............................................................................. 25

     7.2   DELINEATION OF PRIVILEGES ....................................................................... 25
           7.2-1 Requests ................................................................................................ 25
           7.2-2 Basic for Privilege Determination............................................................ 25
           7.2-3 Procedure............................................................................................... 26

     7.3   PRIVILEGES ..................................................................................................... 26

     7.4   SPECIAL CONDITIONS FOR DENTAL PRIVILEGES ....................................... 27

     7.5   SPECIAL CONDITIONS FOR PODIATRIC PRIVILEGES.................................. 27

     7.6   SPECIAL CONDITIONS FOR ALLIED HEALTH PRACTITIONERS .................. 27

     7.7   INTERIM, CASE LIMITED, OR TIME LIMITED PRIVILEGES ............................ 27
           7.7-1 Circumstances ....................................................................................... 27
           7.7-2 Conditions .............................................................................................. 28
           7.7-3 Termination ............................................................................................ 29
           7.7-4 Rights of the Practitioner ........................................................................ 29

     7.8   EMERGENCY PRIVILEGES .............................................................................. 29

     7.9   DISASTER PRIVILEGES ................................................................................... 29




                                                         iii
ARTICLE VIII: CORRECTIVE ACTION                                                                                             30

     8.1    ROUTINE CORRECTIVE ACTION .................................................................... 30
            8.1-1 Criteria for Initiation ................................................................................ 30
            8.1-2 Requests and Notices ............................................................................ 30
            8.1-3 Investigation ........................................................................................... 30
            8.1-4 Medical Executive Committee Action...................................................... 30
            8.1-5 Procedural Rights ................................................................................... 31
            8.1-6 Other Action ........................................................................................... 31

     8.2    PRECAUTIONARY SUSPENSION .................................................................... 31
            8.2-1 Criteria for Initiation ................................................................................ 31
            8.2-2 Medical Executive Committee Action...................................................... 31
            8.2-3 Procedural Rights ................................................................................... 31

     8.3    AUTOMATIC SUSPENSION ............................................................................. 32
            8.3-1 License ................................................................................................... 32
            8.3-2 Drug Enforcement Administration (DEA) Number .................................. 32
            8.3-3 Failure to Satisfy Special Appearance Requirements ............................. 32
            8.3-4 Medical Records..................................................................................... 32
            8.3-5 Failure to Practice Actively ..................................................................... 33
            8.3-6 Impairment ............................................................................................. 33
            8.3-7 Exclusion or Withdrawal From Federal Health Care Programs ............... 33
            8.3-8 Procedural Rights ................................................................................... 33

ARTICLE IX: INTERVIEWS, HEARINGS, AND APPELLATE REVIEW                                                                      34

     9.1    INTERVIEWS .................................................................................................... 34

     9.2    HEARING AND APPELLATE REVIEW .............................................................. 34
            9.2-1 Adverse Medical Executive Committee Recommendation ...................... 34
            9.2-2 Adverse Board Decision ......................................................................... 34
            9.2-3 Procedure and Process .......................................................................... 35
            9.2-4 Exceptions.............................................................................................. 35

     9.3    REMOVAL FROM OFFICE OF MEDICO-ADMINISTRATIVE OFFICER............ 35
            9.3-1 General Manner of Removal .................................................................. 35
            9.3-2 Statement of Grounds ............................................................................ 35
            9.3-3 Joint Conference Committee .................................................................. 35
            9.3-4 Board Decision ....................................................................................... 36

ARTICLE X: FAIR HEARING PLAN                                                                                                36

     10.1   SPECIAL DEFINITIONS .................................................................................... 36

     10.2   INITIATION OF HEARING ................................................................................. 36
            10.2-1 When Deemed Adverse ......................................................................... 37
            10.2-2 Notice of Adverse Recommendation or Action ....................................... 37

     10.3   REQUEST FOR HEARING ................................................................................ 38


                                                          iv
          10.3-1 Waiver by Failure to Request a Hearing ................................................. 38

10.4      HEARING PREREQUISITES ............................................................................. 38
          10.4-1 Notice of Time and Place of Hearing ...................................................... 38
          10.4-2 State of Issues and Grounds .................................................................. 39
          10.4-3 Appointment of the Hearing Committee.................................................. 39

10.5      HEARING PROCEDURE ................................................................................... 39
          10.5-1 Personal Presence ................................................................................. 39
          10.5-2 Presiding Officer..................................................................................... 40
          10.5-3 Representation ....................................................................................... 40
          10.5-4 Rights of Parties ..................................................................................... 40
          10.5-5 Procedure and Evidence ........................................................................ 40
          10.5-6 Evidentiary Notice .................................................................................. 41
          10.5-7 Burden of Proof ...................................................................................... 41
          10.5-8 Record of Hearing .................................................................................. 41
          10.5-9 Postponement ........................................................................................ 42
          10.5-10 Presence of Hearing Committee Members and Vote ............................ 42
          10.5-11 Recesses and Adjournment .................................................................. 42

10.6      HEARING COMMITTEE REPORT AND FURTHER ACTION ............................ 42
          10.6-1 Hearing Committee Report ..................................................................... 42
          10.6-2 Action on Hearing Committee Report ..................................................... 42
          10.6-3 Notice and Effect of Result ..................................................................... 43

10.7      INITIATION AND PREREQUISITES OF APPELLATE REVIEW........................ 43
          10.7-1 Request for Appellate Review ................................................................ 43
          10.7-2 Waiver by Failure to Request Appellate Review ..................................... 44
          10.7-3 Notice of Time and Place of Appellate Review ....................................... 44
          10.7-4 Appellate Review Body ........................................................................... 44

10.8      APPELLATE REVIEW PROCEDURE................................................................ 44
          10.8-1 Nature of Proceedings............................................................................ 44
          10.8-2 Written Statements................................................................................. 44
          10.8-3 Presiding Officer..................................................................................... 45
          10.8-4 Oral Statement ....................................................................................... 45
          10.8-5 Consideration of New of Additional Matters ............................................ 45
          10.8-6 Powers ................................................................................................... 45
          10.8-7 Presence of Members and Vote ............................................................. 45
          10.8-8 Recesses and Adjournment ................................................................... 45
          10.8-9 Action Taken .......................................................................................... 46
          10.8-10 Conclusion ............................................................................................ 46

10.9      FINAL DECISION OF THE BOARD ................................................................... 46
          10.9-1 Board Action........................................................................................... 46
          10.9-2 Joint Conference Review........................................................................ 46

10.10 GENERAL PROVISIONS................................................................................... 46
      10.10-1 Hearing Officer Appointments and Duties ............................................. 46
      10.10-2 Attorneys .............................................................................................. 47



                                                        v
            10.10-3 Waiver .................................................................................................. 47
            10.10-4 Number of Reviews............................................................................... 47
            10.10-5 Extensions ............................................................................................ 47
            10.10-6 Release ................................................................................................ 47

ARTICLE XI: OFFICERS                                                                                                            47

     11.1   OFFICERS......................................................................................................... 47
            11.1-1 Identification ........................................................................................... 47

     11.2   QUALIFICATIONS ............................................................................................. 48
            11.2-1 ............................................................................................................... 48
            11.2-2 ............................................................................................................... 48
            11.2-3 ............................................................................................................... 48
            11.2-4 ............................................................................................................... 48
            11.2-5 ............................................................................................................... 48

     11.3   NOMINATIONS ................................................................................................. 48

     11.4   ELECTION ......................................................................................................... 49

     11.5   TERM OF OFFICE............................................................................................. 49

     11.6   VACANCIES AND REMOVAL FROM OFFICE .................................................. 49
            11.6-1 Vacancies............................................................................................... 49
            11.6-2 Removal From office .............................................................................. 49

     11.7   RESPONSIBILITIES .......................................................................................... 50
            11.7-1 All Officers .............................................................................................. 50
            11.7-2 The President ......................................................................................... 50
            11.7-3 The President Elect ................................................................................ 51
            11.7-4 The Secretary / Treasurer ...................................................................... 51
            11.7-5 The Immediate Past President ............................................................... 52
            11.7-6 Board Service ......................................................................................... 52

ARTICLE XII: COMMITTEES                                                                                                         52

     12.1   MEDICAL EXECUTIVE COMMITTEE................................................................ 52
            12.1-1 Responsibilities ...................................................................................... 53

     12.2   BYLAWS/CREDENTIALS COMMITTEE (B/C) .................................................. 55
            12.2-1 Responsibilities ...................................................................................... 55
            12.2-2 Credentialing Recommendations............................................................ 55
            12.2-3 Bylaws Review and Recommendations .................................................. 56
            12.2-4 Miscellaneous......................................................................................... 56

     12.3   QUALITY REVIEW COMMITTEE (QRC) ........................................................... 56
            12.3-1 Duties – Responsibilities ........................................................................ 56
            12.3-2 Performance Improvement Activities ...................................................... 57



                                                            vi
     12.4     MULTIDISCIPLINARY COMMITTEES ............................................................... 58

     12.5     COMMITTEES FOR SPECIAL SERVICES OR FUNCTIONS ............................ 58
              12.5-1 Medical Staff Support Committee ........................................................... 58

ARTICLE XIII: DIVISION OF THE MEDICAL STAFF and SPECIALTY                                                                         59
              REPRESENTATION

     13.1     ORGANIZATION ............................................................................................... 59
              13.1-1 Hospital Based ....................................................................................... 59
              13.1-2 Surgeons and Interventionalists ............................................................. 59
              13.1-3 Medicine ................................................................................................. 59
              13.1-4 Community Medicine .............................................................................. 59

     13.2     ASSIGNMENT TO / CHANGE OF DIVISIONS .................................................. 59
              13.2-1 ............................................................................................................... 59
              13.2-2 ............................................................................................................... 59

     13.3     RESPONSIBILITIES OF DIVISIONS ................................................................. 60
              13.3-1 ............................................................................................................... 60
              13.3-2 ............................................................................................................... 60
              13.3-3 ............................................................................................................... 61
              13.3-4 ............................................................................................................... 61

     13.4     DIVISION CHIEFS, VICE CHIEFS, AND MEMBERS AT LARGE ...................... 61
              (I.E. DIVISION LEADERSHIP)
              13.4-1 Division Chiefs........................................................................................ 62
              13.4-2 Vice Chiefs and Members at Large ........................................................ 62
              13.4-3 ............................................................................................................... 62
              13.4-4 ............................................................................................................... 62

     13.5     SPECIALTY REPRESENTATIVES .................................................................... 63
              13.5-1 ............................................................................................................... 63
              13.5-2 ............................................................................................................... 63
              13.5-3 ............................................................................................................... 63

     13.6     INDIVIDUAL MEMBERS .................................................................................... 64
              13.6-1 ............................................................................................................... 64
              13.6-2 ............................................................................................................... 64
              13.6-3 ............................................................................................................... 64
              13.6-4 ............................................................................................................... 64
              13.6-5 ............................................................................................................... 64

     13.7     PEER REVIEW .................................................................................................. 64

     13.8     REMOVAL OF LEADERSHIP FROM OFFICE ................................................... 65

     13.9     QUORUM .......................................................................................................... 65

     13.10 SPECIAL MEETINGS ........................................................................................ 65


                                                             vii
     13.11 NOTICE OF MEETINGS .................................................................................... 65

     13.12 VOTING ............................................................................................................. 65

     13.13 CONSENT AGENDAS ....................................................................................... 65

     13.14 ATTENDANCE .................................................................................................. 65

     13.15 RECORD OF ALL PROCEEDINGS OF DIVISION MEETINGS ......................... 66

     13.16 AD HOC AND/OR STANDING COMMITTEES .................................................. 66

ARTICLE XIV: MEDICAL STAFF MEETINGS                                                                                                66

     14.1      REGULAR STAFF MEETINGS .......................................................................... 66

     14.2      SPECIAL STAFF MEETINGS ............................................................................ 66

     14.3      QUORUM / VOTING / RECORD KEEPING ....................................................... 66

     14.4      CLOSED MEETINGS / EXECUTIVE SESSIONS .............................................. 66

ARTICLE XV: PRIVILEGE AND IMMUNITY / CONFIDENTIALITY                                                                               67

     15.1      AUTHORIZATIONS AND CONDITIONS ........................................................... 67
               15.1-1 ............................................................................................................... 67
               15.1-2 ............................................................................................................... 67
               15.1-3 ............................................................................................................... 67
               15.1-4 ............................................................................................................... 67

     15.2      CONFIDENTIALITY OF INFORMATION ........................................................... 67

     15.3      IMMUNITY FROM LIABILITY ............................................................................ 67
               15.3-1 For Action Taken .................................................................................... 67
               15.3-2 For Providing Information ....................................................................... 68

     15.4      ACTIVITIES AND INFORMATION COVERED .................................................. 68
               15.4-1 Activities ................................................................................................. 68
               15.4-2 Information ............................................................................................. 68

     15.5      RELEASES ........................................................................................................ 68

     15.6      CUMULATIVE EFFECT ..................................................................................... 69

ARTICLE XVI: RULES, REGULATIONS, POLICIES and FORMS                                                                                69


ARTICLE XVII: CONFLICT RESOLUTION                                                                                                  69




                                                              viii
ARTICLE XVIII: DUES AND ASSESSMENTS                                                                                             71

ARTICLE XIX: HISTORIES AND PHYSICALS                                                                                            71

ARTICLE XX: BYLAWS AMENDMENTS / REVISIONS and ADOPTION                                                                          71

     20.1   MEDICAL STAFF RESPONSIBILITY ................................................................ 71

     20.2   METHODOLOGY .............................................................................................. 72
            20.2-1 ............................................................................................................... 72
            20.2-2 ............................................................................................................... 72




                                                            ix
ORGANZATIONAL CHART:




                       x
                             BYLAWS OF THE MEDICAL STAFF
                              ASPIRUS WAUSAU HOSPITAL
                                  Wausau Wisconsin


                                          PREAMBLE

WHEREAS,              It is recognized that the medical staff of Aspirus Wausau Hospital is
                      responsible for the quality of the medical care in the hospital and must
                      accept and discharge this responsibility, subject to the ultimate authority
                      of the hospital governing body, and that the cooperative efforts of the
                      medical staff, the chief operating officer and the governing body are
                      necessary to fulfill the hospital’s obligation to its patients;

THEREFORE,            the physicians, dentists, and podiatrists practicing in this hospital hereby
                      organize themselves into a medical staff in conformity with these bylaws.

                                         DEFINITIONS

APPLICATION COMPLETE means (1) all blanks on the application form are filled and
necessary additional explanations and attachments are provided; (2) verification of the
information is complete; that is, all information necessary to properly evaluate an applicant’s
qualifications has been received including reports from the National Practitioner Data Bank, the
Federation of State Medical Boards, and Office of Inspector General (OIG) Exclusion List and
(3) as required, responsive letters of reference and information from past hospitals and other
affiliations have been received including letters from department chiefs or other
physicians/dentists/podiatrists who have worked with or observed the applicant.

BOARD OF DIRECTORS or BOARD means the governing body of the hospital, and duly
created committees of the Board performing duties delegated by the Board.

CLINICAL PRIVILEGES or PRIVILEGES means the permission granted to a practitioner to
render specific diagnostic, therapeutic, medical, dental, podiatric or surgical services.

DENTIST means an individual who has received a Doctor of Dentistry degree and is currently
fully licensed to practice dentistry in the State of Wisconsin.

DIVISION LEADERSHIP means the Chief, Vice Chief and Member at large of a Division.

EX-OFFICIO means service as a member of a body by virtue of an officer or position held and,
unless otherwise expressly provided, means without voting rights.

FAIR HEARING PLAN means the procedure set forth in Article X.

GOOD STANDING means the staff member is not under a suspension of his/her appointment
or admitting privileges.

HIS OR HER shall apply to members of the medical staff.




                                               1
HOSPITAL means Aspirus Wausau Hospital, Inc., (Aspirus Wausau Hospital) of Wausau,
Wisconsin.

HOSPITAL PRESIDENT / COO means the individual appointed by the Board to act on its
behalf in the overall management of the hospital.

HOUSE STAFF means all physicians who are in a recognized training program under the
direction of the faculty of an approved residency program.

JOINT CONFERENCE means a committee composed of a total of ten (10) members with an
equal number of medical staff and Board members.

ALLIED HEALTH PRACTITIONER means an individual, other than a licensed physician,
dentist or podiatrist whose clinical care activities require that the authority to perform specified
patient care services be processed through the medical staff channels or with involvement of
medical staff representatives.

MALICE means the dissemination of a known falsehood or of information with a reckless
disregard for whether it is true or false, or the absence of a reasonable belief that an action,
statement or recommendation is warranted by the facts.

MEDICAL EXECUTIVE COMMITTEE or MEC means the executive committee of the medical
staff.

MEDICO-ADMINISTRATIVE OFFICER means a practitioner employed by, or otherwise serving
the hospital, on a full or part-time basis, whose duties include responsibilities, some of which
are purely administrative in nature, some purely clinical in nature and some both administrative
and clinical in nature. Clinical responsibilities are defined as those involving professional
capability as a practitioner such as to require the exercise of clinical judgment with respect to
patient care.

MEMBERSHIP shall be extended only to professionally competent physicians, dentists and
podiatrists who continuously meet the qualifications, standards and requirements set forth in
these bylaws. Appointment to and membership on the staff shall confer on the staff member
such clinical privileges and prerogatives as have been granted by the Board in accordance with
these bylaws, and shall include staff category, and department assignment.

PHYSICIAN means an individual who has received a Doctor of Medicine or Doctor of
Osteopathy degree and is currently fully licensed to practice medicine in the State of Wisconsin.

PODIATRIST means an individual who has received a Doctor of Podiatry degree and is fully
licensed to practice podiatry in the State of Wisconsin.

PRACTITIONER means, unless otherwise expressly limited, any physician, dentist or podiatrist
applying for or exercising clinical privileges in the hospital.

PREROGATIVES means a participatory right granted, by virtue of the staff category or
otherwise, to a staff member or allied health practitioner exercisable subject to the conditions
imposed in these bylaws and in other hospital and medical staff policies.



                                                 2
PROCTOR means an individual who holds active or provisional active staff status within a
respective department/section of the medical staff of Aspirus Wausau Hospital. This individual
is appointed by the chair of the clinical department in which proctoring is to occur.
Responsibilities of the proctor are:

1)     To coordinate in a reasonable manner with the individual to be proctored an agreed
       upon schedule for patient/procedure/case review,
2)     Observe the appropriate number of specified patients/procedures/cases as delineated
       by the chair of the department, and fulfilling bylaws requirements:

       a)     It is permissible that the proctor may provide first assistant services;
       b)     It is permissible that the proctor may intervene in the event of an unanticipated
              outcome;
       c)     It is not anticipated that the proctor provides formal educational services during a
              proctoring sequence, but may provide anecdotal advice/insight.

3)     The proctor shall provide a written result to the chair of the department upon completion
       of the proctoring responsibility. Said report shall include: a) patient identifier; b) date of
       proctoring; c) general description of proctoring event; d) patient outcome; and e)
       recommendations/conclusions.

QUORUM means those members present who are eligible to vote at any regular or special
general staff meeting or any department or committee meeting. Ex-officio members shall not
be counted in determining the presence of a quorum.

REPRESENTATIVE means a Board and any director or committee thereof; a chief operating
officer or his/her designee; a medical staff organization and any member, officer, department or
committee thereof; and any individual authorized by any of the foregoing to perform specific
information gathering or disseminating functions.

SPECIAL NOTICE means written notification sent by certified mail, return receipt requested.

THIRD PARTIES means both individuals and organizations providing information to any
representative.



ARTICLE I:    NAME

The name of this organization shall be the Medical Staff of Aspirus Wausau Hospital.

ARTICLE II:   PURPOSES AND RESPONSIBILITIES

2.1    PURPOSES

       The purposes of the medical staff are:

       2.1-1 To be the formal organizational structure through which




                                                 3
             (a)    The benefits of membership on the staff may be obtained by individual
                    practitioners and

             (b)    The obligations of staff membership may be fulfilled.

      2.1-2 To serve as the primary means for accountability to the Board to the
            appropriateness of the professional performance and ethical conduct of its
            members and allied health practitioners and to strive toward assuring that the
            pattern of patient care in the hospital is consistently maintained at the level of
            quality and efficiency achievable by the state of the healing arts and the
            resources locally available.

      2.1-3 To provide a means through which the medical staff may participate in the
            hospital’s policy making and planning process.

      2.1-4 To provide an educational setting that will maintain scientific standards and lead
            to continuous advancement in professional knowledge and skill.

      2.1-5 To cooperate with affiliated medical schools and other educational institutions in
            undergraduate, graduate, and post graduate education.

2.2   RESPONSIBILITIES

      The responsibilities of staff, to be fulfilled through the actions of its officers,
      departments, and committees include:

      2.2-1 Accountability

             The accounting of quality and appropriateness of patient care rendered by all
             practitioners and allied health practitioners authorized to practice in the hospital
             though the following measures:

             (a)    A credentials program, including mechanisms for appointment and
                    reappointment, and the matching of clinical privileges to be exercised or
                    of specified services to be performed, with the verified credentials and
                    current demonstrated performance of the applicant, staff member or
                    allied health practitioner.

             (b)    A continuing education program, fashioned at least in part on the needs
                    demonstrated through the quality/utilization management program.

             (c)    A utilization review program to allocate inpatient and outpatient medical
                    and health services based upon patient specific determinations of
                    individual medical needs.

             (d)    An organizational structure that allows continuous monitoring of patient
                    care practices.




                                              4
             (e)    A program to assist the impaired practitioner in receiving professional
                    help through the Medical Staff Support Committee and that an
                    appropriate monitoring system is in place.

      2.2-2 Recommendation to Board

             To recommend to the Board action with respect to appointments,
             reappointments, staff category, departmental assignments, clinical privileges and
             corrective action.

      2.2-3 Quality/Utilization Management

             To account to the Board for the quality and efficiency of patient care rendered to
             patients in the hospital through regular reports and recommendations concerning
             the implementation, operation and results of the quality/utilization management
             activities.

      2.2-4 Corrective Action

             To initiate and pursue corrective action with respect to practitioners and allied
             health practitioners, when warranted.

      2.2-5 Compliance with Bylaws, Rules & Regulations

             To develop, administer and seek compliance with these bylaws, the rules and
             regulations of the staff and other patient care related hospital policies.

      2.2-6 Identification of Needs and Goals

             To assist in identifying community health needs and in setting appropriate
             institutional goals and implementing programs to meet those needs.

      2.2-7 Authority

             To exercise the authority granted by these bylaws as necessary to adequately
             fulfill the foregoing responsibilities.

ARTICLE III: MEDICAL STAFF MEMBERSHIP

3.1   NATURE OF MEDICAL STAFF MEMBERSHIP

      Membership on the staff of Aspirus Wausau Hospital shall be extended only to
      professionally competent physicians, dentists and podiatrists who continuously meet the
      qualifications, standards and requirements set forth in these bylaws.

      Appointment to and membership on the staff shall confer on the staff member only such
      clinical privileges and prerogatives as have been granted by the Board in accordance
      with these bylaws, and shall include staff category and department.




                                             5
3.2   BASIC QUALIFICATIONS FOR MEMBERSHIP

      3.2-1 Basic Qualifications

             Only physicians, dentists, oral and maxillofacial surgeons, and podiatrists
             licensed to practice in the State of Wisconsin who meet the following
             requirements will be eligible for appointment and/or clinical privileges:

             (a)    Document their experience, background, training, demonstrated ability,
                    and their physical and/or mental health status, with sufficient adequacy to
                    demonstrate to the staff and the Board that they will provide care to
                    patients at the generally recognized professional level of quality, and
                    utilization standards in effect at the hospital;

             (b)    Are determined, on the basis of documented references, to adhere
                    strictly to the ethics of their respective professions, to work cooperatively
                    with others relating to patient care, and to be willing to participate in the
                    discharge of staff responsibilities; and

             (c)    Possess a current license to practice in the State(s) where the
                    practitioner currently provides care for patients with no past or present
                    restriction(s) or adverse action(s).

             (d)    Have satisfactorily completed approved postgraduate training relevant to
                    the specialty in which the applicant is seeking to practice, as further
                    defined on specialty-specific privilege forms.

             (e)    Have or will attain board certification within 5 years of post graduate
                    training completion in primary specialty of practice by a Board recognized
                    by the ABMS, AOA, ADA, ABPS or ABPOPPM (or other equivalent
                    recognized by these Boards), and as further defined in specialty-specific
                    privilege forms. Exceptions may be made for residents moonlighting in
                    the Emergency Department or Walk In Clinics and for general dentists for
                    which a Board Certification does not exist.

             (f)    Possess DEA certification with no record of past or present restriction(s),
                    sanction(s), or voluntary relinquishment.

             (g)    Have a formal coverage arrangement with another member of this
                    medical staff with equivalent privileges to ensure continuous care for
                    established patients who may present to the Hospital, including but not
                    limited to the Emergency Department.

             (h)    Possess appropriate professional liability insurance coverage specific to
                    privileges requested, as applicable, without prior history of restriction or
                    reduction of coverage.

             (i)    Have no record of conviction of Medicare, Medicaid, or insurance fraud
                    and abuse, payment of civil money penalties for same, or exclusion from
                    such programs.



                                              6
              (j)     Have no record of, conviction of, or plea of guilty or not contest to, any
                      felony or misdemeanor related to violence, controlled substances, third-
                      party reimbursement or the practitioner’s professional practice.
                      Reference: Practitioner Background Check Policy (ID #6039).

              (k)     Have no record of denial, revocation, relinquishment or termination of
                      appointment, affiliation, or clinical privileges at any healthcare facility for
                      reasons related to professional competence or conduct.

A waiver of a criterion may infrequently be granted solely by the Board of Directors upon the
recommendation of the Medical Executive Committee when exceptional circumstances exist.
The individual requesting the waiver bears the burden of demonstrating that exceptional
circumstances exist.

       3.2-2 Effect of Other Affiliations

              No physician, oral and maxillofacial surgeon, dentist or podiatrist is entitled to
              membership on the staff or to the exercise of particular clinical privileges solely
              because he/she is licensed to practice in this or in any other state, or because
              he/she is a member of any professional organization, or is certified by any
              clinical Board or presently or formerly held staff membership or privileges at
              another health care facility or in another practice setting.

       3.2-3 Nondiscrimination

              Staff membership or particular clinical privileges shall not be granted or denied
              on the basis of any physical or mental condition or other criterion unrelated to the
              efficient delivery of patient care at the generally recognized professional level of
              quality in the hospital, including, but not limited to race, creed, color, handicap,
              marital status, sex, national origin, ancestry, sexual orientation, arrest record,
              conviction record, membership in armed forces, use or non-use of lawful
              products off hospital premises.

       3.2-4 Administrative and Medico-Administrative Officers

              A practitioner employed by the hospital in a purely administrative capacity with
              no clinical duties or privileges is subject to the regular personnel policies of the
              hospital and to the terms of his/her contract or other conditions of employment,
              and need not be a member of the medical staff. Conversely, a medico-
              administrative officer (i.e., one with clinical responsibilities) must be a member of
              the medical staff, achieving his/her status by the procedure provided in
              accordance with Article VII. The medical staff membership and clinical privileges
              of any medico-administrative officer shall not be contingent on his/her continued
              occupation of that position, unless otherwise provided in his/her employment
              agreement.

3.3    BASIC RESPONSIBILITIES OF INDIVIDUAL STAFF MEMBERSHIP
       The responsibilities of all members of the Medical Staff are to:




                                                 7
3.3-1 Provide his/her patients with care at the generally recognized professional level
      of quality and efficiency and utilization standards at the Hospital


3.3-2 Abide by the Bylaws rules, regulations, and associated policies of the Medical
      Staff and the Hospital, Principles and Codes of Medical Ethics of the American
      Medical Association, the American Osteopathic Association, the Code of Ethics
      of the American Dental Association, American Board of Podiatric Surgery, as
      applicable based on each member’s credential.

3.3-3 Provide emergency medical care for any patient following accepted guidelines of
      his or her respective department and specialty society. Any individual with
      delineated clinical privileges may provide emergency care to any patient in a life-
      threatening emergency or a situation that threatens serious harm, provided that
      the care provided is within the scope of the individual's license.

3.3-4 Agree to and recognize the Hospital's obligation to query and report adverse
      actions to the National Practitioner Data Bank as established by federal statute.
      Information obtained by query of the Data Bank will be used in evaluating the
      Practitioner's qualification for initial and/or continued membership, and if
      applicable, privileges.

3.3-5 Provide appropriate and timely care to those patients for whom they are
      assigned as attending or consulting physician, or to ensure that this care is
      provided by an appropriate level of physician coverage.

3.3-6 Make appropriate arrangements for coverage of patients to ensure continuous
      care, ensuring that such arrangements are effectively communicated to the
      Hospital and Medical Staff.

3.3-7 Participate in Emergency Department call coverage for unattached patients
      unless otherwise exempted by Staff Category or the Division to which the
      member is assigned. For purposes of EMTALA compliance, the designated on-
      call physician shall be deemed the physician designated as "on call" for the
      specific specialty group. Reference Policy: Emergency Department Call
      Coverage (#6740).

3.3-8 Maintain personal medical malpractice insurance coverage in accordance with
      Wisconsin regulations.

3.3-9 Inform the Medical Staff in a timely manner of any changes made, or formal
      action initiated, including pending criminal charges or convictions, that could
      result in a change to license, state or federal controlled substance registration,
      professional liability insurance coverage, and voluntary or involuntary reduction
      of clinical privileges at other health care institutions. Final judgments or
      settlements for any malpractice activity must be reported.

3.3-10 Work with other individuals and organizations in a cooperative, professional and
       civil manner and refraining from any activity that is disruptive of Hospital or
       Medical Staff operations.



                                        8
       3.3-11 Cooperate with and participate in performance improvement and peer review
              activities, whether related to self or others.

       3.3-12 Complete in a timely fashion all medical records for the patients to whom care is
              provided in the Hospital.

       3.3-13 Refuse to engage in improper inducements for patient referral or any other
              unethical behavior.

       3.3-14 Pay Medical Staff dues and assessments.

       3.3-15 Exercise privileges only as specifically granted by the Board of Directors which
              includes refraining from practice of all or any privilege until granted by the Board.

       3.3-16 Assume medical and legal responsibility for allied health practitioners performing
              duties on behalf of the Practitioner via employed or contracted relationship with
              the Practitioner, as described in associated policies.

       3.3-17 Appropriately supervise residents (house staff) rendering patient care under his
              or her authority and credentials.

       3.3-18 Reflect the Hospital's customer service ideals, as reflected in its Mission, Vision,
              and Values statement.

       3.3-19 To ensure that all hospitalized patients are visited daily by their attending
              physician or by another medical staff member designated by the attending
              physician, unless otherwise exempted by other rules and regulations of the
              Medical Staff. Exception exists for the Rehab unit where a visit is required no
              less than every three (3) days.

Compliance with the above is necessary to apply for or maintain membership, and if applicable
privileges, with the Medical Staff.

3.4    DURATION OF APPOINTMENT

       3.4-1 Appointments

              Appointment to the staff shall be for a period of two (2) years.

3.5    PROFESSIONAL PRACTICE EVALUATION

       3.5-1 The granting of initial clinical privileges, as well as the addition of new privileges
             for existing members, is subject to focused professional practice evaluation
             (FPPE). FPPE requirements for each specialty are described in each specialty-
             specific privilege form.

       3.5-2 FPPE automatically concludes when an appropriate medical staff leader
             concludes that competency has been verified via the means described in each
             specialty-specific privilege form and/or additional activities.




                                                 9
      3.5-3 Upon the conclusion of FPPE, each individual with clinical privileges is subject to
            Ongoing Professional Practice Evaluation (OPPE) as described in the Medical
            Staff Peer Review Policy (#6883)

3.6   CONTRACT PHYSICIANS

      The staff appointment of any staff member who has a contractual relationship with the
      hospital, or is either an employee, partner or principal of, or in any entity that has a
      contractual relationship with the hospital, relating to providing services to patients at the
      hospital shall be governed by the terms and conditions by the contract. If at any time
      the contracting staff member’s individual competence or fitness is questioned, he/she
      shall be entitled to due process rights otherwise provided practitioners under Article IX
      or Article X or both. In no event shall contracting staff members be entitled to due
      process rights not afforded to non-contracted staff members under similar
      circumstances.

3.7   LEAVE OF ABSENCE

      3.7-1 Leave Status

             (a)     A staff member may request a voluntary leave of absence from the staff
                     by submitting a written request to the Medical Executive Committee and
                     the chief operating officer, which states the period of time for the leave,
                     which may not exceed the remainder of the current staff appointment. A
                     leave of absence request may be granted by the Medical Executive
                     Committee, subject to such conditions or limitations as the Medical
                     Executive Committee shall determine to be appropriate. During the
                     period of a leave of absence the staff member’s privileges and
                     prerogatives shall not be exercised.

             (b)     A leave of absence shall occur automatically when the Medical Staff
                     Support Committee, with concurrence of the Medical Executive
                     Committee determines that a staff practitioner requires treatment for
                     impairment and such is agreed to by the practitioner. The impaired
                     practitioner must agree to enroll in a long-term treatment program
                     approved by the Medical Staff Support Committee.

      3.7-2 Termination of Leave

             A staff member on a leave of absence, which is less than six (6) months, may
             request to return from leave by providing fifteen (15) days written notice to the
             chief operating officer. If the leave is for six (6) months or more, sixty (60) days
             written notice is required.

             As provided in the above paragraph, the staff member may request
             reinstatement of his/her privileges and prerogatives by submitting a written notice
             to that effect to the executive officer for transmittal to the Medical Executive
             Committee. The staff member shall submit a written summary of his/her relevant
             activities during the leave, if the Medical Executive Committee or the Board so
             requests. The Medical Executive Committee shall make a recommendation to



                                               10
              the Board concerning the reinstatement of the member’s privileges and
              prerogatives. Thereafter, the procedure provided in Sections 6.4-6 and 6.4-11
              shall be followed.

              Failure without good cause to request reinstatement or to provide a requested
              summary of activities as above provided before termination of the leave shall
              result in automatic termination of staff membership. privileges, and prerogatives,
              without right of hearing or appellate review. A request for staff membership
              subsequently received from a staff member so terminated shall be submitted and
              processed in the manner specified for applications for initial appointment.

              If a staff member is denied return from a leave of absence, it shall be considered
              a suspension and the right to a fair hearing shall apply.

3.8    RESIGNATION

       In the event a physician, dentist or podiatrist wishes to resign from the medical staff,
       he/she shall present in writing to the president of the staff, for transmittal to the
       bylaws/credentials committee, a statement to that effect noting the date of termination.
       If a physician, dentist or podiatrist leaves the community or otherwise discontinues
       practice and does not notify the president of the staff, an effort will be made by the
       bylaws/credentials committee to reach the physician, dentist or podiatrist by special
       notice to determine his/her wishes. If he/she does not respond, termination will be
       automatic thirty (30) days after the special notice has been sent. The physician, dentist
       or podiatrist will be notified of this action with no hearing or appellate rights.

ARTICLE IV: CATEGORIES OF THE MEDICAL STAFF

The medical staff shall be divided into Active, Courtesy, Affiliate, Honorary, and House Staff
categories.

4.1    ACTIVE STAFF

       4.1-1 Qualifications

              The active staff shall consist of physicians, dentists and podiatrists, each of
              whom:

              (a)    Meet the basic qualifications set forth in Section 3.2-1

              (b)    Have completed their status as members of the provisional staff
                     members and have been recommended for advancement to active staff
                     status.

              (c)    Regularly admit patients to, or are otherwise regularly involved in the care
                     of patients at the hospital.

              (d)    Are located in reasonable proximity to the hospital to provide continuous
                     care to hospitalized patients.




                                              11
      4.1-2 Prerogatives

             The prerogatives of an active staff member shall be to:

             (a)    Admit patients to the hospital as follows:

                    (1)      A physician member may admit patients according to his/her
                             privileges.

                    (2)      A dentist member may admit patients in conformity with the
                             requirements in Section 7.4.

                    (3)      A podiatrist member may admit patients in conformity with the
                             requirements in Section 7.5.

             (b)    Exercise of clinical privileges as granted pursuant to Article VII.

             (c)    Voting rights at all general and special meetings of the medical staff, and
                    department and committee meetings in which he/she is a member.

             (d)    Eligibility to hold office and/or serve as chair of a clinical department.

      4.1-3 Responsibilities

             The responsibilities of the active staff shall include:

             (a)    Meet the basic responsibilities set forth in Section 3.3.

             (b)    Retain responsibility within his/her area of professional competence for
                    the care and supervision of each patient in the hospital for whom he/she
                    is providing services, or arrange a suitable alternative for such care and
                    supervision.

             (c)    Actively participate in quality/utilization management activities required of
                    the staff, in monitoring new appointees of his/her same profession, in
                    discharging such other functions as may from time to time be required by
                    the medical executive committee.

4.2   COURTESY STAFF

      4.2-1 Qualifications

             The courtesy staff shall consist of physicians, dentists and podiatrists who:

             (a)    Provide history and physical services for their patients referred to the
                    hospital for treatment.

             (b)    Admit not more than six (6) patients per quarter, or performs not more
                    than six (6) consultations per quarter, or performs not more than six (6)




                                               12
                    procedures per quarter.      (This excludes performance of histories/
                    physicals which are unlimited.)

             (c)    Meet the basic qualifications set forth in Section 3.2-1.

             (d)    May live geographically removed from the hospital but can demonstrate
                    to the medical executive committee that he/she or an acceptable
                    alternate can provide continuous care to his/her hospitalized patients.

      4.2-2 Prerogatives

             The prerogatives of the courtesy staff member shall be to:

             (a)    Serve as a member of committees, with the exception of bylaws/
                    credentials and quality review committees.

             (b)    Courtesy staff members shall not be eligible to vote, except when serving
                    as a member of a committee

             (c)    Courtesy staff members shall not be eligible to hold medical staff office,
                    as defined in Article XII Officers, Section-12.1 president, president-elect,
                    secretary/ treasurer, immediate past-president.

             (d)    Exercise of clinical privileges as granted pursuant to Article VII.

      4.2-3 Responsibilities

             The responsibilities of the courtesy staff shall include:

             (a)    Discharge the basic responsibilities specified in Section 3.3.

             (b)    Retain responsibility within his/her area of professional competence for
                    the care and the supervision of each patient in the hospital for whom
                    he/she is providing services, or arrange a suitable alternative for such
                    care and supervision.

             (c)    Members of the courtesy staff shall not be granted elective surgical or
                    procedural privileges unless they can provide pre-arranged adequate/
                    complete (same specialty) coverage. Coverage shall be for 90 days.
                    The consequence for not providing coverage for either surgical or
                    procedural patients could result in loss of all privileges.

4.3   AFFILIATE STAFF

      4.3-1 Qualifications:

             The affiliate staff shall consist of physicians, dentists, and podiatrists, who:

             (a)    Desire to be associated with the hospital through the granting of
                    membership on the affiliate staff



                                               13
       (b)     Shall not be granted clinical privileges

       (c)     Desire to attend educational programs sponsored by the hospital or the
               medical staff

       (d)     Meet the basic qualifications set forth in Section 3.2-1.

4.3-2 Prerogatives

       The prerogatives of the affiliate staff member:

       (a)     Shall not be eligible to hold medical staff office as defined in Article Xii,
               Section 12.1

       (b)     Shall not to vote in elective proceedings of the organized medical staff,
               but shall be eligible to vote when serving as a member of a committee

       (c)     Shall pay all application fees and staff dues as established by the hospital
               and the medical staff

       (d)     May provide history and physical services for active staff members
               contingent upon the active staff member countersigning the appropriate
               documentation provided by the affiliate staff member

       (e)     May refer patients to other members of the staff for admission, evaluation
               and/or care and treatment

       (f)     May visit their hospitalized patients and review their patient’s medical
               record, but shall not be permitted to admit patients, to attend patients, to
               exercise any clinical privileges, to write orders or progress notes, to make
               notations in the medical record or to actively participate in the provision of
               care or management of their patients in the hospital.

4.3-3 Responsibilities

       The responsibilities of the affiliate staff shall include:

       (a)     To abide by the medical staff bylaws, rules and regulations, and by all
               other established standards, policies and rules of the hospital

       (b)     To discharge such staff, department, committee and hospital functions
               for which he/she is responsible by appointment, election or otherwise

       (c)     To promptly notify the president of the medical staff of revocation or
               suspension of his/her professional license, or the imposition of terms or
               probation or limitation of practice by any state, or of his/her staff
               membership or loss of or restriction of privileges at any hospital or other
               health care institution




                                          14
4.4   HONORARY STAFF

      4.4-1 Qualifications

             The honorary staff shall consist of physicians, dentists and podiatrists each of
             whom:

             (a)    Are recognized for their outstanding reputations, their noteworthy
                    contributions to the health and medical sciences, or their previous long-
                    standing service to the hospital.

      4.4-2 Prerogatives

             Honorary staff members are not eligible to admit patients to the hospital or to
             exercise clinical privileges in the hospital. The prerogatives of an honorary staff
             member shall be to attend staff and department meetings and any staff or
             hospital educational meetings. Honorary staff members shall not be eligible to
             vote or hold office in this medical staff organization.

4.5   RESIDENTS

      Residents shall consist of all physicians who are in recognized training programs under
      the direction of the faculty of an approved residency program and shall be eligible for
      medical staff committee membership and to participate in medical staff conferences,
      seminars and teaching programs. They shall not be members of the medical staff nor
      entitled to the rights, privileges, duties, and obligations of staff membership.

      Residents will function in accordance with responsibilities and expectations described in
      the Residency’s curriculum in conjunction with the University of Wisconsin-Madison
      Medical School. The curriculum will be updated annually based upon feedback from
      attendings and residents.


      4.5-1 Resident Supervision

             To safeguard patient care and to enhance graduate medical education by setting
             standards for the supervision of residents.

             (a)    Licensed practitioners with appropriate clinical privileges must supervise
                    residents in their patient care responsibilities.

             (b)    The admitting or attending physician must countersign all orders written
                    by residents who are unlicensed physicians.

             (c)    Medical staff members may write patient care orders on patients who are
                    cared for in part by a resident.

             (d)    The Director of the Residency Program will annually communicate to the
                    Medical Staff, through the Medical Executive Committee, and to the
                    governing body of the hospital, a report on the performance of the



                                             15
                     residents, any identified patient safety issues, the quality of care provided
                     by the residents and the educational needs of the residents.

4.6   LIMITATION OF PREROGATIVES

      The prerogatives set forth under each staff category are general in nature and may be
      subject to limitations by special conditions attached to a physician’s, dentist’s, or
      podiatrist’s staff appointment recommended by the medical executive committee,
      through other sections of these bylaws, the rules and regulations of the staff, or by
      policies of the hospital.

4.7   WAIVER OF QUALIFICATIONS

      Any qualifications, requirements, or limitations in this article or any other article of these
      bylaws, not required by law or governmental regulations, may be waived in the
      discretion of the Board, in consultation with the medical executive committee, upon
      determination that such waiver will serve the best interests of the patients and of the
      hospital.

ARTICLE V: ALLIED HEALTH PRACTITIONERS

5.1   GRANTING OF SCOPE OF PRACTICE

      The medical executive committee may recommend to the Board the granting to allied
      health practitioners, including but not limited to psychologists, physician assistants and
      nurse practitioners, the right to provide services within their scope of practice, based
      upon investigation and evaluation of the education, training, experience and
      demonstrated ability and judgment of individuals requesting scope of practice services
      as independent and dependent allied health practitioners, according to procedures
      established in the rules and regulations of the staff or other document approved by the
      Board.

      5.1-1 Definition

             Allied health practitioners are defined in greater detail in Policy #4910 and shall
             be defined as:

             (a)     Licensed Independent Practitioners (LIP’s) – Provide care to patients in
                     accordance with state licensure laws and clinical privileges granted by the
                     Hospital to provide patient services in the Hospital. Current approved
                     disciplines include: Psychologists and Certified Nurse Midwives. LIPs
                     are granted clinical privileges but are not members of the Medical Staff.

             (b)     Advanced Dependent Practitioners (ADPs) – Provide care to patients in
                     the accordance with state licensure laws and clinical privileges granted by
                     AWH to provide patient services in the Hospital. ADPs must have a
                     collaborative/supervisory agreement with a sponsoring medical staff
                     member with equivalent privileges.       Currently approved disciplines
                     include: Physician Assistants, Nurse Practitioners, and Certified Nurse




                                               16
                     Anesthetists. ADPs are granted clinical privileges but are not members
                     of the Medical Staff.

             (c)     Dependent Allied Health Practitioner (Dependent AHP) – Provide care to
                     patients in the hospital under the supervision of a member of the Medical
                     Staff, in accordance with state licensure laws, as applicable, and the
                     scope of practice granted by the Hospital. Wherever possible the scope
                     of practice will be fashioned after the job description used by AWH for
                     employees in like positions. Dependent AHPs are not members of the
                     medical staff. Currently approved disciplines include:

5.2   RECONSIDERATION OF SCOPE OF PRACTICE SERVICES

      A recommendation by the medical executive committee (MEC) to deny, reduce, modify,
      or terminate scope of practice services requested or held by an allied health practitioner
      shall be provided in writing to the allied health practitioner, and include reasons for the
      recommendation. The allied health practitioner shall have fifteen (15) days to request in
      writing an appearance before the MEC to explain any reasons why the allied health
      practitioner believes the recommendation is incorrect.

      The MEC shall then reconsider its initial recommendation, submit its final
      recommendation to the Board, and supply a copy to the allied health practitioner. The
      allied health practitioner shall have the right to submit a written statement to the Board
      concerning the MEC recommendation, which must be received by the Board at least ten
      (10) days before the meeting at which the MEC recommendation is considered. The
      decision of the Board shall be final. Allied health practitioners shall not be entitled to any
      procedural rights set forth in Article IX – Interviews, Hearings, and Appellate Review or
      Article X – Fair Hearing Plan.

ARTICLE VI: PROCEDURES FOR APPOINTMENT AND REAPPOINTMENT

6.1   GENERAL PROCEDURE

      The medical staff through its designated divisions, specialties, and officers shall
      investigate and consider each application for appointment and reappointment to the staff
      and each request for modification of staff membership status and shall adopt and
      transmit recommendations thereon to the Board. The medical staff shall perform these
      same investigations, evaluations and recommendations in connection with any allied
      health practitioner.

6.2   APPLICATION FOR INITIAL APPOINTMENT

      6.2-1 Application Form

             Each application for appointment to the staff shall be in writing, and signed by
             the applicant. All written requests for application forms from persons claiming to
             be physicians, dentists or podiatrists or allied health practitioner shall be acted
             upon promptly, and a copy of the staff bylaws, rules and regulations and policies
             shall be furnished to each such person.




                                               17
      6.2-2 Content

             The application form shall include such provisions as are necessary to secure
             information useful for evaluation of the applicant. In addition the form shall
             include a statement that the applicant has been furnished a copy of the bylaws,
             rules and regulations and policies of the staff, and that he/she agrees to be
             bound by the terms thereof during the time the application is under consideration
             and, if staff appointment is granted, while a member of the staff.

      6.2-3 Application Processing Fee

             The Board may establish an application processing fee in consultation with the
             medical executive committee.

      6.2-4 The Board in consultation with the medical executive committee may develop a
            pre-application procedure for initial applicants. Such shall be a screening
            process to determine if the applicant meets the Board’s qualifications for medical
            staff membership, or if there are reasons apart from the qualifications for
            membership (e.g., inability of the hospital to accommodate a particular
            subspecialty, etc.) which would result in an inability to appoint the applicant.

6.3   EFFECTS OF APPLICATION

      By applying for appointment to the medical staff, the applicant:

      6.3-1 Signifies his/her willingness to appear for interviews in regard to his/her
            application.

      6.3-2 Authorizes hospital representatives to consult with others who have been
            associated with him/her and/or may have information bearing on his/her
            competence and qualifications.

      6.3-3 Consents to the inspection by hospital representatives of all records and
            documents that may be material to an evaluation of his/her interpersonal and
            professional qualifications and ability to carry out the clinical privileges he/she
            requests as well as of his/her ethical qualifications for staff membership.

      6.3-4 Releases from any liability all hospital representatives for acts performed in good
            faith and without malice in connection with evaluating the applicant and his/her
            credentials.

      6.3-5 Releases from all liability all individuals and organizations who provide
            information, including otherwise privileged or confidential information to hospital
            representatives in good faith and without malice concerning the applicant’s
            ability, professional ethics, character, physical and mental health, emotional
            stability, and other qualifications for staff appointment and clinical privileges.

      6.3-6 Pledges to maintain an ethical practice and provide continuous care to his/her
            patients.




                                              18
      6.3-7 Agrees that any lawsuit brought by the applicant against an individual or
            organization providing information to a hospital representative, or against a
            hospital representative shall be brought in a court, federal or state, in the state in
            which the defendant resides or is located.

             For purposes of this Section, the term “hospital representative” includes the
             Board, its directors and committees; the chief operating officer or designee; all
             medical staff members; Divisions and committees which have responsibility for
             collecting or evaluating the applicant’s credentials or acting upon his/her
             application; and any authorized representative of any of the foregoing.

6.4   PROCESSING THE APPLICATION

      6.4-1 Applicant’s Burden

             The applicant shall have the burden of producing adequate information for a
             proper evaluation of his/her experience, background, training, demonstrated
             ability, and physical and mental health status, and of resolving any doubts about
             these or any of the other basic qualifications specified in Section 3.2-1.

      6.4-2 Verification of Information

             The applicant shall deliver a completed application to the chief operating officer,
             who shall, within thirty (30) days, seek to collect or verify the references,
             licensure, and other qualification evidence submitted. The chief operating officer
             shall promptly notify the applicant of any problems in obtaining the information
             required, and it shall then be the applicant’s obligation to obtain the information.
             When collection and verification is accomplished the chief operating officer shall
             transmit the application and all supporting materials to the specialty
             representative, vice chair of each division, or an appropriate designee in which
             the applicant seeks privileges and to the bylaws/credentials committee. The
             bylaws/credentials committee may also conduct an interview of the applicant to
             which the specialty representative of division vice chief in which the applicant
             seeks privileges shall be invited to attend and to participate.

      6.4-3 Division Action

             Upon receipt, the specialty representative or division vice chief shall review the
             application and supporting documentation, which may include conducting a
             personal interview with the applicant, and transmit to the bylaws/credentials
             committee on the prescribed form a written report and recommendations as to
             staff appointment and if appointment is recommended as to staff category,
             department affiliation, clinical privileges to be granted and any special conditions
             to be attached to the appointment. A specialty representative or division vice
             chief may also recommend that the Medical Executive Committee defer action
             on the application. The reason for each recommendation shall be stated and
             supported by reference to the completed application and all other documentation
             considered by a committee, all minority views shall also be reduced to writing,
             supported by reasons and references, and transmitted with the majority report.




                                              19
6.4-4 Bylaws/Credentials Committee Action

      The bylaws/credentials committee shall review the application, the supporting
      documentation, the specialty representative or division vice chief’s report and
      recommendations, and such other information available to it that may be relevant
      to consideration of the applicant’s qualifications for the staff category,
      department affiliation, and clinical privileges requested. The bylaws/credentials
      committee shall then transmit to the medical executive committee on the
      prescribed form a written report and recommendation as to staff appointment
      and, if appointment is recommended as to staff category and department
      affiliations, clinical privileges to be granted, and any special conditions to be
      attached to the appointment. The committee may also recommend that the
      medical executive committee defer action on the application. The reason for
      each recommendation shall be stated and supported by reference to the
      completed application and all other documentation considered by the committee,
      all of which shall be transmitted with the report. Any minority views shall also be
      reduced to writing, supported by reasons and references, and transmitted with
      the majority report.

6.4-5 Medical Executive Committee Action

      At its next regular meeting after receipt of the bylaws/credentials committee
      report and recommendations, the medical executive committee shall consider
      the report and such other relevant information available to it. The committee
      shall then forward to the board a written report and recommendations on the
      prescribed form as to staff appointment and, if appointment is recommended, as
      to staff category, and any special conditions to be attached to the appointment.
      The committee may also defer action on the application pursuant to Section 6.4-
      6(a). The reasons for each recommendation shall be stated and supported by
      reference to the completed application and all other documentation considered
      by the committee, all minority views shall also be reduced to writing, supported
      by reasons and references, and transmitted with the majority report.

6.4-6 Effect of Medical Executive Committee Action

      (a)    Deferral: Action by the medical executive committee to defer the
             application for further consideration must be followed up within thirty (30)
             days with a stated recommendation from the medical executive
             committee for provisional appointment with specified clinical privileges, or
             for rejection for staff membership.

      (b)    Favorable Recommendation: When the recommendation of the medical
             executive committee is favorable to the applicant, it shall promptly be
             forwarded to the Board together with all supporting documentation. For
             the purposes of this Section 6.4-6(b) “all supporting documentation”
             includes the application form and its accompanying information and the
             reports and recommendations of the department chair and of the
             credentials committee and minority views.




                                      20
      (c)    Adverse Recommendation: When the recommendation of the medical
             executive committee is adverse to the applicant, the chief operating
             officer shall within thirty (30) days inform the practitioner by special notice
             and he/she shall be entitled to the procedural rights as provided in Article
             IX and in the Fair Hearing Plan. For the purpose of this Section 6.4-6(c)
             an “adverse recommendation” by the medical executive committee is
             defined in the Fair Hearing Plan.

6.4-7 Board Action

      (a)    On Favorable Medical Executive Committee Recommendation: The
             Board shall, in whole or in part, adopt or reject a favorable
             recommendation of the medical executive committee or refer the
             recommendation back to the medical executive committee for further
             consideration stating the reasons for such referral back and setting a time
             limit within which a subsequent recommendation shall be made. If the
             Board’s action is adverse to the applicant as defined in the Fair Hearing
             Plan, the chief operating officer shall within thirty (30) days so inform the
             applicant by special notice and he/she shall be entitled to the procedural
             rights as provided in Article IX and in the Fair Hearing Plan.

      (b)    Without Benefit of Medical Executive Committee Recommendation: If the
             Board does not receive a medical executive committee recommendation
             within the time period specified in Section 6.4-2, it may take action on its
             own initiative in the manner set forth in the hospital corporate bylaws. If
             such action is favorable, it shall become effective as the final decision of
             the Board. If such action is adverse, as defined in the Fair Hearing Plan,
             the chief operating officer shall promptly so inform the applicant by
             special notice and he/she shall be entitled to the procedural rights as
             provided in Article IX and in the Fair Hearing Plan.

      (c)    After Procedural Rights: In the case of an adverse medical executive
             committee recommendation pursuant to Section 6.4-6(c) or an adverse
             Board decision pursuant to Section 6.4-7(a) or (b), the Board shall take
             final action in the matter only after the applicant has exhausted or has
             waived his/her procedural rights as provided in Article IX and in the Fair
             Hearing Plan. Action thus taken shall be the conclusive decision of the
             Board except that the Board may defer final determination by referring
             the matter back for further recommendation. Any such referral back shall
             state the reasons, therefore, shall set a time limit within which a
             subsequent recommendation to the Board shall be made, and may
             include a directive that an additional hearing be conducted to clarify
             issues which are in doubt.          After receipt of such subsequent
             recommendation and of new evident in the matter, if any, the Board shall
             make a final decision either to appoint the applicant to the staff or to
             reject him/her for staff membership.




                                       21
6.4-8 Conflict Resolution

       Whenever the Board’s proposed decision will be contrary to the medical
       executive committee’s recommendation, the Board shall submit the matter to a
       joint conference of equal numbers of medical staff and board members for
       review and recommendation before making its final decision and giving notice of
       final decision required by Section 6.4-9.

6.4-9 Notice of Final Decision

       (a)    Notice of the Board’s final decision shall be given within thirty (30) days
              through the chief operating officer, to the chair of the medical executive
              committee, the credentials committee, to the chair of each department
              concerned, and to the applicant by means of special notice.

       (b)    A decision and notice to appoint shall include:

              (1)     The staff category to which the applicant is appointed;

              (2)     The specialty to which he/she is assigned;

              (3)     The clinical privileges he/she may exercise; and

              (4)     Any special conditions attached to the appointment.

6.4-10 Reapplication After Adverse Appointment Decision

       An applicant who has received a final adverse decision regarding appointment
       shall not be eligible to reapply to the medical staff for a period of one (1) year.
       Any such reapplication shall be processed as an initial application, and the
       applicant shall submit such additional information as the staff or the Board may
       require in demonstration that the basis for the earlier adverse action no longer
       exists.

6.4-11 Time Period for Processing

       Applications for staff appointments shall be considered in a timely and good faith
       manner by all individuals and groups required by these bylaws to act thereon and
       except for good cause, shall be processed within the time periods specified in
       this Section.     The staff upon completing the information collection and
       verification tasks, usually within thirty (30) days after receiving the application.
       The applicable specialty representative or division vice chief and credentials
       committee shall endeavor to act on an application within thirty (30) days after
       receiving it from the chief operating officer. The medical executive committee
       shall review the application and endeavor to make its recommendation to the
       Board at its next meeting after receiving the bylaws/credentials committee report.
       The Board or the appropriate committee thereof shall then endeavor to take the
       final action on the application at its next regular meeting. The time periods
       specified herein are to assist those named in accomplishing their tasks and shall
       not be deemed to create any right for the practitioner to have the application
       processed within those periods.


                                        22
6.5   REAPPOINTMENT PROCESS

      6.5-1 Information Form for Reappointment

             The chief operating officer shall, at least 120 days prior to the expiration date of
             the present staff appointment of each medical staff member, provide such staff
             member with an interval information form for use in considering his/her
             reappointment. Each staff member who desires reappointment shall, at least
             ninety (90) days prior to such expiration date, send his/her interval information
             form to the chief operating officer. Failure without good cause to so return the
             form shall be deemed a voluntary resignation from the staff and shall result in
             automatic termination of membership at the expiration of the member’s current
             term.

      6.5-2 Verification of Information

             The chief operating officer shall, within thirty (30) days seek to collect or verify
             the additional interval information regarding the staff member’s professional
             activities, performance and conduct in this hospital. The chief operating officer
             shall promptly notify the staff member of any problems in obtaining the
             information required. The staff member shall then have the same burden of
             producing adequate information and resolving doubts as provided in Section 6.4-
             1. When collection and verification are accomplished, the chief operating officer
             shall transmit the information form and supporting materials to the chair of each
             department in which the staff member requests privileges and to the
             bylaws/credentials committee.

      6.5-3 Division Action

             A specialty representative or division vice chief shall review the information form
             and the staff member’s file and shall transmit to the bylaws/credentials
             committee on the prescribed form a report and recommendation that
             appointment be renewed, renewed with modified staff category, department
             affiliation and/or clinical privileges, or terminated. A chair may also recommend
             that the bylaws/credentials committee defer action. Each such report shall
             satisfy the requirements of Section 6.5-7.

      6.5-4 Bylaws/Credentials Committee Action

             The bylaws/credentials committee shall review each information form and all
             other pertinent information available on each member being considered for
             reappointment, including the recommendation of the specialty representative or
             division vice chief, and shall transmit to the medical executive committee on the
             prescribed form its report and recommendation that appointment be either
             renewed, renewed with modified staff category, department affiliation and/or
             clinical privileges, or terminated. The committee may also recommend that the
             medical executive committee defer action. Each such report shall satisfy the
             requirements of Section 6.5-7. Any minority views shall also be reduced to
             writing and transmitted with the majority report.




                                              23
      6.5-5 Medical Executive Committee Action

            The medical executive committee shall review each information form and all
            other relevant information available to it and shall, on the prescribed form,
            transmit to the Board its report and recommendation that appointment be either
            renewed, renewed with modified staff category, department affiliation and/or
            clinical privileges, or terminated. The committee may also defer action. Each
            such report shall satisfy the requirements of Section 6.5-7. Any minority views
            shall also be reduced to writing and transmitted with the majority report.

      6.5-6 Final Processing and Board Action

            Thereafter, the procedure provided in Sections 6.4-6 through 6.4-10 shall be
            followed. For purposes of reappointment, the terms “applicant” and
            “appointments” as used in those Sections shall be read, respectively, as “staff
            member” and “reappointment.”

      6.5-7 Basis for Recommendation

            Each recommendation concerning the reappointment of a staff member and the
            clinical privileges to be granted upon reappointment shall be based upon such
            member’s professional ability and clinical judgment in the treatment of patients,
            his/her professional ethics, his/her discharge of staff obligations, his/her health
            status, his/her compliance with the medical staff bylaws, rules and regulations
            and policies and other matters bearing on his/her ability and willingness to
            contribute to quality patient care in the hospital.

      6.5-8 Time Periods for Processing

            The time periods specified herein are to guide the acting parties in
            accomplishing their tasks. If a reappointment application has not been returned
            timely, or sufficiently complete to enable processing, or the required processing,
            peer review and approval has not been completed by the expiration date of the
            reappointment, the staff member’s appointment will expire at the end of the
            current appointment term. No appointment to be the medical staff may exceed
            two (2) years.

6.6   REQUESTS FOR MODIFICATIONS OF TERMS OF APPOINTMENTS

      6.6-1 Request Status Modification

            A staff member may, either in connection with reappointment or at any other
            time, request modification of his/her staff category, specialty or division
            assignment, or clinical privileges by submitting a written application to the chief
            operating officer on the prescribed form. Such application shall be processed in
            substantially the same manner as provided in Section 6.5 for reappointment.




                                            24
      6.6-2 Request New Privileges

             The applicant presents in writing the described new privilege being sought. This
             is directed to the bylaws/credentials committee. This application shall be
             accompanied by a certificate or other documents from a recognized training
             facility which grants AMA Category I CME credits, or credits deemed appropriate
             by the bylaws/credentials committee in the absence of a recognized program.

             The specialty representative or division vice chief in which the privilege is being
             sought must also acknowledge by signature, the applicant’s interest. Temporary
             privileges may then be granted if deemed appropriate.

             During the performance of the requested privilege the performance is assessed
             in one of two methods:

             (a)     By a medical staff member who has experience in this technique;

             (b)     By outcome assessment if no medical staff member has experience in
                     this technique.

                     The appropriate preparation by the privilege seeking applicant will be
                     determined by the specialty or division of which he/she is a member.
                     Based on current literature no less than five (5) cases should be
                     assessed before the specialty representative or division vice chief will
                     sign off at the conclusion of “a” or “b”. Then permanent privileges can be
                     recommended to the bylaws/credentials committee.

ARTICLE VII: DETERMINATION OF CLINICAL PRIVILEGES

7.1   EXERCISE OF PRIVILEGES
      Every practitioner or other professional providing direct clinical services at this hospital
      by virtue of medical staff membership or otherwise shall, in connection with such
      practice and except as otherwise provided in Section 7.6 and 7.7, be entitled to exercise
      only those clinical privileges or specified services specifically granted to him/her by the
      Board.

7.2   DELINEATION OF PRIVILEGES IN GENERAL

      7.2-1 Requests

             Each applicant for appointment or reappointment to the medical staff must
             contain a request for the specific clinical privileges desired by the applicant. A
             request by a staff member pursuant to Section 6.6 for a modification of privileges
             must be supported by documentation of additional training and/or experience
             supportive of the request.

      7.2-2 Basic for Privilege Determination

             Requests for clinical privileges shall be evaluated on the basis of the
             practitioner’s education, training, experience and demonstrated ability and



                                              25
             judgment. The basis for privilege determination to be made in connection with
             periodic reappointment or otherwise shall include observed clinical performance
             and the documented results of quality review and evaluation activities required
             by these bylaws to be conducted at the hospital. Privilege determination shall
             also be based on pertinent information concerning clinical performance obtained
             from other sources especially other institutions and health care settings where a
             practitioner exercises clinical privileges. This information shall be added to and
             maintained in the staff file established for a staff member.

      7.2-3 Procedure

             All requests for clinical privileges shall be processed pursuant to the procedures
             outlined in Article VI.

7.3   PRIVILEGES

      7.3-1 A physician applicant for medical staff appointment seeking privileges must have
            completed the number of years of residency sufficient to satisfy the specialty
            board requirements of the American Board of Medical Specialties or the
            American Osteopathic Association for eligibility to become certified, in effect at
            the date application for staff appointment is requested to be effective.

      7.3-2 A dentist applicant for medial staff appointment seeking privileges, must have
            completed the number of years of training/residency in a program approved by
            the American Dental Association Commission on Dental Accreditation, sufficient
            to satisfy the training/specialty board requirements for eligibility to become
            licensed/certified in effect at the date application for staff appointment is
            requested to be effective.

      7.3-3 A podiatrist applicant seeking surgical or non-surgical privileges must have
            completed the number of years residency approved by the American Board of
            Podiatric Surgery, sufficient to satisfy the specialty board requirements for
            eligibility to become certified in effect at the date application for staff appointment
            is requested to be effective.

      7.3-4 The requirements in paragraphs (a), (b), and (c) do not apply to practitioners with
            staff appointments made prior to August 25, 1987. The residency requirements
            in paragraph (a) do not apply to:

             (a)     General practitioners requesting clinical privileges in Family Medicine who
                     are currently members of the American Academy of Family Medicine, or;

             (b)     Emergency service physicians who have completed the number of years
                     of residency approved by the Accreditation Council for Graduate Medical
                     Education, sufficient to satisfy the specialty board requirements for
                     eligibility to become certified in a compatible primary care specialty and
                     have demonstrated clinical experience in emergency medicine.




                                               26
7.4   SPECIAL CONDITIONS FOR DENTAL PRIVILEGES

      Requests for clinical privileges from dentists shall be processed in the manner specified
      in Section 7.2. Surgical procedures performed by dentists shall be under the overall
      supervision of the chair of the division of surgery. All dental patients shall receive the
      same basic medical appraisal as patients admitted to other surgical services.            A
      physician member of the staff shall be responsible for the care of any medical problem
      that may be present at the time of admission or that may arise during hospitalization and
      shall determine the risk and effect of the proposed surgical procedure based on the total
      health status of the patient. The responsible physician member of the staff shall be
      identified prior to admission of the patient for surgery to be performed by a dentist
      member of the staff.

7.5   SPECIAL CONDITIONS FOR PODIATRIC PRIVILEGES

      Requests for clinical privileges from such podiatrists shall be processed in the manner
      specified in Section 7.2. Surgical procedures performed by podiatrists shall be under
      the supervision of the chair of the division of surgery. Non-surgical procedures
      performed by a podiatrist shall be under the supervision of the division of surgery. All
      podiatric patients shall receive the same basic medical appraisal as patients admitted to
      other surgical services. A physician member of the staff shall be responsible for the
      care of any medical problem that may be present at the time of admission or that may
      arise during hospitalization and shall determine the risk and effect of the proposed
      surgical procedure based on the total health status of the patient. The responsible
      physician member of the staff shall be identified prior to admission of the patient for
      surgery to be performed by a podiatrist member of the staff.

7.6   SPECIAL CONDITIONS FOR ALLIED HEALTH PRACTITIONERS

      In accordance with Section 5.1, the staff may recommend to the Board the granting of
      scope of practice services to the allied health practitioner, including, but not limited to
      psychologists, physician assistants, and nurse practitioners based upon investigation
      and evaluation of the education, training, experience and demonstrated ability and
      judgment of individuals requesting scope of practice services as allied health
      practitioners, according to established procedures or other documents approved by the
      Board. A recommendation by or on behalf of the staff to not grant scope of practice
      services to an applicant as an allied health practitioner, or to suspend, to terminate, or to
      discontinue such scope of practice services as set forth in Article V, Section 5.2.

7.7   INTERIM, CASE LIMITED OR TIME LIMITED PRIVILEGES

      7.7-1 Circumstances

             Upon the written concurrence of specialty representative or vice chief where the
             privileges will be exercised and of the president of the medical staff (or
             designee), the chief operating officer (or designee) may grant interim privileges
             in the following circumstances:

             (a)     Interim Privileges




                                               27
             Pendency of Application: Class I privileges may be granted for thirty (30)
             days, only if the applicant’s credentials file is complete and ready to be
             forwarded to the Bylaws/Credentials Committee. An extension of thirty
             (30) days may be granted upon the recommendation of the
             bylaws/credentials committee chair (or designee). Requests for Class IV
             privileges, accompanied with documentation of training and experience
             will be reviewed by the bylaws/credentials committee prior to being
             granted as interim privileges. In exercising such privileges the applicant
             shall act under the supervision of the specialty representative or division
             vice chief of which he/she is assigned and in accordance with the
             conditions specified in Section 7.2.

             All letters granting interim privileges shall be signed by the specialty
             representative or division vice chief, the chair of the bylaws/credentials
             committee, the president of the medical staff and the chief operating
             officer (or their designee).

      (b)    Case Limited Privileges
             Care of Specific Patients: Upon receipt of a written request for specific
             case limited privileges an appropriately licensed practitioner of
             documented competence who is not an applicant for membership may be
             granted such privileges for the care of one or more specific patients.
             Such privileges shall be restricted to the treatment of not more than five
             (5) patients in any one year by any practitioner, after which the
             practitioner shall be required to apply for membership on the medical
             staff before being allowed to attend additional patients.

      (c)    Time Limited Privileges
             Locum Tenens: Upon receipt of a written request an appropriately
             licensed practitioner who is serving as a locum tenens for a member of
             the staff may, without applying for membership on the staff, be granted
             time limited privileges for an initial period of thirty (30) days. Such
             privileges may be renewed for one additional period of thirty (30) days but
             may not exceed his/her services as locum tenens.

7.7-2 Conditions

      Interim, case limited, or time limited privileges shall be granted only when the
      information available reasonably supports a favorable determination regarding
      the requesting practitioner’s qualifications, ability and judgment to exercise the
      privileges requested, and only after the practitioner has provided evidence of
      professional liability insurance coverage in the amount consistent with Wisconsin
      state statutes or other evidence of financial responsibility in accordance with the
      Medical Staff Bylaws, Section 3.2-1(c). Special requirements of consultation and
      reporting may be imposed by the specialty representative or division vice chief
      responsible for supervision of a practitioner granted such privileges. Before
      interim, case limited, or time limited privileges are granted, the practitioner must
      acknowledge in writing that he/she has received and read the medical staff
      bylaws, and the rules and regulations, and that he/she agrees to be bound by the
      terms thereof in all matters relating to his/her privileges.



                                       28
      7.7-3 Termination

             On the discovery of any information or the occurrence of any event of a nature
             which raises question about a practitioner’s professional qualifications or ability
             to exercise any or all of the privileges granted, the chief operating officer, after
             consultation with the president of the medical staff, and the specialty
             representative or division vice chief responsible for supervision, may terminate
             any or all of such practitioner’s privileges, provided that where the life or well-
             being of a patient is determined to be endangered by continued treatment by the
             practitioner, the termination may be effected by any person entitled to impose
             summary suspension under the Medical Staff Bylaws, Article VIII. In the event of
             any such termination, the practitioner’s patients then in the hospital shall be
             assigned to another practitioner by the specialty representative or division vice
             chief responsible for supervision. The wishes of the patient shall be considered,
             where feasible, in choosing a substitute practitioner. The terminated practitioner
             shall confer with the substitute practitioner to the extent necessary to safeguard
             the patient.

      7.7-4 Rights of the Practitioner

             A practitioner shall not be entitled to the procedural rights afforded by the
             Medical Staff Bylaws, Article IX or Article X because his/her request for interim,
             case limited, or time limited privileges is refused or because all or any portion of
             such privileges are terminated or suspended.

7.8   EMERGENCY PRIVILEGES

      For the purposes of this Section, an “emergency” is defined as a condition in which
      serious or permanent harm would result to a patient or in which the life of a patient is in
      immediate danger and any delay in administering treatment would add to that danger.
      In the case of an emergency, any practitioner, to the degree permitted by his/her license
      and regardless of staff status, or clinical privileges, shall be permitted to do, and shall be
      assisted by hospital personnel in doing everything possible to save the life of a patient or
      to save a patient from serious harm. A practitioner utilizing emergency privileges shall
      promptly provide the medical executive committee in writing a statement explaining the
      circumstances giving rise to the emergency.

7.9   DISASTER PRIVILEGES

      For the purpose of this Section a “disaster” is defined as any officially declared
      emergency whether it is local, state or national, and that creates healthcare demands
      that exceed the capabilities of the hospital and/or the Medical Staff. A practitioner
      providing patient care in the event of a disaster must be granted privileges by the chief
      operating officer or designee, prior to providing patient care. Such privileges shall be
      valid only for the duration of the disaster and shall automatically terminate at the end of
      needed services.

      The process for granting disaster privileges is outlined in the policy Credentialing
      Physicians and Allied Health Practitioners in Event of a Disaster (07-06-52).




                                               29
ARTICLE VIII: CORRECTIVE ACTION

8.1   ROUTINE CORRECTIVE ACTION

      8.1-1 Criteria for Initiation

             Whenever the activities or professional conduct of any practitioner with clinical
             privileges are, or are reasonably likely to be, detrimental to patient safety or to
             the delivery of quality care as set forth in the Disruptive Practitioner Policy,
             corrective action against such practitioner may be initiated by any officer of the
             medical staff, by the leadership of a division or standing committee of the
             medical staff, by the chief operating officer, or by the Board.

      8.1-2 Requests and Notices

             All requests for corrective action shall be in writing, submitted to the medical
             executive committee, and supported by reference to the specific conduct or
             activities which constitute the grounds for the request. The president of the
             medical staff shall promptly notify the chief operating officer in writing of all
             requests for corrective action received by the committee and shall continue to
             keep the chief operating officer fully informed of all action taken in connection
             therewith.

      8.1-3 Investigation

             After consideration of the request, the medical executive committee shall either
             reject the request and report the reasons for its decision to the chief operating
             officer, or forward the request either to the specialty representative or a division
             leader in which the questioned activities or conduct occurred, or to an ad hoc
             committee appointed by the president of the medical staff to conduct an
             investigation. The staff member who is under investigation may be invited to
             appear before the investigating committee. Any such appearance shall be
             informal in nature and not constitute a hearing. Within thirty (30) days after the
             receipt of the request, the division leader or the investigating committee shall
             forward a written report of the investigation to the medical executive committee.

      8.1-4 Medical Executive Committee Action

             Within thirty (30) days following receipt of the report of the investigation, the
             medical executive committee shall take action upon the request. Such action
             may include, without limitation:

             (a)     Rejecting the request for corrective action.

             (b)     Issuing a warning, a letter of admonition, or a letter of reprimand.

             (c)     Recommending terms of probation or requirements of consultation.

             (d)     Recommending reduction, suspension, or revocation of clinical privileges.




                                              30
             (e)     Recommending reduction of staff category or limitation of any staff
                     prerogatives directly related to patient care.

             (f)     Recommending suspension or revocation of staff appointment.

      8.1-5 Procedural Rights

             Any action by the medical executive committee pursuant to Section 8.1-4(c); 8.1-
             4(d); 8.1-4(e); or 8.1-4(f), or any combination of such actions, shall entitle the
             practitioner to the procedural rights as provided in Article IX, and the matter shall
             be processed in accordance with the provisions of Article X.

      8.1-6 Other Action

             If the medical executive committee’s recommended action is as provided in
             Section 8.1-4(a) or 8.1-4(b), such recommendation, together with all supporting
             documentation, shall be transmitted to the Board. Thereafter, the procedure to
             be followed shall be as provided in Sections 6.4-7 and 6.4-9 as applicable.

8.2   PRECAUTIONARY SUSPENSION

      8.2-1 Criteria for Initiation

             The president of the medical staff, a division leader, the chief operating officer,
             the executive committee of either the medical staff or of the Board, or the
             Medical Staff Support Committee shall have the authority to suspend the medical
             staff membership status or all or any portion of the clinical privileges of a
             practitioner, whenever failure to take such action may result in an imminent
             danger to the health and/or safety of any individual.

             Such precautionary suspension shall be deemed an interim precautionary step in
             the professional review activity related to the ultimate professional review action
             that will be taken with respect to the suspended individual but is not a complete
             professional review action in and of itself. It shall not imply any final finding of
             responsibility to the situation that caused the suspension.

      8.2-2 Medical Executive Committee Action

             As soon as possible and in any event no longer than five (5) days after such
             precautionary suspension, a meeting of the medical executive committee shall
             be convened to review and consider the action taken. The medical executive
             committee may modify, continue or terminate the terms of the precautionary
             suspension.

      8.2-3 Procedural Rights

             Unless the medical executive committee recommends immediate termination of
             the suspension and cessation of all further corrective action, the staff member
             shall be entitled to the procedural rights as provided in Article IX, and the matter
             shall be processed in accordance with the provisions of Article X. The terms of



                                              31
            the precautionary suspension as sustained by the medical executive committee
            shall remain in effect pending a final decision by the Board.

            If the medical executive committee recommends termination of the suspension
            and cessation of all further corrective action, the suspension shall remain in
            effect until the Board has reviewed the recommendation and taken action to
            terminate the suspension. If the Board, after such review, decides to continue
            the suspension, the staff member shall be entitled to the procedural rights
            provided in Article IX, and the matter shall be processed in accordance with the
            provisions of Article X.

            If the medical executive committee recommends less restrictive terms of
            suspension, the original suspension shall remain in effect until the Board has
            reviewed the recommendation and taken action to terminate the suspension. If
            the Board, after such review, decides to continue the suspension, either original
            or as modified; the staff member shall be entitled to the procedural rights as
            provided in Article IX, and the matter shall be processed in accordance with the
            provisions of Article X.

8.3   AUTOMATIC SUSPENSION

      8.3-1 License

            If a staff member’s license to practice his/her profession in the State of
            Wisconsin is revoked or suspended, or the licensing agency imposes limitation
            of practice on the practitioner, such staff member shall immediately and
            automatically be suspended from practicing in the hospital

      8.3-2 Drug Enforcement Administration (DEA) Number

            A staff member whose DEA number is revoked, suspended or is voluntarily
            relinquished shall immediately and automatically be divested of his/her right to
            prescribe medications covered by such number. Within seven (7) days of such
            automatic suspension, the medical executive committee shall convene to review
            and consider the facts under which the DEA number was revoked, suspended,
            or relinquished. The medical executive committee may then recommend such
            further corrective action as appropriate to the facts disclosed in its investigation.

      8.3-3 Failure to Satisfy Special Appearance Requirements

            A staff member who fails to satisfy the requirements of Section 10.7-3 shall
            immediately and automatically be suspended from exercising all or such portion
            of his/her clinical privileges in accordance with the provisions of said Section
            10.3-1.

      8.3-4 Medical Records

            An automatic suspension shall be imposed in accordance with Medical Staff
            Policy 7-12-38 for failure to complete medical records in a timely fashion. For




                                             32
       the purpose of enforcing this Section 8.3-4, justified reasons for delay in
       completing medical records may include without limitation:

       (a)    The attending physician or any other individual contributing to the record
              is ill or otherwise unavailable for a period of time due to circumstances
              beyond his/her control.

       (b)    A practitioner is waiting for the results of a late report and the record is
              otherwise complete except for the discharge summary and final
              diagnosis.

       (c)    The practitioner has dictated reports and is waiting for hospital personnel
              to transcribe them.

8.3-5 Failure to Practice Actively

       At the time of reappointment when a member of the staff with admitting
       privileges has not admitted a patient to the hospital or has not provided
       professional services to any patient in the hospital for two (2) years, he/she shall
       be given special notice that in thirty (30) days his/her staff appointment will be
       automatically reviewed by the bylaws/credentials committee unless he/she either
       admits a patient to the hospital or provides services to a patient in the hospital
       during that thirty (30) day period.

8.3-6 Impairment

       When a practitioner has been judged to be impaired by the Medical Staff Support
       Committee and refuses appropriate treatment (to be determined by the Medical
       Staff Support Committee), the chief operating officer and/or president of the
       medical staff, or their designees, after consultation may initiate immediate and
       automatic suspension. The practitioner is afforded all rights of appeal as
       provided by the medical staff bylaws.

8.3-7 Exclusion or Withdrawal From Federal Health Care Programs

       A staff member who is excluded or who voluntarily withdraws from participation
       in the Medicare, Medicaid, or other federal health care programs, shall be
       immediately and automatically divested of his/her right to treat, care for, or order
       studies for any beneficiary of such programs (in accordance with 41USC
       1001.1001). Within seven (7) days of such automatic suspension, the medical
       executive committee shall convene and consider the facts under which exclusion
       or withdrawal occurred. The medical executive committee may then recommend
       such further corrective action as appropriate to the facts disclosed in the
       investigation.

8.3-8 Procedural Rights

       A staff member under automatic suspension by operation of Section 8.3-4 shall
       be entitled to the procedural rights provided in Article IX and Article X for only the
       purpose of establishing justification for the delay in completing medical records.



                                        33
             A staff member whose appointment or privileges has been automatically
             suspended or revoked by operation of Sections 8.3-1, 8.3-2, 8.3.3 and 8.3-4 may
             request a hearing by a committee appointed by the Board to present evidence to
             establish that the automatic suspension or revocation was invoked in error. The
             hearing and any subsequent proceedings shall be conducted in accordance with
             provisions of Article X. The invoking of an automatic suspension does not
             preclude initiation of corrective action pursuant to Section 8.1.


ARTICLE IX: INTERVIEWS, HEARINGS, AND APPELLATE REVIEW

9.1   INTERVIEWS

      When the medical executive committee, other relevant staff committee, or the Board or
      any appropriate committee thereof receives or is considering initiating an adverse
      recommendation concerning a practitioner, the practitioner may be afforded an
      interview. The interview shall not constitute a hearing, shall be preliminary in nature,
      and shall not be conducted according to the procedural rules provided with respect to
      hearings. The practitioner shall be informed of the general nature of the circumstances
      and may present information relevant thereto. A record of such interview shall be made.

9.2   HEARING AND APPELLATE REVIEW

      9.2-1 Adverse Medical Executive Committee Recommendation

             When any practitioner receives special notice of an adverse recommendation of
             the medical executive committee, he/she shall be entitled upon request, to a
             hearing before an ad hoc committee of the medical staff appointed by the
             president of the staff. Said individuals shall not be in direct economic
             competition with the physician involved. If the recommendation of the medical
             executive committee following such hearing is still adverse to the practitioner,
             he/she shall then be entitled, upon request, to an appellate review by the Board
             before a final decision is rendered.

      9.2-2 Adverse Board Decision

             When any practitioner receives special notice of an adverse decision by the
             Board taken either contrary to a favorable recommendation by the medical
             executive committee under circumstances where no right to a hearing existed, or
             on the Board’s own initiative without benefit of a prior recommendation by the
             medical executive committee such practitioner shall be entitled, upon request, to
             a hearing by an ad hoc hearing committee appointed by the Board. If such
             hearing does not result in a favorable recommendation, he/she shall then be
             entitled upon request, to an appellate review by the Board before a final decision
             is rendered.




                                             34
      9.2-3 Procedure and Process

            All hearings and appellate reviews shall be in accordance with the procedure and
            safeguards set forth in Article X.

      9.2-4 Exceptions

            The denial, termination or reduction of temporary privileges or any other actions,
            except those specified in Article X, shall not give rise to any right to a hearing or
            appellate review.

9.3   REMOVAL FROM OFFICE OF MEDICO-ADMINISTRATIVE OFFICER

      9.3-1 General Manner of Removal

            Removal from office of a medico-administrative officer for grounds unrelated to
            his/her professional clinical capability or to his/her exercise of clinical privileges
            may be accomplished in accordance with the usual personnel policies of the
            hospital or the terms of such officer’s employment agreement, contract, or other
            arrangements if any. To the extent that the grounds for removal would require a
            report to the National Practitioner Data Bank relating to competence in
            performing professional clinical tasks, in supervising the professional activities of
            practitioners under his/her direction or in exercising clinical privileges, resolution
            of the matter shall be in accordance with Articles VIII and IX and the Fair Hearing
            Plan.

      9.3-2 Statement of Grounds

            Prior to removal of a medico-administrative officer, the Board, through the chief
            operating officer, shall transmit to such medico-administrative officer and to the
            medical executive committee a written notice of the proposed removal from
            office together with a statement specifying the grounds for removal. The extent
            that such grounds explicitly relate to professional clinical capability or to the
            exercise of clinical privileges, the notice to the officer whose removal is sought
            shall take the form of a special notice, and for hearing purposes, the proposed
            removal shall be deemed equivalent to an adverse recommendation of the
            medical executive committee. If the stated grounds for dismissal are based
            solely on nonclinical matters, the procedure specified in Section 9.3-3 shall apply
            at the discretion of the chief operating officer in consultation with the officers of
            the medical staff.

      9.3-3 Joint Conference Committee

            Within thirty (30) days of receipt by the medical executive committee of the
            notice as provided in Section 9.3-2, a Joint Conference Committee of equal
            members from the medical staff and the Board shall be convened. Five (5)
            Board members shall be selected by the chair of the Board and five (5) medical
            staff members by the president of the medical staff.




                                             35
              This Joint Conference Committee shall review the statement of dismissal and
              conduct such other inquiry as it may deem appropriate for the purpose of
              rendering an advisory opinion on the categorization of the grounds for removal.
              The Joint Conference Committee may, but is not required to interview the
              medico-administrative officer. Within ten (10) days of its deliberations, the Joint
              Conference Committee shall, by written memorandum to the medical executive
              committee and to the Board, submit its opinion on the matter. The advisory
              panel’s deliberations shall not be deemed a hearing as that term is used in
              Section 9.2 and shall not be conducted as such, but a record shall be kept.

       9.3-4 Board Decision

              After considering the Joint Conference Committee’s opinion, the Board shall
              make its final decision as to the categorization of the grounds for dismissal.
              Removal of the officer shall be effected in the manner appropriate to the Board’s
              final categorization and consistent with Section 9.3-1.

ARTICLE X: FAIR HEARING PLAN

10.1   SPECIAL DEFINITIONS

       For the purpose of this Article, the following definitions shall apply:

       10.1-1 APPELLATE REVIEW BODY: means the group designated pursuant to Section
              9.2 of this plan to hear a request for appellate review properly filed and pursued
              by a practitioner.

       10.1-2 HEARING COMMITTEE: means the committee appointed pursuant to Section
              10.4-3 of this plan to hear a request for evidentiary hearing properly filed and
              pursued by a practitioner.

       10.1-3 PARTIES: means the practitioner who requested the hearing or appellate review
              and the body or bodies upon whose adverse action a hearing or appellate review
              request is predicated.

10.2   INITIATION OF HEARING

       The following recommendations or actions shall, if deemed adverse, entitle the
       practitioner affected thereby to a hearing:

             Denial of initial staff appointment.
             Denial of reappointment.
             Suspension of staff membership.
             Revocation of staff appointment.
             Denial of requested modification of staff category.
             Reduction in staff category.
             Limitation of admitting prerogatives.
             Denial of requested division assignment.
             Denial of requested clinical privileges.
             Reduction of clinical privileges.


                                                 36
     Suspension of clinical privileges.
     Revocation of clinical privileges.
     Terms of probation.
     Individual requirement of consultation.

10.2-1 When Deemed Adverse

      A recommendation or action listed in Section 10.2 shall be deemed adverse
      action only when it has been:

      (a)    Recommended by the medical executive committee; or unanimously
             recommended by the Bylaws/Credentials Committee; or

      (b)    A suspension continued in effect after review by the medical executive
             committee and/or the Board; or

      (c)    Taken by the Board contrary to a favorable recommendation by the
             medical executive committee or bylaws/credentials committee under
             circumstances where no prior right to a hearing existed; or

      (d)    Taken by the Board on its own initiative without benefit of a prior
             recommendation      by   the     medical executive committee     or
             bylaws/credentials committee; or

      (e)    Imposed automatically.

10.2-2 Notice of Adverse Recommendation or Action

      A practitioner against whom adverse action has been taken pursuant to Section
      10.2-1 shall promptly be given special notice of such action by the chief
      operating officer. The notice shall indicate that the practitioner may request a
      hearing in accordance with the medical staff bylaws and Article X.

      The notice shall indicate that a professional review action has been taken
      against the practitioner, reasons for the proposed action, that the practitioner has
      a right for thirty (30) days within which to request a hearing on the proposed
      action. The notice further shall indicate that: A) if a hearing is requested on a
      timely basis, the hearing shall be held before a hearing officer or panel of
      individuals appointed pursuant to the bylaws who are not in direct economic
      competition with the practitioner: B) the right to a hearing may be forfeited if the
      practitioner, without good cause, fails to appear: C) in the hearing the
      practitioner has a right (1) to representation by an attorney or other person of the
      practitioner’s choice, (2) to have a record made of the proceedings, copies of
      which may be obtained by the practitioner upon payment of any reasonable
      charges associated with the preparation thereof: (3) to call, examine and cross
      examine witnesses: (4) to present evidence determined to be relevant by the
      hearing officer or panel, regardless of its admissibility in a court of law: and (5)
      submit a written statement at the close of the hearing. The notice further shall
      indicate that the practitioner, upon completion of the hearing, has a right: (1) to
      receive the written recommendation of the officer or panel, including the



                                       37
              statement of the basis for the recommendations, and (2) to receive a written
              decision of the health care entity, including a statement of the basis for the
              decision.

10.3   REQUEST FOR HEARING

       A practitioner shall have at least thirty (30) and not more than forty-five (45) days
       following the receipt of a notice pursuant to Section 10.2-2 to file a written request for a
       hearing. Such request shall be deemed to have been made when delivered to the chief
       operating officer in person or when sent by certified mail to the chief operating officer,
       properly addressed and postage prepaid.

       10.3-1 Waiver by Failure to Request a Hearing

              A practitioner who fails to request a hearing within the time and in the manner
              specified waives any right to such hearing and to any appellate review to which
              he/she might otherwise have been entitled. Such waiver in connection with:

              (a)     An adverse action by the Board shall constitute acceptance of that action,
                      which shall thereupon become effective as the final decision of the Board.

              (b)     An adverse recommendation by the medical executive committee or
                      unanimous recommendation of the bylaws/credentials committee shall
                      constitute acceptance of that recommendation, which shall there-upon
                      become and remain effective pending the final decision of the Board.
                      The Board shall consider the committee’s recommendation at its next
                      regular meeting following the waiver. In its deliberations, the Board shall
                      review all the information and material considered by the committee and
                      may consider all other relevant information received from any source. If
                      the Board’s action on the matter is in accord with the medical executive
                      committee or bylaws/credentials committee’s recommendation such
                      action shall constitute a final decision by the Board. If the Board’s action
                      has the effect of changing the medical executive or bylaws/credentials
                      committee’s recommendation, the matter shall be submitted to a joint
                      conference as provided in this plan. The Board’s action on the matter
                      following receipt of the joint conference recommendation shall constitute
                      its final decision.

                      The chief operating officer shall promptly send the practitioner a special
                      notice informing him/her of each action taken pursuant to this Section
                      and shall notify the president of the staff of each such action.

10.4   HEARING PREREQUISITES

       10.4-1 Notice of Time and Place of Hearing

              Upon receipt of a timely request for hearing, the chief operating officer shall
              deliver such request to the president of the medical staff or to the Board,
              depending on whose recommendation or action prompted the request for a
              hearing. At least thirty (30) days prior to the hearing, the chief operating officer



                                               38
              shall send the practitioner special notice of the time, place and date of the
              hearing and a list of witnesses the medical staff or Board expects to call. The
              hearing date shall not be less than thirty (30) days from the date of notice of the
              hearing; unless the practitioner voluntarily waives in writing the thirty (30) day
              period, whereupon the chief operating officer and the practitioner shall endeavor
              to mutually agree on a hearing date. In the event an agreed upon date cannot
              be reached the date contained in the notice shall be the hearing date.

       10.4-2 State of Issues and Grounds

              The notice of hearing provided shall contain a concise statement of the
              practitioner’s alleged acts or omissions, a list by number of the specific or
              representative patient record in question and/or the other reasons or subject
              matter forming the basis for the adverse recommendation or action which is the
              subject of the hearing.

       10.4-3 Appointment of the Hearing Committee

              (a)    By Medical Staff: A hearing occasioned by a medical executive or
                     bylaws/credentials committee recommendation pursuant to Section 10.2-
                     1 shall be conducted by a hearing committee appointed by the president
                     of the staff and composed of five (5) members of the active staff. One of
                     the members so appointed shall be designated as chair.

              (b)    By Board: A hearing occasioned by an adverse action of the Board
                     pursuant to Section 10.2-1 or upon a request pursuant to Section 10.3
                     shall be conducted by a hearing committee appointed by the chair of the
                     Board and composed by five (5) persons, including two (2) active staff
                     members chosen with advice from the president of the staff shall be
                     included on this committee when issues concern professional
                     competence or performance. One of the appointees to the committee
                     shall be designated as chair.

              (c)    A medical staff or Board member shall be disqualified from serving on a
                     hearing committee if he/she participated in initiating, investigating, or has
                     an economic interest in the underlying matter at issue. In no event shall
                     a member of the body whose adverse recommendation or action
                     occasioned the hearing serve on the hearing committee.

10.5   HEARING PROCEDURE

       10.5-1 Personal Presence

              The personal presence of the practitioner who requested the hearing shall be
              required. A practitioner who fails without good cause to appear and proceed at
              such hearing shall be deemed to have waived his/her rights in the same manner
              and with the same consequence as provided in Section 10.3-1.




                                              39
10.5-2 Presiding Officer

       Either the hearing officer, if one is appointed, pursuant to Section 10.10-1, or the
       chair of the hearing committee shall be the presiding officer. The presiding
       officer shall act to maintain decorum and to assure that participants in the
       hearing have a reasonable opportunity to present relevant oral and documentary
       evidence. He/she shall be entitled to determine the order of procedure during
       the hearing and shall make all rulings on matters of law, procedure, and the
       admissibility of evidence.

10.5-3 Representation

       The practitioner who requested the hearing shall be entitled to be accompanied
       and represented at the hearing by a member of the medical staff in good
       standing or by a member of his/her local professional society. The Medical
       Executive Committee or the Board, depending on whose recommendation or
       action prompted the hearing shall appoint an individual to represent it at the
       hearing to present the facts in support of its adverse recommendation or action
       and to examine witnesses. Representation of either party by an attorney at law
       shall be governed by the provisions of Article X.

10.5-4 Rights of Parties

       During a hearing, each of the parties shall have the right to:

       (a)    Be presented by an attorney or other representative; however, the
              Hearing Committee has the right to define the role of counsel for the
              practitioner or Committee.

       (b)    Have a record of the proceedings made according to Section 10.5-8 and
              to obtain a copy of the record upon payment of a reasonable charge,

       (c)    Call, examine, and cross-examine witnesses,

       (d)    Present relevant evidence,

       (e)    Submit a written statement at the close of the hearing,

       (f)    Receive any written recommendation based on the hearing, including the
              basis for the recommendation; and

       (g)    Receive a written final decision, including the basis for the decision.

10.5-5 Procedure and Evidence

       The hearing shall not be conducted strictly according to rules of law relating to
       the examination of witnesses or presentation of evidence. Any relevant matter
       upon which responsible persons customarily rely in the conduct of serious affairs
       shall be admitted, regardless of the admissibility of such evidence in a court of
       law. Each party shall, prior to or during the hearing, be entitled to submit



                                        40
       memoranda concerning any issue of law or fact, and such memoranda shall
       become a part of the hearing record. The hearing committee may require one or
       both parties to prepare and submit to the committee, written statements of their
       position on the issues, prior to, during, or after, the hearing. The hearing
       committee may establish rules of procedure, including, but not limited to,
       requiring the submission prior to the hearing of lists of proposed witnesses and
       exhibits. The presiding officer, may but shall not be required to order that oral
       evidence be taken only on oath or affirmation administered by any person
       designed by him/her/her and entitled to notarize documents in the State of
       Wisconsin.

10.5-6 Evidentiary Notice

       In reaching a decision, the hearing committee may take note, for evidentiary
       purposes, either before or after submission of the matter for decision, of any
       generally accepted technical or scientific matter relating to the issues under
       consideration and of any facts that may be judicially noticed by the courts of the
       State of Wisconsin. Parties present at the hearing shall be informed of the
       matters to be noticed and those matters shall be recited in the hearing record.
       Any party shall be given opportunity on timely request, or request that a matter
       be evidentiary noticed and to refute the evidentiary noticed matters by evidence
       or by written or oral presentation of authority, the manner of such refutation to be
       determined by the hearing committee. The committee shall also be entitled to
       consider any pertinent material contained on file in the hospital, and all other
       information that can be considered, pursuant to the medical staff bylaws, in
       connection with applications for appointment or reappointment to the staff and
       for clinical privileges.

10.5-7 Burden of Proof

       When a hearing relates to an adverse action or recommendation set forth in
       Section 10.2 a-n of the provisions above entitled Initiation of Hearing, the
       practitioner who requested the hearing shall have the burden of proving, by clear
       and convincing evidence, that the adverse recommendation or action lacks any
       substantial factual basis or that such basis or the conclusions drawn therefrom
       are either arbitrary, unreasonable, or capricious. Otherwise, the body whose
       adverse recommendation or action occasioned the hearing shall have the initial
       obligation to present evidence in support thereof, but the practitioner shall
       thereafter be responsible for support thereof, but the practitioner shall thereafter
       be responsible for supporting his/her challenge to the adverse recommendation
       or action by a preponderance of the evidence that the grounds therefore lack any
       substantial factual basis of that such basis or the conclusions drawn therefrom
       are either arbitrary, unreasonable, or capricious.

10.5-8 Record of Hearing

       A record of the hearing shall be kept that is of sufficient accuracy to assure that
       an informed and valid judgment can be made by any group that may later be
       called upon to review the record and render a recommendation or decision in the
       matter. The hearing committee chair, unless his/her decision is reversed by a



                                        41
             majority vote of the hearing committee, shall select the method to be used for
             making the record, such as court reporter, electronic recording unit, detailed
             transcription, or minutes of the proceedings. A practitioner requesting an
             alternate method shall bear the cost thereof. The practitioner is entitled to a
             copy of the record of the hearing.

       10.5-9 Postponement

             Requests for postponement of a hearing shall be granted by the hearing
             committee only upon a showing of good cause.

       10.5-10 Presence of Hearing Committee Members and Vote

             All members of the hearing committee must be present throughout the hearing
             and deliberations. If a committee member is absent from any part of the
             proceedings, he/she shall not be permitted to participate in the deliberations or
             the decision.

       10.5-11 Recesses and Adjournment

             The hearing committee may recess the hearing and reconvene the same without
             additional notice for the convenience of the participants or for the purpose of
             obtaining new or additional evidence or consultation. Upon conclusion of the
             presentation of oral and written evidence, the hearing shall be closed. The
             hearing committee, shall thereupon, at a time convenient to itself, conduct its
             deliberations outside the presence of the parties. Upon the conclusion of its
             deliberations, the hearing shall be declared finally adjourned.

10.6   HEARING COMMITTEE REPORT AND FURTHER ACTION

       10.6-1 Hearing Committee Report

             Within ten (10) days after final adjournment of the hearing, the hearing
             committee shall make a written report of its findings and recommendations
             specifically addressing each charge made in the matter and shall forward the
             same, together with the hearing record an all other documentation considered by
             it, to the body whose adverse recommendation or action occasioned the hearing.
             All findings and recommendations by the hearing committee shall be supported
             by reference to the hearing record and the other documentation considered by it.

       10.6-2 Action on Hearing Committee Report

             Within thirty (30) days after receipt of the report of the hearing committee, the
             Medical Executive Committee or the Board, as the case may be, shall consider
             the same and affirm, modify or reverse its recommendation or




                                            42
       10.6-3 Notice and Effect of Result

              (a)    Notice: The chief operating officer shall promptly send a copy of the
                     result to the practitioner by special notice, to the president of the staff,
                     and to the board.

              (b)    Effect of Favorable Result:

                     (1)     Adopted by the Board: If the board's result pursuant to Section
                             10.4-3 is favorable to the practitioner, such result shall become
                             the final decision by the board and the matter shall be considered
                             finally closed.

                     (2)     Adopted by Medical Executive Committee: If the medical
                             executive committee's result pursuant to Section 10.4-3 is
                             favorable to the practitioner, the chief operating officer shall
                             promptly forward it, together with all supporting documentation, to
                             the board for its final action. The board shall take action thereon
                             by adopting or rejecting medical executive committee's result in
                             whole or in part, or by referring the matter back to the medical
                             executive committee for further reconsideration. Any such referral
                             back shall state the reasons therefore, set a time limit within which
                             a subsequent recommendation to the board must be made, and
                             may include a directive that an additional hearing be conducted to
                             clarify issues that are in doubt. After receipt of such subsequent
                             recommendation and any new evidence in the matter, the board
                             shall take final action. The chief operating officer shall promptly
                             send the practitioner special notice pursuant to Section 10.5-4(g)
                             informing him/her of each action taken. Favorable action shall
                             become the final decision of the board, and the matter shall be
                             considered finally closed. If the board's action is adverse in any of
                             the respects listed in Section 10.2, the special notice shall inform
                             the practitioner of his/her right to request an appellate review by
                             the board as provided in Section 10.8 of this plan.

              (c)    Effect of Adverse Result: If the result of the medical executive committee
                     or of the board continues to be adverse to the practitioner in any of the
                     respects listed in this Plan, the special notice required above shall inform
                     the practitioner of his/her right to request an appellate review by the
                     board as provided in this Plan.

10.7   INITIATION AND PREREQUISITES OF APPELLATE REVIEW

       10.7-1Request for Appellate Review

              A practitioner shall have thirty (30) days following his/her receipt of a notice as
              provided immediately above to file a written request for an appellate review.
              Such request shall be delivered to the chief operating officer either in person or
              by certified mail. The chief operating officer shall forward a copy to the
              practitioner of the report and record of the hearing committee and all other



                                              43
              material, favorable or unfavorable, if not previously forwarded, that was
              considered in marking the adverse action or result.

       10.7-2 Waiver by Failure to Request Appellate Review

              A practitioner who fails to request an appellate review within the time and in the
              manner specified in Section 10.7-1 waives any right to such review. Such waiver
              shall have the same force and effect as that provided in Section 10.3-1.

       10.7-3 Notice of Time and Place of Appellate Review

              Upon receipt of a timely request for appellate review, the chief operating officer
              shall deliver such request to the board. As soon as practical, the board shall
              schedule and arrange for an appellate review which shall be not less than ten
              (10) days nor more than thirty (30) days from the date of receipt of the appellate
              review request; provided, however, that an appellate review for a practitioner
              who is under suspension then in effect shall be held as soon as arrangements
              for it may reasonably be made, but not later than forty (40) days from the date of
              receipt of the request for review. At least ten (10) days prior to the appellate
              review, the chief operating officer shall send the practitioner special notice of the
              time, place, date of the review and a list of witnesses the board will call. The
              time for the appellate review may be extended by the appellate review body for
              good cause.

       10.7-4 Appellate Review Body

              The board shall determine whether the appellate review shall be conducted by
              the board as a whole or by an appellate review committee composed of five (5)
              members of the board appointed by the chair. If a committee is appointed, one
              of its members shall be designated as chair.

10.8   APPELLATE REVIEW PROCEDURE

       10.8-1 Nature of Proceedings

              The proceedings by the review body shall be in the nature of an appellate review
              based upon the record of the hearing before the hearing committee, that
              committee's report, and all subsequent results and action thereon. The appellate
              review body shall also consider the written statements, if any, submitted as
              provided below and such other material as may be presented and accepted
              within the terms of this plan.

       10.8-2 Written Statements

              The practitioner seeking the review may submit a written statement detailing the
              findings of fact, conclusions and procedural matters with which he/she
              disagrees, and his/her reasons for such disagreement. This written statement
              may cover any matters raised at any step in the hearing process, and legal
              counsel may assist in its preparation. The statement shall be submitted to the
              appellate review body through the chief operating officer at least seven (7) days



                                               44
       prior to the scheduled date of the appellate review, except if such time limit is
       waived by the appellate body. A written statement in reply must be submitted to
       the medical executive committee or by the board, and if submitted, the chief
       operating officer shall provide a copy thereof to the practitioner at least two (2)
       days prior to the scheduled date of the appellate review.

10.8-3 Presiding Officer

       The chair of the appellate review body shall be the presiding officer. He/she
       shall determine the order of procedure during the review, make all required
       rulings, and maintain decorum.

10.8-4 Oral Statement

       The appellate review body, in its sole discretion, may allow the parties or their
       representatives to personally appear and make oral statements in favor of their
       positions. Any party or representative so appearing shall be subject to answer
       questions put to him/her by any member of the appellate review body.

10.8-5 Consideration of New or Additional Matters

       New or additional matters or evidence not raised or presented during the original
       hearing or in the hearing report and not otherwise reflected in the record shall be
       introduced at the appellate review only in the discretion of the appellate review
       body, following an explanation by the party requesting the consideration of such
       matter or evidence as to why it was not presented earlier.

10.8-6 Powers

       The appellate review body shall have all powers granted to the hearing
       committee, and such additional powers as are reasonably appropriate to the
       discharge of its responsibilities.

10.8-7 Presence of Members and Vote

       All members of the appellate review body must be present throughout the review
       and deliberations. If a member of the review body is absent from any part of the
       proceedings, he/she shall not be permitted to participate in the deliberations or
       the decision.

10.8-8 Recesses and Adjournment

       The appellate review body may recess and review proceedings and reconvene
       the same without additional notice for the convenience of the participants or for
       the purpose of obtaining new or additional evidence or consultation. Upon the
       conclusion of oral statements, if allowed, the appellate review shall be closed.
       The appellate review body shall thereupon, at a time convenient to itself, conduct
       its deliberations outside the presence of the parties. Upon the conclusion of
       these deliberations, the appellate review shall be declared finally adjourned.




                                       45
       10.8-9 Action Taken

              The appellate review body may recommend that the board affirm, modify or
              reverse the adverse result or action taken by the medical executive committee or
              by the board, or in its discretion, may refer the matter back to the hearing
              committee for further review and recommendation to be returned to it within
              fifteen (15) days and in accordance with its instructions. Within fifteen (15) days
              after receipt of such recommendation after referral, the appellate review body
              shall make its recommendation to the board as provided in this Section.

       10.8-10 Conclusion

              The appellate review shall not be deemed to be concluded until all of the
              procedural steps provided herein have been completed or waived.

10.9   FINAL DECISION OF THE BOARD

       10.9-1 Board Action

              Within thirty (30) days after the conclusion of the appellate review, the board
              shall render its final decision in the matter in writing and shall send notice to the
              president of the staff, and to the Medical Executive or Bylaws/Credentials
              Committee as appropriate. If this decision is in accord with the Medical
              Executive Committee's last recommendation in the matter, if any, it shall be
              immediately effective and final. If the board's action has the effect of changing
              the medical executive committee's last such recommendation, if any, the board
              shall refer the matter to a joint conference as provided below. The board's
              action on the matter following receipt of the joint conference recommendation
              shall be immediately effective and final.

       10.9-2 Joint Conference Review

              Within thirty (30) days of its receipt of a matter referred to it by the board
              pursuant to the provisions of this Plan, a joint conference of equal number of
              medical staff and board members shall convene to consider the matter and shall
              submit its recommendation to the board. The joint conference shall be
              composed of a total of ten (10) members selected in the following manner: the
              board representatives shall be appointed by the board; the medical staff
              representatives shall be appointed by the president of the medical staff with
              medical executive committee approval.

10.10 GENERAL PROVISIONS

       10.10-1 Hearing Officer Appointment and Duties

              The use of a hearing officer to preside at an evidentiary hearing is optional. The
              use and appointment of such officer shall be determined by the board after
              consultation with the president of the medical staff. A hearing officer may or may
              not be an attorney at law but must be experienced in conducting hearings.
              He/she shall act in an impartial manner as the presiding officer of the hearing. If



                                               46
              requested by the hearing committee, he/she may participate in its deliberations
              and act as its legal advisor, but he/she shall not be entitled to vote.

       10.10-2 Attorneys

              If the affected practitioner desires to be represented by an attorney at any
              hearing or at any appellate review appearance pursuant to Section 10.5-3,
              his/her request for such hearing or appellate review must so state. The medical
              executive committee or the board may also be represented at the hearing or
              appellate review by an attorney. The foregoing shall not be deemed to limit the
              practitioner or the board in the use of legal counsel in connection with
              preparation for a hearing or an appellate review.

       10.10-3 Waiver

              If at any time after receipt of special notice of an adverse recommendation,
              action or result, a practitioner fails to make a required request or appearance or
              otherwise fails to proceed or to comply with this Fair Hearing Plan, consented to
              such adverse recommendation, action or result and to have voluntarily waived all
              rights to which he/she might otherwise have been entitled under the medical staff
              bylaws then in effect or under this Fair Hearing Plan with respect to the matter
              involved.

       10.10-4 Number of Reviews

              Notwithstanding any other provision of the medical staff bylaws or of this Plan,
              no practitioner shall be entitled as a right to more than one evidentiary hearing
              and appellate review with respect to an adverse recommendation or action.

       10.10-5 Extensions

              Stated time periods and limits for actions, notices, requests, submissions of
              material and scheduling in Article X may be extended upon the agreement of the
              parties and, when necessary, the hearing committee or appellate review body.

       10.10-6 Release

              By requesting a hearing or appellate review under Article X, a practitioner agrees
              to be bound by the provisions in article XVI of the medical staff bylaws and by
              the laws of the State of Wisconsin relating to immunity from liability.

ARTICLE XI: OFFICERS

11.1   OFFICERS:

       11.1-1 Identification

              The officers of the medical staff shall be:

              (a) President



                                               47
                (b) President Elect

                (c) Secretary / Treasurer

                (d) Immediate Past President

11.2   QUALIFICATIONS

       Medical Staff Officer candidates should have a proven track record of distinguished
       leadership and service to the medical community and be willing to commit to a program
       of further leadership development. All Medical Staff Officers must possess and maintain
       the qualifications defined below. Failure to do so shall automatically remove the member
       from the office involved:

       11.2-1    Members of the Active Medical Staff in good standing for whom AWH is their
                 primary hospital at time of nomination and election and throughout the entire
                 term of office.

       11.2-2    Currently Board certified in an appropriate specialty area, or have affirmatively
                 established that they possess comparable competence through the
                 credentialing process;

       11.2-3    Not presently serving as a Medical Staff Officer, Division/Committee Chair,
                 Board member or paid Executive at any healthcare organization which is
                 considered a direct hospital competitor of Aspirus Wausau Hospital and shall
                 not so serve during the term of office;

       11.2-4    Willing and able to discharge faithfully the duties and responsibilities of the
                 position to which the individual aspires.

       11.2-5    Willing and able to utilize email and other electronic means of communication
                 to carry out their responsibilities.

11.3   NOMINATIONS

       A Nominating Committee of the Medical Staff shall exist for purposes of managing
       leadership development and identifying qualified candidates for Medical Staff
       Leadership positions, including Medical Staff Officers and Division Leadership. The
       Committee shall be composed of the two immediate past Medical Staff Presidents, the
       current President and President Elect and one additional member appointed by the
       current Medical Staff President. The Immediate Past President shall serve as Chair.

       The Nominating Committee shall annually review members of the Active Staff
       demonstrating proven leadership capability and meeting the qualifications described in
       this Article to determine a slate of at least one nominee for each vacant position. At least
       thirty (30) calendar days prior to the meeting of the Nominating Committee, the Medical
       Staff shall be notified of its ability to recommend nominees for Committee consideration.
       Potential nominees must be recommended to a Committee member at least fourteen
       (14) calendar days prior to the meeting. The Nominating Committee is responsible to
       bring forward the final slate.



                                                48
11.4   ELECTION

       Officers may be elected using the same provision for amending the Bylaws as described
       in Article XVIII.

11.5   TERM OF OFFICE

       Commencing on July 1 following election, each Officer shall serve for two years at which
       time he/she shall resign or be removed from office. At the end of the two-year term, the
       President shall automatically assume the office of Immediate Past President, and the
       President Elect shall automatically assume the office of President.

11.6   VACANCIES AND REMOVAL FROM OFFICE

       11.6-1   Vacancies

                Should any Officer resign their position prior to fulfillment of their term, such
                resignation must be tendered in writing to the Hospital President/COO or
                designee and to the Medical Executive Committee.

                Vacancies in these offices shall be addressed by recommendation of the
                remaining Officers, following approval of the MEC and voted upon by the
                Medical Staff at a special election held for that purpose. The special election
                shall be initiated within fourteen (14) calendar days of the MEC approval and
                will follow the standard election process described in these Bylaws. The
                recommendation may modify the number of officers serving and/or the
                responsibilities of each officer, as described in Section 7 of this Article.
                Vacancies in Division Leadership will be addressed in a like manner.

                Service in an amended role due to unanticipated vacancy shall not count
                toward the term limitations described in these Bylaws.

       11.6-2   REMOVAL FROM OFFICE

                The Medical Executive Committee by a seventy-five percent (3/4) vote, may
                remove any medical staff leader for conduct detrimental to the interests of the
                Hospital as defined by the Medical Executive Committee, or if the individual is
                suffering from a physical or mental infirmity that renders the individual
                incapable of fulfilling the duties of that office. Notice of the meeting at which
                such action shall be decided must be given in writing to the affected individual
                at least fourteen (14) calendar days prior to the meeting. The officer shall be
                afforded the opportunity to speak prior final decision concerning removal.

                Any medical staff leader who is found by the Board, in consultation with the
                MEC, to no longer meet the qualifications for the position set forth in these
                bylaws shall automatically relinquish his/her office.




                                                49
11.7   RESPONSIBILITIES

       Unless amended as described in Section 6 of this Article, the following are the
       responsibilities of Medical Staff Officers.
       11.7-1 All Officers

                While these responsibilities are primarily those of the President of the Medical
                Staff, they are also expectations of the other Medical Staff Officers. All Officers
                shall:

                (a)   Be accountable to the board in conjunction with the medical executive
                      committee, for the quality and efficiency of clinical services and
                      performance within the hospital and for the effectiveness of quality review
                      and evaluation functions delegated to the staff by means of regular
                      reports and recommendations based on he/she results of these activities;

                (b)   Communicate and represent the opinions, policies, concerns, needs and
                      grievances of the medical staff to the board, the Hospital President/COO
                      and other officials of the staff;

                (c)   Act in coordination and cooperation with the Hospital President/COO in
                      all matters of mutual concern within the hospital;

                (d)   Develop and implement, in cooperation with other medical staff
                      leadership, methods for quality review activities including ongoing
                      monitoring of practice, credentials review, delineation of privileges and
                      specified services, continuing education and utilization review; and,

                (e)   Be responsible for the enforcement of the medical staff bylaws, rules and
                      regulations, for implementation of sanctions where these are indicated,
                      and for the medical staff's compliance with procedural safeguards in all
                      instances where corrective action has been requested against a
                      practitioner.

       11.7-2   The President shall:

                (a)   Call, preside at, and be responsible for the agenda of all general
                      meetings of the Medical Staff;

                (b)   Chair the MEC, assuming oversight authority of the responsibilities of the
                      MEC;

                (c)   Serve as Ex officio member of all Medical Staff Divisions and Committees
                      without vote;

                (d)   Appoint members to Divisions and Committees as described in these
                      Bylaws;

                (e)   Be the spokesperson for the Medical Staff in its external professional and
                      public relations; and,



                                               50
         (f)   Receive and interpret the policies of the governing board to the medical
               staff and report to the governing board on the performance and
               maintenance of quality with respect to the medical staff’s delegated
               responsibilities to provide medical care.

11.7-3   The President Elect shall:

         (a)   Assume all the responsibilities and have the authority of the President in
               the absence of the President in the event of his/her temporary inability to
               perform due to illness, absence from the community or unavailability for
               any other reason;

         (b)   Serve as vice chair and member of the MEC with vote;

         (c)   Chair the Bylaws/Credentials Committee;

         (d)   Automatically succeed to the office of the President during the third year
               following election; and,

         (e)   Perform such responsibilities as assigned by the President.

11.7-4   The Secretary / Treasurer shall:

         (a)   Assume all the responsibilities and have the authority of the President in
               the absence of the President and President Elect in the event of their
               temporary inability to perform due to illness, absence from the community
               or unavailability for any other reason;

         (b)   Serve as member of the MEC with vote;

         (c)   Chair the Quality Review Committee;

         (d)   Perform such responsibilities as assigned by the President;

         (e)   Ensure accurate and complete records of medical staff meetings as
               appropriate;

         (f)   Collect staff dues and funds, oversee disbursements as described in the
               associated policies, and report annually on the financial status of the
               Medical Staff;

         (g)   Call Medical Staff meetings on order of the President; and

         (h)   Attend to all correspondence and perform such other responsibilities as
               pertain to the functions of Secretary-Treasurer.




                                        51
       11.7-5   The Immediate Past President shall:

                (a)  Assume all the responsibilities and have the authority of President,
                     President Elect and/or Secretary / Treasurer in the event of their
                     temporary inability to perform due to illness, absence from the community
                     or unavailability for any other reason.
       11.7-6   Board Service

                As described in the Hospital Bylaws, one of the Medical Staff Officers shall be
                selected by the Board of Directors for appointment to the Board.

ARTICLE XII: COMMITTEES

Committees of the Medical Staff will be designated by the Medical Executive Committee. All
meetings of the Medical Staff shall be considered peer review meetings. Thus all minutes and
correspondence of a peer review committee shall be confidential and all members and
personnel of the peer review committee shall enjoy all the rights, responsibilities, and
protections of the Wisconsin peer review statute. The President of the Medical Staff may attend
any meeting of the Medical Staff.

The Chairs of Medical Staff Committees shall usually be Active Staff members, meeting the
same qualifications as Medical Staff Officers. They will be appointed annually by the President
of the Medical Staff subject to the approval of the Medical Executive committee. The Medical
Executive Committee composition is explicitly defined in Section 1 of this Article. Committee
members may also be appointed by the President, subject to MEC approval, unless otherwise
described in these Bylaws. Committee members are expected to utilize email and other means
of electronic communication in order to fulfill their responsibilities.

Each committee will ensure rules, regulations and policies document committee responsibilities,
meeting frequency, attendance requirements, if any, quorum, voting mechanisms, record
keeping, and other key elements, if not already defined in the Bylaws. Consent Agendas are
encouraged. A Board member appointed by the Chair of the Board may serve on
administrative committees without voting right. When requested by Medical Staff Leadership,
non-Medical Staff members may serve as members of Committees without vote.

12.1   MEDICAL EXECUTIVE COMMITTEE (MEC)

       The Medical Executive Committee is chaired by the President of the Medical Staff and
       has primary authority for activities related to self-governance of the Medical Staff, and
       oversight of Allied Health practitioners, to ensure the quality of medical care, treatment,
       and services and for performance improvement of the professional services provided by
       the Medical Staff, reporting to the Hospital Board of Directors. Their ultimate priority is to
       support the Medical Staff’s provision of safe and quality patient care, placing the best
       interests of patients first in all matters.

       The MEC shall coordinate the activities and general policies of the organized medical
       staff and shall represent and act for the Medical Staff as whole, under such limitations
       as may be imposed by the Medical Staff. The Medical Staff may limit or expand the
       powers of the MEC by amending this Article using the Bylaws amendment process




                                                52
described in Article XVIII, and if necessary, the conflict resolution process described in
Article XVII.

The Medical Executive Committee shall consist of the Medical Staff Officers (usually the
Immediate Past President, President, President Elect, and Secretary / Treasurer), the
Chiefs of the Divisions, and the Vice Chiefs of the Hospital-Based, Surgeons &
Interventionalists, and Medicine Divisions, all of whom serve with vote. As Chair, the
President of the Medical Staff normally votes only when there is a tie amongst the other
voting members.

Other Committee Chairs, the Chair of the Board of Directors and Program Director of
the Family Medicine residency may serve without vote. There will be standing ex-officio
members (without vote) including the Immediate Past President, the Hospital
President/COO and a maximum of three (3) administrative representatives jointly
appointed by the Hospital President/COO and the President of the Medical Staff. The
administrative representatives, including the COO, shall be nonvoting members.
Membership may be modified by a seventy-five percent (3/4) vote of the committee in
the interim between Bylaws reviews.

No medical staff member actively practicing in the Hospital is ineligible for membership
solely because of his/her professional designation or discipline.

In the absence of the President of the Medical Staff, the President elect or his/her
appointee, shall act as chair.

Individual members of the Medical Staff may attend the MEC as described in Article XIII,
Section 6.c.

12.1-1   Responsibilities:

         The responsibilities of the Medical Executive Committee shall be to:

         (a)   Represent and to act on behalf of the Medical Staff, including the
               authority to act on behalf of the Medical Staff between Medical Staff
               meetings, subject to such limitations as may be imposed by these
               Bylaws;

         (b)   Recommend revisions to and updating of the Medical Staff Bylaws and all
               medical staff rules, regulations, policies, forms, and associated
               documents;

         (c)   Approve and coordinate the activities and general policies of the various
               Specialties / Divisions /Committees, receiving and acting upon reports
               and recommendations from medical staff committees, divisions, and
               specifically-assigned groups. (Reference Articles XII & XIII);

         (d)   Recommend those serving in medical staff leadership positions for Board
               of Director confirmation;




                                         53
         (e)   Establish Medical Staff Committees, or discontinue them when their
               purpose has been served, by a seventy-five (75) percent or three-
               quarters (3/4) vote;

         (f)   Implement rules, regulations, and policies and procedures of the Medical
               Staff based on the recommendations of Specialties, Divisions, and
               Committees;

         (g)   Recommend action to the Board of Directors and the Hospital
               President/COO of the Hospital on hospital management matters (i.e. long
               range planning, etc.);

         (h)   Fulfill the Medical Staff's accountability to the Board of Directors for the
               medical care provided to patients;

         (i)   Be responsible for Medical Staff compliance with Wisconsin Department
               of Health regulations, accreditation standards of the Joint Commission,
               and other relevant accreditation-granting or regulatory organizations;

         (j)   Review all applicants, including Medical Staff, and where applicable Allied
               Health, for initial appointment/affiliation, reappointment/reaffiliation, and if
               applicable clinical privileges, as recommended by the Bylaws/Credentials
               Committee; and then to make recommendations to the Board of Directors
               for appointment/affiliation and delineation of Clinical privileges;

         (k)   Take all reasonable steps to ensure professionally ethical conduct and
               competent clinical performance on the part of all members of the Medical
               Staff, and where applicable Allied Health, including the initiation of and/or
               participation in collegial, disciplinary, or review measures when
               warranted;

         (l)   Lead the Medical Staff, and applicable Allied Health, in collaboration with
               the organization’s performance improvement activities, including
               measuring, assessing and improving processes that primarily depend on
               the activities of Medical Staff or Allied Health;

         (m) Keep the Medical Staff, and applicable Allied Health, apprised of Medical
             Executive Committee activities on an ongoing basis and solicit input.

The Chair of the committee shall determine the time and date of each meeting. Fifty
percent (50%) of members shall constitute a quorum. The committee has an
attendance requirement of at least fifty percent (50%) of the meetings. Attendance by
the Member at Large from the Hospital-based, Surgeons & Interventionalists, and
Medicine Divisions may be designated in the absence of the Chief or Vice Chief.
Attendance by the Vice Chief or Member at Large from the Community Medicine
Division may be designated in the absence of the Chief.

A simple majority of those present and voting at a meeting in which quorum is present
shall be the action of the Committee except as described above. Use of Consent
Agenda is encouraged. Ad hoc committees may be appointed as needed to complete
special projects. Policies may be developed to further guide the work of the committee.


                                         54
       The President of the Medical Staff, the President Elect, the Secretary/Treasurer or any
       three (3) or more members of the Committee may request a meeting. Such a request
       must be honored within a period of one (1) week following such notification to the
       President of the Medical Staff or designee. A record of all proceedings of the MEC shall
       be made and retained indefinitely.

12.2   BYLAWS/CREDENTIALS COMMITTEE (B/C)

       The Bylaws/Credentials Committee is chaired by the President Elect and shall be
       composed of the elected Vice Chiefs from each Division (4) and by four (4) other
       individuals appointed by the President of the Medical Staff, to ensure a diverse
       representation of the specialties of the medical staff, subject to MEC approval.
       Members appointed by the President will be reviewed every two years for appointment
       continuation or termination.

       The Committee shall meet as necessary. Fifty percent (50%) of members shall
       constitute a quorum. The committee has an attendance requirement of at least fifty
       percent (50%) of the meetings. A simple majority of those present and voting at a
       meeting in which quorum is present shall be the action of the Committee. Consent
       Agendas are encouraged. Ad hoc committees may be appointed as needed to
       complete special projects. Policies may be developed to further guide the work of the
       committee.

       12.2-1 Responsibilities:

              Mechanism/Policy Development:

              (a)    To approve and monitor the qualifications, criteria, and other policies and
                     requirements for consideration of credentialing recommendations, as well
                     as review and act upon requests for development of cross-specialty
                     privilege criteria, as described in associated medical staff policies and in
                     accordance with Articles VI and VII of these Bylaws;

              (b)    To approve and monitor the mechanisms used to verify and evaluate
                     information used in the formation of credentialing recommendations, in
                     accordance with Article VI & VII of these Bylaws;

              (c)    To recommend to the MEC the Specialties to be recognized by the
                     Medical Staff for specific representation in the Medical Staff structure.

       12.2-2 Credentialing Recommendations:

              (a)    To review the credentials of all applicants for appointment and
                     reappointment and to make recommendations to the Medical Staff
                     Executive Committee for membership and delineation of clinical
                     privileges, if any requested, as described in Article VI & VII of these
                     Bylaws;

              (b)    To review at least biennially the current competence of members and
                     Advanced Practice Registered Nurses and Physician Assistants, and as a


                                              55
                     result of such reviews to make recommendations to the Medical Staff
                     Executive Committee for the granting reappointment and renewed clinical
                     privileges. Such review will include: Patient Care; Medical/Clinical
                     Knowledge; Practice Based Learning and Improvement; Interpersonal
                     and Communication Skills; Professionalism; and Systems Based
                     Practices.

       12.2-3 Bylaws Review & Recommendation

              Conduct a review of the Bylaws on at least a triennial basis and submit
              recommendations to the Medical Executive Committee.

       12.2-4 Miscellaneous

              To review reports that are referred by the Medical Executive Committee or other
              committees and respond as requested.

12.3   QUALITY REVIEW COMMITTEE (QRC)

       The purpose of the quality review committee, a joint Medical Staff/Hospital committee, is
       to provide organizational wide leadership, guidance, and oversight for the
       implementation of the performance improvement program.


       The Quality Review Committee is chaired by the Secretary / Treasurer and shall be
       composed of the elected Members at Large from each Division (4), the Vice President of
       Corporate Quality Services/Patient Safety Officer as Vice Chair, and by other
       administrative representatives to equal the but not exceed the number of physician
       members. The administrative representatives shall be jointly appointed by the President
       of the Medical Staff and Hospital President/COO, in consultation with the Chair of QRC.

       The Committee shall meet as necessary. Fifty percent (50%) of members shall
       constitute a quorum. The committee has an attendance requirement of at least fifty
       percent (50%) of the meetings. A simple majority of those present and voting at a
       meeting in which quorum is present shall be the action of the Committee Consent
       Agendas are encouraged. Ad hoc committees may be appointed as needed to
       complete special projects, and Policies may be developed to further guide the work of
       the committee.

       12.3-1 Duties-Responsibilities

              (a)    Provide organization wide leadership, guidance, and oversight for the
                     implementation of multidisciplinary clinical quality improvement initiatives.

              (b)    Ensure that quality care initiatives are consistent with current standards
                     of practice and comparative performance data where available.

              (c)    Review results of all patient care outcomes and procedure efficacy for
                     new procedures approved by the bylaws/credentials committee.




                                              56
      (d)    Ensure that quality initiatives are acted upon and reported in a timely
             fashion.

      (e)    Assist in the identification of and ensure the execution of new clinical care
             opportunities for improvement.

      (f)    Act as decision-making body for organizational quality of care issues
             (standards of care, conflict resolution, peer review process and/or
             external review, adverse occurrence/sentinel event issues, etc.)

      (g)    Provide consultation to service areas regarding report completeness,
             comprehensiveness, and continuity with performance improvement
             program.

      (h)    Act as the coordinating body in the chartering of performance
             improvement teams, delegate responsibility to appropriate team,
             committee, or division and ensure follow-through of performance
             improvement process.

      (i)    Work collaboratively to facilitate and ensure an integrated approach to
             performance improvement activities.

      (j)    Provide oversight and act as central repository for organizational wide
             quality program reporting and for the tracking and sharing of quality
             performance improvement results. Ensure activities are well balanced
             and non-duplicative.

      (k)    Provide summary reports, aggregate and trended data on the progress
             and results to the Medical Executive Committee, Aspirus Wausau
             Hospital Operations Council, and Aspirus Wausau Hospital Accountability
             Committee regarding performance improvement activities.

      (l)    Participate in the annual evaluation of organizational wide quality
             program structures, coordination, and effectiveness and make
             recommendations for improvement.          Ensure annually that the
             performance improvement plan is current and executed.

      (m)    Issues raised through the medical staff specialty peer review process will
             be brought by the specialty representative or division leadership to the
             chair of the QRC for evaluation and action as necessary.

      (n)    Communicate policy decisions to medical staff through specialty
             representatives or division leadership and to hospital personnel through
             appropriate resources.

12.3-2 Performance Improvement Activities

      Performance improvement activities include, but are not limited to:

      (a)    Ongoing monitoring and evaluation of specific quality indicators.



                                      57
              (b)     Clinical process improvement teams with focus on key aspects of care.

              (c)     Review and evaluation of clinical risk management trend data.

              (d)     Patient/customer satisfaction feedback and complaint management
                      information

              (e)     Key functions where continuous quality improvement shall be performed
                      include but are not limited to: blood use, pharmacy and therapeutics and
                      medication use, surveillance, control and prevention of infection,
                      operative and invasive procedures, medical record review, clinical risk
                      management, utilization management, patient care and assessment,
                      patient rights and patient education, clinical care improvement (in select
                      patient populations – cancer, cardiac, maternal/child, surgical, medical,
                      emergency); and autopsy evaluation.

12.4   MULTIDISCIPLINARY COMMITTEES

       Multidisciplinary committees will be developed by the Medical Staff or Hospital on an
       ongoing basis for designated purposes, with medical staff membership appointed by the
       President of the Medical Staff in consultation with each Chair. Each committee will
       document its purpose and responsibilities in rules, regulations, and policies as
       appropriate, and retain a record of its proceedings for at least 10 years. Consent
       Agendas are encouraged.

       The MEC will receive reports from these committees as necessary, provide leadership
       and resources, and approve business as related to their responsibilities as described in
       these Bylaws (Article XIII, Section 1). An official listing of these committees will appear
       on the annual Medical Staff Committee List.

12.5   COMMITTEES FOR SPECIAL SERVICES OR FUNCTIONS

       Other committees for special services or functions may be established by the MEC, as
       described in this Article. Each committee will ensure policies document meeting
       frequency, attendance requirements, if any, quorum, voting mechanisms, record
       keeping, and other key elements.

       12.5-1 Medical Staff Support Committee

              The Medical Staff Support Committee, with membership appointed by the
              Medical Staff President, will provide a forum for assistance, advocacy,
              monitoring, educating, consulting, intervening and recommending policies related
              to impairment and disruptive behavior. This committee, while separate from any
              disciplinary or enforcement activities, will take referrals from any concerned
              source, report findings, and make recommendations to Bylaws/Credentials and
              MEC, as indicated. Attendance requirements, quorum, manner of action,
              composition, and other details will be described in committee policies. This
              committee is identified as a peer review committee under the Wisconsin Peer
              Review Statute.



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ARTICLE XIII: DIVISIONS OF THE MEDICAL STAFF and SPECIALTY REPRESENTATION

13.1   ORGANIZATION

       The Medical Staff shall be organized into the Divisions described below:

       13.1-1 Hospital-Based: Members of the medical staff in any specialty who practice the
              majority of the time within Aspirus Wausau Hospital. Examples may include but
              are not limited to: Emergency Medicine, Anesthesia, Pathology, Diagnostic
              Radiology, and Hospitalists;

       13.1-2 Surgeons & Interventionalists: Members of the medical staff in any specialty
              who practice invasive procedures on a regular basis at Aspirus Wausau Hospital.
              Examples may include but are not limited to: Surgeons, Gastroenterologists,
              OB/GYNs, Cardiologists and Interventional Radiologists;

       13.1-3 Medicine: Members of the medical staff in any specialty who maintain an active
              hospital practice that does not include invasive procedures on a regular basis.
              Examples may include but are not limited to: Internal Medicine, Endocrinology,
              Family Medicine, and Pediatrics; and,

       13.1-4 Community Medicine: Members of the medical staff in any specialty who
              consider AWH their primary hospital relationship, and who infrequently admit and
              manage patients in the hospital, but desire to maintain a relationship for
              purposes ranging from referrals to hospital-provided services to medical staff
              professional development. Examples may include but are not limited to:
              Dermatology, Psychiatry, Dentists covering the Emergency Department, and
              Family Medicine.

       All meetings of Divisions, or designated subsets and ad hoc committees of Divisions,
       and Specialties shall be considered peer review meetings, as such are directed to
       improve the quality of health care and/or avoid improper utilization or services. As such,
       all minutes and correspondence of a peer review committee shall be confidential and all
       members and personnel of the peer reviews committee shall enjoy all the rights,
       responsibilities, and protections of the Wisconsin peer review statute.

13.2   ASSIGNMENT TO / CHANGE OF DIVISIONS

       13.2-1 The President of the Medical Staff will assign members to Divisions that relate
              most closely to each member’s practice and interests. This process is intended
              to ensure assignments follow the guidelines described in Section 1 of this Article
              and provide a reasonable balance and representation across the medical staff.
              Members are welcome to request to change Divisions as their practice evolves
              and may do so by communicating with Provider Support Services who will in turn
              advise the Medical Staff President and Chiefs of the affected Divisions.
              Members will receive written notification of the outcome of their requests;

       13.2-2 The Hospital President/COO and/or designee will serve as Ex officio non-voting
              member of all Divisions. A board member appointed by the Chair of the Board,



                                               59
              in consultation with the President of the Medical Staff and the Division Chief,
              may serve on a Division or administrative committee as Ex officio member
              without vote. When requested by Medical Staff Leadership, non-Medical Staff
              members may serve as members of the Division or its ad hoc committees
              without vote.

13.3   RESPONSIBILITIES OF DIVISIONS

       The Medical Executive Committee shall be accountable for fulfilling the responsibilities
       of the medical staff as defined by Joint Commission and other regulators (Article 12.1-
       1). Reporting to the Medical Executive Committee, the ultimate responsibility of a
       Division is to support the MEC in assuring safe and quality patient care and services
       through the following activities:

       13.3-1 In partnership with related Specialties, endeavor to ensure current competence
              in patient care, medical / clinical knowledge, practice-based learning and
              improvement, interpersonal and communication skills, professionalism and
              systems based practices of all members of the Division and others who may
              provide services independently through:

              (a)     Formation of recommendations related to qualifications and criteria for
                      specific clinical and other activities, as well as application of such
                      information to individual requests for initial appointment, reappointment,
                      change of privileges, etc.;

              (b)     Surveillance and assessment of the professional performance of all
                      members and the Division, as described in the related policies;

              (c)     To assure quality patient care through approving and monitoring the
                      mechanisms used to evaluate the quality and appropriateness of the
                      clinical activities of all individuals with delineated clinical privileges
                      through a hospital-wide quality assurance/performance improvement
                      program;

              (d)     Undertaking proactive measures and interventions with members of the
                      Division whose performance in any area is in question, referring issues
                      as appropriate to the Medical Executive Committee for their review; and,

              (e)     Recommend orientation and continuing education for members,
                      Advanced Practice Nurses and Physician Assistants.

       13.3-2 Endeavor to ensure the smooth function and effective integration of the Division
              with the rest of the Medical Staff organization and Hospital operations through:

              (a)     facilitation of effective communication throughout the Division with the
                      rest of the Medical Staff, Hospital, and Board;

              (b)     provision of opportunity for members to contribute their professional
                      views and insights into the formulation of Medical Staff and Hospital
                      policies and plans;



                                                60
              (c)     collaboration with the rest of the Medical Staff and Hospital on the
                      identification of performance improvement opportunities, including patient
                      care, treatment and services, and their implementation;

              (d)     coordination and integration of the provision of care provided by the
                      Division’s members with other Medical Staff members, Hospital staff,
                      contracted and off-site sources of patient care. Recommending the
                      resources needed by services related to the Division;

              (e)     in partnership with related Specialties, development of recommendations
                      as needed and appropriate regarding sufficient numbers and
                      qualifications and competency assessments for care providers who are
                      not licensed independent practitioners who provide care or services, as
                      well as space and other resource needs;

              (f)     in partnership with related Specialties, development and implementation
                      of policies and procedures that guide and support the provision of care,
                      treatment, and services;

              (g)     in partnership with related Specialties, provision of continuous patient
                      coverage, including coverage for attached and unattached patients; and,

              (h)     planning and facilitation of effective ad hoc, division leadership, and
                      division meetings.

       13.3-3 Divisions, as described in Section 3 of this Article, shall meet as determined by
              the Division Chief to accomplish the responsibilities of the Division. Attendance is
              strongly encouraged.

       13.3-4 Minutes of all regular and special meetings of the Division shall be prepared and
              shall include a record of members in attendance and vote taken on each matter.
              Less formal ad hoc meetings are encouraged with reports to Division Leadership
              regarding outcomes and recommendations.

13.4   DIVISION CHIEFS, VICE CHIEFS, AND MEMBERS AT LARGE (I.E. DIVISION
       LEADERSHIP)

       Each Division shall elect Leadership who have the qualifications, authority, duties, and
       responsibilities as specified in these Bylaws, and who shall lead the Division and
       represent it to the Medical Staff. Each Division will elect a Division Chief, Vice Chief and
       Member at Large, with the Vice Chief and Member at Large assisting the Division Chief
       in fulfilling leadership responsibilities. Ideally, the Vice Chief and Member at Large are
       developed as nominees for future leadership roles. Within a Division, the Chief, Vice
       Chief, and Member at Large may not be from the same specialty.

       Division Chiefs, and as applicable Vice Chiefs and Members at Large, will be elected by
       the members of the Division for a term of two (2) years beginning in July. Terms of all
       positions will be limited to not more than two (2) consecutive terms. Every effort shall be
       made to stagger election process to ensure a mix of experienced and new leadership.
       Each Division is responsible for developing a slate of at least one nominee for each role
       for vote by the full Division for ballot, in accordance with guidelines defined by the


                                               61
Division for voting. The Nominating Committee of the Medical Staff is responsible for
overseeing and facilitating these activities.

The Division Chief and Vice Chief of each Division will serve on the Medical Executive
committee; except the Community Medicine Division will be represented only by the
Division Chief.

These leaders shall have the following responsibilities:

13.4-1 Division Chiefs shall serve as the clinical & administrative leaders of the
       Divisions of the Medical Staff, including:

       (a)     Assure that the Division effectively carries out its responsibilities with
               regard to safe and quality patient care (see Section 3).

       (b)     Serve as the Division’s liaison with other Medical Staff Divisions,
               Specialties and Committees, and Hospital Administration.

       (c)     Preside at Division and Division Leadership meetings

       (d)     Oversee the discharge of the Division’s clinical and administrative duties.

13.4-2 Vice Chiefs and Members at Large are responsible to assist the Division Chief in
       leading the Division. In addition the Member at Large shall serve on QRC and be
       responsible for overseeing the Peer Review activities of the Division, while the
       Vice Chief shall represent the Division on the Bylaws/Credentials Committee.
       Vice Chiefs and Members at Large may serve as the Division Chief in the Chief’s
       absence.

13.4-3 On a regular, but as needed, basis, the Chief, Vice Chief and Member at Large
       shall as a “division leadership committee” meet to review and facilitate the
       business of the Division.

13.4-4 Members serving in these positions shall possess the following qualifications:

       (a)     Members of the Active Medical Staff for whom AWH is their primary
               hospital, and who are in good standing and practicing according to the
               nature of Division in which the leadership position is sought;

       (b)     Currently Board certified in an appropriate specialty area, or have
               affirmatively established that they possesses comparable competence
               through the credentialing process;

       (c)     Not presently serving as a Medical Staff Officer, Division/Committee
               Chair, Board member or paid Executive at any healthcare organization
               which is considered a direct Hospital competitor of Aspirus Wausau
               Hospital and shall not so serve during the term of office;

       (d)     Willing and able to discharge faithfully the duties and responsibilities of
               the position to which the individual aspires; and,



                                         62
              (e)     Willing and able to utilize email and other electronic means of
                      communication to carry out their responsibilities.

13.5   SPECIALTY REPRESENTATIVES

       Separate from the Division activities, each specialty represented on the medical staff
       may organize and elect a Specialty Representative. If Specialties are represented in
       more than one Division each shall have a Specialty Representative. Specialties of the
       Medical Staff are determined upon the recommendation of the Bylaws/Credentials
       Committee to the Medical Executive Committee and are defined by the presence of a
       Specialty-specific privilege form.

       13.5-1 Specialty-specific Representatives shall assist the other leaders of the Medical
              Staff in carrying out the work of the Medical Staff, including:

              (a)     Represent the perspective of their Specialty to Divisions, other
                      Specialties, Committees, and Medical Staff; and

              (b)     Oversee the processes of peer review and performance improvement for
                      their Specialty, reporting on activities to the Member at Large of the
                      Division.

              (c)     Oversees credentialing and privileging recommendations for their
                      Specialty, reporting on activities to the Vice Chief of the Division.

              (d)     Provide consultation regarding activities affecting their Specialty; and,

              (e)     Facilitate communication, action, and resolution of affairs affecting the
                      operation of the Specialty and its role within the Medical Staff, including
                      organizing meetings of their Specialty as needed or utilizing technology to
                      facilitate interactions. Meetings may be managed informally, and as such
                      minutes are not required. Recommendations made by a Specialty must
                      be reported to Provider Support Services to ensure documentation and
                      referral to Division Leadership and MEC, or other committees as
                      indicated.

       13.5-2 Specialty-specific Representatives shall be elected for two-year terms. There is
              no maximum number of terms a Specialty-specific Representative may serve.
              Should a Representative from a specific specialty be unavailable, the Medical
              Staff may function without a Representative from that specialty, however,
              additional effort is expected to gain input for matters that significantly impact that
              specialty.

       13.5-3 Members serving in Specialty Representative positions shall possess the
              following qualifications:

              (a)     Members of the Active Medical Staff in good standing;

              (b)     Currently Board certified in the appropriate specialty area, or have
                      affirmatively established that they possesses comparable competence
                      through the credentialing process; and


                                                63
              (c)     Willing and able to discharge faithfully the duties and responsibilities of
                      the position to which the individual is elected.

              (d)     Willing and able to utilize email and other electronic means of
                      communication to carry out their responsibilities.

13.6 INDIVIDUAL MEMBERS

       13.6-1 Individual members in any Specialty may contact an appropriate medical staff
              leader to raise any issue of concern. If an issue impacts a single Specialty, the
              issue can be raised to the Specialty Representative of that specialty. If an issue
              impacts more than one Specialty, the issue can be raised to a Division Chief,
              Vice Chief or Member at Large. Medical Staff-wide issues should be raised to a
              member of the Medical Executive Committee;

       13.6-2 If a member believes that a concern is not being addressed, or that a conflict of
              interest is preventing resolution of an issue, the concern should be brought to
              any Officer of the Medical Staff;

       13.6-3 Individual members may attend any meeting of the Medical Executive Committee
              as a non-voting guest, having indicated such desire at least one week before
              each meeting and stating the reason for their interest, i.e. an issue to discuss,
              general interest, etc. The MEC may excuse these guests during discussions of a
              confidential nature, including but not limited to, peer review, strategic information
              that must remain confidential, etc.;

       13.6-4 An individual member may be invited by their Division Leader or designee to
              attend any meeting of the Medical Executive Committee. Such invitation will be
              extended when an issue is at stake for which the member is needed for
              adequate representation of the issue and/or the member wishes to speak to the
              MEC on the issue. In these instances, the member will be afforded a right to
              vote at MEC on the issue; and,

       13.6-5 Each member of the Medical Staff is responsible to engage in timely
              communication. Every effort will be made by Medical Staff Leadership to provide
              timely information and opportunity for input and/or vote, as appropriate.
              Members, however, are also responsible to avail themselves of the information
              and respond as requested on matters of interest. Failure by any member to
              provide timely response will not be considered adequate cause to revisit any
              matter, as described in Article XVI.

13.7   PEER REVIEW

       The Member at Large of each Division will oversee Peer Review. Each Specialty will
       undertake peer review as appropriate to the Specialty, providing assurance of these
       activities via regular reports to the Division Member at Large, who in turn advises QRC
       and MEC. Should conflicts of interest exist, or issues not be otherwise resolvable at the
       individual Specialty level, they will be referred to the Member at Large. As described in
       the “Medical Staff Peer Review Process” Policy, the Member(s) at Large may convene a
       multi-specialty peer review committee (“alternate internal peer review”).



                                                64
13.8   REMOVAL OF LEADERSHIP FROM OFFICE

       Division Chiefs, Vice Chiefs, Members at Large, and Specialty Representatives are
       subject to the provisions for Removal of Officers (Article XI, Section 6.b). Failure of any
       member of Division Leadership or Specialty Representatives to maintain Active staff
       status in good standing shall immediately cause his/her removal.

       Leaders may also be removed from office by a seventy-five percent (3/4) vote of the
       Active staff members of the Division or Specialty involved.

       In the absence of any leader, the President of the Medical Staff shall appoint temporary
       leadership until election can occur, ideally in no more than 45 days. Such elections will
       complete unfulfilled terms and will not apply toward standing term limitations.

13.9   QUORUM

       Quorum at any meeting is those present. For technology-driven voting of Divisions and
       Specialties, Quorum is those who submit votes during the balloting period. No balloting
       period may be for fewer than fourteen (14) calendar days.

13.10 SPECIAL MEETINGS

       A special meeting of a Division or Specialty may be called by or at the request of the
       Division Chief, appropriate specialty representative, by the President of the Medical
       Staff, or by the lesser of 10 or one-third (1/3) of the constituency’s members. Members
       will be provided adequate notification.

13.11 NOTICE OF MEETINGS

       Notification is required when Division or Specialty meetings are held. Adequate notice is
       also required for the use of a Consent Agenda process.

13.12 VOTING

       Unless otherwise provided in this Article, a simple majority of those present and voting
       at a meeting in the presence of quorum shall be the action of a Division, Specialty, or ad
       hoc or standing committee. Voting by proxy is not permitted. Use of mail, phone or
       videoconference, email, fax, electronic bulletin board, or other forms of communication,
       to conduct business efficiently is encouraged.

13.13 CONSENT AGENDAS

       Are encouraged for efficient voting on matters that are routine and non-controversial in
       nature.

13.14 ATTENDANCE

       Attendance at any meeting of a Division or Specialty is strongly encouraged. All Division
       meetings are open to any interested member of the Medical Staff, however members
       may only vote in their assigned Division. The meeting leader may “close” all or any



                                                65
       portion of a meeting to all but voting members when sensitive matters, such as peer
       review, will be discussed.

13.15 RECORD OF ALL PROCEEDINGS OF DIVISION MEETINGS

       A Record of all proceedings of Division meetings shall be made and retained for at least
       10 years. Specialties are not required to record proceedings but to report to Provider
       Support Services regarding any outcomes that should be recorded. These reports will
       be retained for at least 10 years.

13.16 AD HOC AND/OR STANDING COMMITTEES

       Ad hoc and/or standing committees of single specialties or multiple specialties may be
       created by Specialty, Division, Committee, or MEC leadership to carry out a specific task
       and terminate when the task is accomplished. The medical staff members appointed by
       medical staff leadership to serve on such committees are all voting members. Other
       committee members may be appointed with a non-voting status to provide appropriate
       liaison with other affected stakeholders and/or needed expertise or support.

ARTICLE XIV: MEDICAL STAFF MEETINGS

14.1   REGULAR STAFF MEETINGS

       The Medical Staff as a whole shall meet at least annually. The medical Staff Officers
       may authorize additional general staff meetings including adequate notice specifying
       time, date, place, and business of meeting.

14.2   SPECIAL STAFF MEETINGS

       Special meetings of the Medical Staff may be called at any time by a Medical Staff
       Officer, the MEC, or at the written request of ten (10) members of the Active Staff.
       Reasons for the special meeting shall be stated on the notice of meeting. The agenda
       shall be limited to the Reading of the notice; Calling the meeting; Discussion of the
       business for which the meeting was called and Adjournment.

14.3   QUORUM / VOTING / RECORD KEEPING

       Quorum at a Regular or Special Meeting is those present. A simple majority of those
       present and voting at a meeting shall be the action of the Medical Staff. Attendance is
       strongly encouraged. Consent Agendas are encouraged.

       Record of Medical Staff meetings will be retained for ten (10) years. In lieu of meeting,
       use of mail, telephone, videoconference, email, fax, or other forms of electronic
       communication, to conduct business is encouraged. .

14.4 CLOSED MEETINGS / EXECUTIVE SESSIONS

       The President of the Medical Staff or leader of any meeting of the Medical Staff or its
       Divisions, Specialties, or Committees may invite or excuse any or all individuals who are
       not voting members of the unit, irrespective of their status.



                                               66
ARTICLE XV: PRIVILEGE AND IMMUNITY / CONFIDENTIALITY

15.1   AUTHORIZATIONS AND CONDITIONS

       By applying for, or exercising clinical privileges or providing specified patient care
       services within this hospital, a practitioner:

       15.1-1 Authorizes representatives of the hospital and the medical staff to solicit, provide
              and act upon information bearing on his/her professional ability and
              qualifications.

       15.1-2 Agrees to be bound by the provisions of this Article and to waive all legal claims
              against any representative who acts in accordance with the provisions of this
              Article.

       15.1-3 Acknowledges that the provisions of this Article are express conditions to his/her
              application for, or acceptance of, staff membership and the continuation of such
              membership, or to his/her exercise of clinical privileges or provision of specified
              patient services at this hospital.

       15.1-4 Acknowledges that the hospital, medical staff and practitioner are bound by the
              provisions of Federal Law, Title IV "Encouraging Good Faith Review Activities."

15.2   CONFIDENTIALITY OF INFORMATION

       Information with respect to any practitioner submitted, collected or prepared by any
       representative of this or any other health care facility or organization or medical staff for
       the purpose of achieving and maintaining quality patient care, reducing morbidity and
       mortality, or contributing to clinical research shall, to the fullest extent permitted by law,
       be confidential and shall not be disseminated to anyone other than a representative nor
       be used in any way except as provided herein or except as otherwise required by law.
       Such confidentiality shall also extend to information of like kind that may be provided by
       third parties. This information shall not become part of any particular patient's file or of
       the general hospital records.

15.3   IMMUNITY FROM LIABILITY

       15.3-1 For Action Taken

              No representative of the hospital or medical staff shall be liable to a practitioner
              for damages or other relief for any action taken or statement or recommendation
              made within the scope of his/her duties as a representative, if such
              representative acts in good faith after a reasonable effort under the
              circumstances to ascertain the truthfulness of the facts and in the reasonable
              belief that the action, statement or recommendation is warranted by such facts.
              Regardless of the provisions of state law, truth shall be an absolute defense in
              all circumstances.




                                                67
       15.3-2 For Providing Information

              No representative of the hospital or medical staff and no third party shall be
              liable to a practitioner for damages or other relief by reason of providing
              information, including otherwise privileged or confidential information, to a
              representative of this hospital or medical staff or to any other health care facility
              or organization of health professionals concerning a practitioner or allied health
              practitioner who is or has been an applicant to or member of the staff or who did
              or does exercise clinical privileges or provided specified services at this hospital,
              provided that such representative or their party acts in good faith.

15.4   ACTIVITIES AND INFORMATION COVERED

       15.4-1 Activities

              The confidentiality and immunity provided by this Article shall apply to all acts,
              communications, reports, recommendations or disclosures performed or made in
              connection with this or any other health care facility's or organization's activities
              concerning, but not limited to:

              (a)     Applications for appointment, clinical privileges, or specified services;

              (b)     Periodic reappraisals for reappointment, clinical privileges or specified
                      services;

              (c)     Corrective action;

              (d)     Hearings and appellate reviews;

              (e)     Utilization reviews; and,

              (f)     Other hospital, specialty, division, committee or staff activities related to
                      monitoring and maintaining quality patient care and appropriate
                      professional conduct.

       15.4-2 Information

              The acts, communications, reports, recommendations, disclosures, and other
              information referred to in this Article may relate to a practitioner's professional
              qualifications, clinical ability, judgment, character, physical and mental health,
              emotional stability, professional ethics, or any other matter that might directly or
              indirectly affect patient care.

15.5   RELEASES

       Each practitioner shall, upon request of the hospital, execute general and specific
       releases in accordance with the tenor and import of this Article, subject to such
       requirements, including those of good faith, absence of malice and the exercise of a
       reasonable effort to ascertain truthfulness, as may be applicable under the laws of




                                                  68
       Wisconsin. Execution of such releases shall not be deemed a prerequisite to the
       effectiveness of this Article.

15.6   CUMULATIVE EFFECT

       Provisions in these bylaws and in application forms relating to authorizations,
       confidentiality of information and immunities from liability shall be in addition to other
       protections provided by law and not in limitation thereof, and in the event of conflict, the
       applicable law shall be controlling.

ARTICLE XVI: RULES, REGULATIONS, POLICIES and FORMS

The Medical Staff, through the Divisions, Specialties, and other Committees, shall adopt such
rules, regulations, policies and forms as may be necessary to implement more specifically the
general principles found within these Bylaws, subject to the approval of the MEC and Board.
These shall relate to the proper conduct of Medical Staff and where applicable Allied Health,
organizational activities, and the level of practice that is to be required of each practitioner in the
Hospital. Such Rules, Regulations, Policies and Forms are attendant to these Bylaws.

Rules, Regulations, Policies and Forms may be created, deleted or modified by
recommendation of the responsible Division, Specialty, or Committee, following their
established rules for quorum and voting, subject to the approval of the MEC and Board. The
Medical Staff shall be informed of these activities via meetings, publications, posting or other
efficient methods of information dissemination, and provided opportunity to comment for MEC
consideration, as described in Policy/Procedure Formulation and Approvals Policy.

Applicants, members of the Medical Staff, and Allied Health shall be governed by such Rules,
Regulations, Policies and Forms as are properly initiated and adopted. If there is a conflict
between the Bylaws and Rules, Regulations, Policies and Forms, the Bylaws shall prevail.

ARTICLE XVII: CONFLICT RESOLUTION

17.1   This Article establishes mechanisms by which the Board will address:

       17.1-1 A situation where the Medical Staff disagrees with an MEC action that is not
              related to a peer review action, which also includes new or revised policy, rules
              and/or regulations.

       17.1-2 A request to revise the medical staff bylaws that is brought by the medical staff
              directly to the Board.

       17.1-3 A proposal to alter a medical staff policy or rule/regulation that is brought by the
              medical staff directly to the Board.

       17.1-4 Conflict between the Medical Executive Committee and the Board of Directors
              that is not otherwise addressed in other sections of these Bylaws.

17.2   Should the Medical Staff have concern regarding an action of the MEC or a new or
       revised policy, rule or regulation following MEC recommendation and Board approval:




                                                  69
       17.2-1 The membership may appeal for MEC reconsideration by written petition of at
              least twenty-five (25) Active Staff members to the MEC, outlining specifically the
              concern(s) and recommended remedies. The MEC must review the request at
              their next regularly-scheduled meeting and respond to the request within sixty
              (60) days of the meeting.

       17.2-2 If, following the above process, dissatisfaction persists, the petition may be
              presented to the Chair of the Board of Directors, or via the President of the
              Hospital with notice to the President of the Medical Staff. Within thirty (30) days
              of receipt of the petition, a Joint Conference Committee of equal members from
              the medical staff and the Board shall be convened (reference Definition: Joint
              Conference Committee). Five (5) Board members shall be selected by the Chair
              of the Board. For purposes of conflict resolution between the medical staff and
              MEC, four (4) medical staff members shall be selected by the petitioners to
              represent the concerns outlined in the written petition and one (1) will be a
              member of the MEC selected by the President of the Medical Staff.

       17.2-3 This Joint Conference Committee shall review the petition, MEC record, any
              related documentation, and conduct such other inquiry as it may deem
              appropriate for the purpose of rendering a recommendation to the Board. Within
              ten (10) days of its final deliberations, the Joint Conference Committee shall, by
              written memorandum to the MEC and to the Board, submit its recommendation
              on the matter. The recommendation will be considered by the Board at its next
              regularly-scheduled meeting and a final decision made within 30 days.

       17.2-4 Should the Medical Staff wish to propose a revision to the Medical Staff Bylaws,
              alter an existing policy, rule or regulation, or propose a new policy, rule, or
              regulation:

              (a)     The Medical Staff should follow the customary processes outlined in
                      these Bylaws (ARTICLES XVI and XVIII) and associated policies to
                      request consideration.

              (b)     If following the customary processes additional consideration is desired,
                      the written petition process to the MEC described in B.1 of this Article is
                      the appropriate next step.

              (c)     If following the petition process, dissatisfaction persists, the process
                      described in B.2 through B.3 may be utilized and will result in a final
                      determination by the Board.

17.3   Should conflict exist between the Medical Executive Committee and the Board of
       Directors that is not otherwise addressed in other sections of these Bylaws, a Joint
       Conference Committee of equal members from the MEC and the Board shall be
       convened. Five (5) Board members shall be selected by the chair of the Board and five
       (5) MEC members by the president of the medical staff. Through the collaboration of
       the Board chair and the Medical Staff president, a time table will be established for
       resolution.




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ARTICLE XVIII DUES AND ASSESSMENTS

The Medical Executive Committee has the authority to levy fees, dues and assessments for
applicants, each category of staff membership and Allied Health affiliation and to determine the
manner of expenditure of funds received. The process of establishing and collecting dues and
assessments is outlined in the Dues and Assessments policy.

ARTICLE XIX: HISTORIES & PHYSICALS

A complete History and Physical (H&P) is required for all inpatient admissions. A H&P is also
required for outpatient operative or other procedures that utilize moderate or deep sedation or
general anesthesia. This can be accomplished by dictation and/or an H&P documented directly
in the chart

The H&P may be accomplished no more than 30 days prior to, or within 24 hours after,
registration or inpatient admission, but prior to surgery or a procedure requiring sedation or
anesthesia services.

For an H&P that was completed within 30 days prior to registration or inpatient admission, an
Update documenting any changes in the patient’s condition is completed within 24 hours of
registration or inpatient admission, but prior to surgery or a procedure requiring sedation or
anesthesia services.
                                                                 nd      rd
All medical staff members with clinical privileges and licensed 2 and 3 year residents may
perform H&Ps. Additionally H&P performance may be delegated to:

              First year and other unlicensed residents; and
              Others as outlined in each individual’s privileges.

But must be co-signed by a medical staff member within 30 days of patient discharge.

H&P performance may be delegated to:

              Providers not on AWH Medical Staff

But must be updated and co-signed by a medical staff member within the time frames provided
for updates.

ARTICLE XX: BYLAWS AMENDMENTS / REVISIONS AND ADOPTION

20.1   MEDICAL STAFF RESPONSIBILITY

       The Medical Staff shall have the initial responsibility to formulate, adopt and recommend
       to the board medical staff bylaws and amendments thereto which shall be effective
       when approved by the board. Such responsibility shall be exercised in good faith and in
       a reasonable, timely and responsible manner, reflecting the interests of providing patient
       care of the generally recognized professional level of quality and efficiency and of
       maintaining harmony of purpose and effort with the board and with the community.




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20.2   METHODOLOGY

       The Bylaws may be adopted by the following combined action:

       20.2-1 Upon recommendation of the MEC, the Medical Staff Bylaws may be amended
              and/or revised in the following manner:

              (a)     Proposed amendments shall be distributed by hand delivery, mail, fax, or
                      other forms of electronic communication to members of the Active Staff.
                      In the event of a vote outside of a Medical Staff Meeting, a ballot shall be
                      enclosed with the proposed amendments that shall be returned to the
                      designee of the President of the Medical Staff. A voting period of
                      fourteen (14) calendar days from the date of distribution shall be
                      established for return of ballots. In order for proposed amendments to be
                      adopted, a simple majority of ballots returned from eligible voters
                      approving adoption of the amendments must be attained; OR

              (b)     Proposed amendments shall be distributed by hand delivery, mail, fax, or
                      other forms of electronic communication to members of the Active Staff
                      at least fourteen (14) days in advance of a medical staff meeting with
                      notice that a vote will occur at the meeting. In order for proposed
                      amendments to be adopted, a simple majority of those present and
                      eligible to vote approving adoption of the amendments must be attained.

       20.2-2 The Medical Staff Bylaws may be adopted by the Board of Directors via an
              affirmative vote of the majority of the Board. Neither the board nor medical staff
              may unilaterally modify the medical staff bylaws. Provided, however, that in the
              event the staff shall fail to exercise its responsibility and authority as required in
              Section B.1, and after notice from the board to such effect, including a joint
              conference committee as required in Article 10, Section 9, the Board may use its
              legal initiative in formulating or amending medical staff bylaws. In such event,
              Medical Staff recommendations and views shall be carefully considered by the
              Board during its deliberations and in its actions which shall be pursuant to this
              Section.




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These Bylaws are adopted by the Hospital Board of Directors on the date set forth below:

REVISED: March 2011


Adopted by the Medical Staff on ______________


President, Medical Staff


Ratified by the Aspirus Wausau Hospital Board of Directors on _____________


Chairman, Aspirus Wausau Hospital Board


President & Chief Operating Officer, Aspirus Wausau Hospital




                                              73
                                RULES AND REGULATIONS
                                         of the
                                     MEDICAL STAFF
                               ASPIRUS WAUSAU HOSPITAL
                                    Wausau, Wisconsin

                                   GENERAL PROVISION

Rules and Regulations (Reference - Bylaws Section 17.1)

                                        DEFINITIONS

For purposes of the Rules and Regulations, the Definitions in the Bylaws shall be applicable
and shall also include:

A.     ADMISSION POLICY

       A.1    Except in an emergency no patient shall be admitted to the hospital until a
              provisional diagnosis has been submitted and an order given by the practitioner.
              In the case of an emergency, the provisional diagnosis shall be stated as soon
              as possible after admission. Practitioners admitting patients shall give such
              information as may be reasonable to assure the protection of other patients and
              to assure protection of the patient from self-harm.

       A.2    In cases of patients who are admitted directly to the medical/surgical intensive
              care unit by a practitioner from outside the hospital.

              A.2-1 The Hospital Supervisor must be notified of all admissions to the
                    medical/surgical intensive care unit to assure that a bed will be available
                    upon the arrival of a patient.

              A.2-2 If a bed is not immediately available, the patient should be directed to the
                    emergency room for monitoring until the medical surgical intensive care
                    unit bed is available.

              A.2-3 In all cases of direct admissions to the medical/surgical intensive care
                    unit the admitting practitioner must personally contact his/her consultant if
                    the latter is to be immediately responsible for the patient who is being
                    admitted or if the patient has not yet been examined by the admitting
                    practitioner.

              A.2-4 Patients who have not been evaluated by a practitioner (except by phone)
                    should be seen in the emergency room by: the emergency room
                    physician, admitting physician, or his/her consultant, to assure that life
                    threatening problems are recognized as quickly as possible upon the
                    patient's arrival at the hospital.

       A.3    The Hospital Supervisor coordinates the assignment of rooms with the nursing
              staff:



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           A.3-1 All disturbed, severely depressed and psychotic patients will be admitted
                 to the Behavioral Health by specific order of the physician.

     A.4   Practitioners' orders and reports of tests completed prior to admission shall be
           sent directly to the hospital admitting office where they will be kept on file until
           the patient is admitted.

B.   CONTINUITY OF CARE

     B.1   The practitioner is responsible within his/her area of professional competence for
           the daily care and supervision of each patient in the hospital for whom he is
           providing services, or shall arrange for a suitable alternate for such care and
           supervision. Any changes in the patient’s attending practitioner shall be clearly
           reflected in the progress or transfer orders.

           B.1-1 In the event a practitioner fails to discharge this responsibility, the
                 patient's nurse shall first attempt to talk with the practitioner; if contact
                 cannot be made or the problem is not resolved, the nurse shall notify
                 his/her direct supervisor who shall attempt to talk with the practitioner; if
                 contact cannot be made or the problem is not resolved the nurse will
                 contact specialty representative or division chief in which the attending
                 practitioner is a member. This individual will assume responsibility or
                 arrange for coverage by another practitioner.

                  If either of the above are not available, the following chain of command
                  shall be followed:

                         Specialty Rep
                         Division Leaders (Chief, Vice Chief, Member at Large)
                         President of the Medical Staff
                         President Elect of the Medical Staff
                         Secretary/Treasurer of the Medical Staff
                         Immediate Past President of the Medical Staff
                         Any other member of the Medical Executive Committee

C.   EMERGENCY DEPARTMENT

     C.1   Every patient, regardless of ability to pay, who seeks care from the regional
           emergency service center ("Emergency Service Center") shall be seen by an
           emergency service practitioner or an attending practitioner from Aspirus Wausau
           Hospital, Inc. medical staff. A medical screening examination shall be performed
           to determine if any emergency medical condition or active labor is present. If
           present, treatment shall be given to stabilize the condition before the patients is
           discharged or transferred. Direct admissions to the hospital will not be seen in
           the Emergency Service Center except in case of emergencies, myocardial
           infarctions, or other conditions as authorized from time to time by the medical
           executive committee.

     C.2   It shall be incumbent on the emergency service practitioner to act first in the best
           interest of the patient. Secondly, the emergency service practitioners shall


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      conduct themselves in such a way as to promote the best interest of the hospital
      and shall be responsible to the emergency room/outpatient committee and the
      medical staff for the efficient and ethical operation of the emergency service
      center.

C.3   Designation of Practitioner
      Patients admitted to the emergency service center will be handled in the
      following manner:

      C.3-1 Each patient admitted to the emergency service center will be asked:
            "Who is your doctor?"

             (a)    If the patient designates a primary care practitioner, (pediatrician,
                    family practitioner or internist), then the emergency service
                    practitioner will either call that practitioner, or his/her designee, or
                    treat the patient himself/herself, (according to that primary care
                    practitioner's wishes which have been previously indicated to the
                    emergency service center). If further care is necessary, the
                    emergency service practitioner will:

                    (1)     notify the primary care practitioner, and

                    (2)     inform the patient as to what is required; and

                    (3)     apprise the patient of the practitioner's name suggested by
                            the primary care practitioner.

             (b)    If a practitioner other than a primary care practitioner is
                    designated by the patient, that practitioner, or his/her designee,
                    shall become the first practitioner contacted by the emergency
                    service practitioner. The patient and his/her family shall then be
                    asked if there is any primary care practitioner they would also
                    wish to be notified. If the patient has not requested the name of a
                    specific primary care practitioner, then the word "NONE" shall be
                    listed on the emergency service center record under "family
                    practitioner."

             (c)    If the patient has not designated any practitioner, the patient shall be
                    treated by the emergency practitioner service practitioner. If another
                    practitioner is necessary, the emergency service practitioner shall select
                    on a rotating basis from the appropriate roster a practitioner acceptable
                    to the patient. The wishes of the patient shall be paramount.

C.4   The emergency service practitioners will make a charge for all patients seen by
      them.

C.5   If an admission is necessary, a practitioner from the medical staff other than the
      emergency practitioner will render all inpatient care.

C.6   All practitioners will arrange for and give prior notice to the emergency service
      center of coverage for days off, weekends and vacations so the emergency


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            service practitioners will have a practitioner to whom they can refer patients who
            need to be admitted.

     C.7    Emergency service practitioners will respond to all Code Blues as soon as
            possible.

D.   OPERATING ROOM

     D.1    Surgeons must be in the operating room and ready to commence operation at
            the time scheduled.

     D.2    The surgical services committee is a jointly appointed group of individuals
            representing the hospital and the departments of the medical staff which utilize
            the operating suites.

            D.2-1 The primary goal of the committee is to provide a smooth functioning
                  operating room for the benefit of patients, surgeons, and hospital
                  personnel.

            D.2-2 The committee will undertake operational issues of concern to the
                  hospital and/or individual users of the operating room.

            D.2-3 Recommendations of the surgical services committee of an operational
                  nature, which impact the hospital and/or departments must be agreed to
                  by the respective parties.

            D.2-4 Medical staff membership will be comprised of but not limited to
                  appointees from the departments of anesthesia, dentistry, OB/GYN, and
                  surgery.

            D.2-5 Management and administrative membership will consist of the following
                  standing committee members:     director surgical services; director
                  surgery; director ambulatory surgery; and the administrative vice
                  president as an ad hoc committee member as well as designated
                  operating room staff.

            D.2-6 The committee will designate a chairperson on an annual basis.

            D.2-7 An annual report of committee activities will be forwarded to the medical
                  executive committee.

            D.2-8 The minutes of the surgical services committee will be distributed to the
                  appropriate medical staff clinical departments.

E.   RESOLUTION OF CONFLICT

     In the case of a problem or concern between a practitioner and hospital personnel, the
     person involved should first attempt to resolve the problem by discussing it with the
     practitioner; if the problem is not resolved or the concern continues, the person shall
     inform their immediate supervisor who shall first attempt to resolve the problem by



                                            77
       discussing it with the practitioner; if the problem is not resolved or the concern
       continues, the specialty representative or chief of the division in which the practitioner is
       a member shall be notified and will make a decision on the appropriate action to be
       taken.

       If either of the above are not available, the following chain of command shall be
       followed:

             Specialty Rep
             Division Leaders (Chief, Vice Chief, Member at Large)
             President of the Medical Staff
             President Elect of the Medical Staff
             Secretary/Treasurer of the Medical Staff
             Immediate Past President of the Medical Staff
             Any other member of the Medical Executive Committee

MEC: 3/8/11
Accountability Committee: 7/9/08 (6/25/08 Medical Staff)




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