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					                  BYLAWS, RULES AND REGULATIONS
                              OF THE
                          MEDICAL STAFF
                                OF
                           LAKE HEALTH

Amended: Board of Trustees:     9-28-78
                                3-22-80
                                9-25-80
                                9-24-81
                                7-24-83
                              10-31-83
                              12-03-84
                                6-24-85
                              10-28-85
                                1-06-86
                                9-17-86
                              10-28-86
                                6-01-87
                              11-30-87
                                6-06-88
                              10-31-88
                                4-26-89
                                1-27-89
                                4-30-90
                                1-26-90
                                5-10-93
                                6-27-94
                                5-22-95
                              10-30-95
                                4-29-96
                                4-28-97
                              10-27-97
                                6-01-98
                                1-01-99
                                4-24-00
                              10-30-00
                                4-30-01
                              10-29-01
                                4-29-02
                              10-26-02
                              10-27-03
                                12-8-03
                                5-14-05
                              10-31-05
                                5-31-06
                               10-30-06
                                4-30-07
                              10-29-07
                               4-28-08
                               9-29-08
                              10-25-08
                                5-27-09
                              10-26-09
                     LAKE HEALTH MEDICAL STAFF BYLAWS

                                   TABLE OF CONTENTS



ARTICLE/SECTION                                        PAGE

Preamble

    I. Name                                             1

   II. Purpose                                          2

  III. Definitions                                      3

  IV. Membership
      A. Nature of Medical Staff Membership             5
      B. Basic Qualifications for Membership            5
      C. Basic Responsibilities of Staff Membership     7

   V. Staff Categories
      A. Change in Category of Staff Membership         9
      B. Categories of Membership                       9
             1. Active                                  9
             2. Provisional                             10
             3. Courtesy                                10
             4. Consulting                              10
             5. Affiliate                               10
      C. Leave of Absence                               10

  VI. Honorary Status                                   11

 VII. Allied Health Professionals
      A. Qualifications                                 11
      B. Categories                                     11
      C. Status                                         12
      D. Departmental Assignments and Privileges        12
      E. Quality Improvement Review                     13

VIII. Appointment
      A. Requests for Appointment                       13
      B. (no title)                                     13
      C. Applicant’s Responsibilities                   13
      D. Appointment Process                            15
      E. Expedited Appointment                          15


Lake Health Medical Staff Bylaws                              October 26, 2009
Medical Staff Bylaws – Table of Contents – Page two
                                                             Page

  IX. Determination of Clinical Privileges
      A. Exercise of Clinical Privileges                     17
      B. Delineation of Privileges in General                17
      C. Special Conditions for Dental Privileges            17
      D. Special Conditions for Podiatric Privileges         18
      E. Special Conditions for Psychologists                18
      F. Special Conditions for Telemedicine Practitioners   19
      G. Temporary Privileges                                19
      H. Residents                                           21
      I. Medical Students & Allied Health Professional       21
         Students & Others
      J. Emergency Privileges                                21
      K. Disaster Privileges                                 22

   X. Reappointment & Recredentialing
      A. Requests for Reappointment                          23
      B. Applicant’s Responsibilities                        23
      C. Criteria for Reappointment                          23
      D. No Name                                             24
      E. No Name                                             24
      F. No Name                                             24

  XI. Corrective Action
      A. Routine Corrective Action                           25
      B. Summary Suspension                                  26
      C. Automatic Suspension and Revocation                 27
      D. Continuity of Patient Care                          28


 XII. Fair Hearing Plan
      A. Definitions                                         28
      B. Initiation of Hearing                               28
      C. Hearing Prerequisites                               31
      D. Hearing Procedure                                   32
      E. Report of Decision and Further Action               35
      F. Action on Recommendations Report                    35
      G. Initiation & Prequisites of Appellate Review        36
      H. Appellate Review Procedure                          37
      I. Final Decision of the Board                         38
      J. General Provisions                                  38
      K. Reporting Professional Review Actions               39




Lake Health Medical Staff Bylaws                                    October 26, 2009
Medical Staff Bylaws – Table of Contents – Page three
                                                        Page

XIII. Officers
      A. Officers                                       40
      B. Election of Officers                           40
      C. Term of Office                                 40
      D. Vacancies                                      40
      E. Duties of Officers                             40

XIV. Staff Departments
     A. Organization of Staff Departments               42
     B. Qualifications, Selection & Tenure of
         Department Chairman                            42
     C. Functions of the Department Chairman            42
     D. Functions of Departments                        43
     E. Extra Departmental Privileges                   43
     F. Section of Dentistry of the Dept. of Surgery    43
     G. Section of Podiatry of the Dept. of Surgery     43
     H. Section of Walk-in Medical Care of the Dept.    44
        of Medicine

 XV. Committees
     A. Appointment                                     45
     B. Standing Committees                             45
     C. Special Committees                              50
     D. Voting                                          50
     E. Nominating Committee                            50
     F. Hospital Committees                             51

XVI. Staff Meetings
     A. Regular Meetings                                52
     B. Special Meetings                                52
     C. Quorum                                          52
     D. Parliamentary Authority                         52
     E. Agenda                                          52

XVII. Committee and Department Meetings
      A. Regular Meetings                               53
      B. Special Meetings                               53
      C. Notice of Meetings                             53
      D. Quorum                                         53
      E. Manner of Action                               53
      F. Rights of Ex-Officio Members                   53
      G. Minutes                                        53



Lake Health Medical Staff Bylaws                               October 26, 2009
 Medical Staff Bylaws – Table of Contents – Page four
                                                            Page
XVIII. Staff, Department and Committee Meeting
       Attendance
       A. Attendance Requirements                           54
       B. Penalty                                           54
       C. Excused Absence                                   54
       D. (No title)                                        54
       E. Notice                                            54

 XIX. Immunity from Liability
      A. Privileged Acts                                    55
      B. Extent of Privileges                               55
      C. Immunity from Liability                            55
      D. Extent of Immunity                                 55
      E. Scope of Acts                                      55
      F. Releases                                           55
      G. Extension of Protection                            55

  XX. Rules and Regulations
      A. Adoption of Rules and Regulations                  56
      B. Amendments                                         56
      C. Effective Date of Amendments                       56

 XXI. Amendments
      A. Procedure for Amendments                           57
      B. Conflict with Bylaws of Lake Health                57



         Dates of Approvals                                 58

         Rules and Regulations
         1. Meetings of the Staff                           59
         2. Admission of Patients                           59
         3. Discharge of Patients                           59
         4. Treatment of Patients                           60
         5. Orders                                          61
         6. Co-Signature of Chart Entries                   62
         7. Laboratory and Radiology                        62
         8. Records                                         62
         9. Temporary Interruption of Clinical Privileges   64
         10. Rules Regarding New Staff Members              65
         11. Consultation                                   65
         12. Mass Casualty Plan                             65




 Lake Health Medical Staff Bylaws                                  October 26, 2009
Medical Staff Bylaws – Table of Contents – Page five
                                                       Page

        13. Contract Physicians                        66
        14. Emergency Center On Call Rosters           66


Position on Use of Services at Lake Health             67




Lake Health Medical Staff Bylaws                              October 26, 2009
PREAMBLE
The Board of Trustees of Lake Health (Board) under Ohio Law has the responsibility for
maintaining the quality of care in its hospitals through the provision of a competent
medical staff. The Board has the duty to credential, appoint and remove members of the
medical staff. The Board retains final approval and authority over decisions to credential
or discipline any physician performing services in the Lake Health hospitals. The Board
exercises this responsibility in partnership with and upon recommendation of the medical
staff.

The Medical Staff of Lake Health hereby organizes itself in conformity with the Bylaws
and Medical Staff Rules and Regulations hereinafter stated. The Board has delegated
certain authorities to the Medical Staff to conduct activities as set forth in these Bylaws.
These Bylaws are adopted for the purpose of governing the actions, recommendations
and functions of the Medical Staff of Lake Health. These Bylaws are not intended to be,
nor shall anything herein be, interpreted in such a way as to be a delegation by the Board
to any person or group, including the Medical Staff, of final authority of the Board to
operate Lake Health.




Lake Health Medical Staff Bylaws              2                               October 26, 2009
    I. NAME
       The name of this organization shall be the Lake Health Medical Staff.




Lake Health Medical Staff Bylaws           1                              October 26, 2009
   II. PURPOSE
       The purpose of this organization shall be to assure optimal care to all patients
       treated within the Hospital or its facilities. To achieve this purpose, the Medical
       Staff acting with the authority of the Board of Trustees shall:

            a. Delineate the qualifications for membership on the staff.

            b. Delineate the general and specific clinical privileges each member may
               exercise,

            c. Establish and maintain a continuous review and evaluation of each
               member’s performance.

            d. Establish and maintain educational standards and programs for members
               and assist in the educational programs for other Hospital personnel,

            e. Establish, maintain and enforce Rules and Regulations for the governance
               and the conduct of the Medical Staff, and,

            f. Establish and maintain communications with the Board of Trustees.




Lake Health Medical Staff Bylaws             2                               October 26, 2009
  III. DEFINITIONS

        Administrator- The Chief Executive Officer, or his/her designee, appointed by the
        Board of Trustees to act in its behalf in management of the Hospital.

        Board of Trustees (Board) – The governing body of the Hospital.

        Dentist, DDS or DMD – Individuals holding a degree of Doctor or Dentistry.

        Emergency – A situation where loss of life or limb or serious permanent damage
        may occur.

        Ex-Officio – A member of a committee by virtue of position or office; privileged
        to speak, without vote unless otherwise provided; not counted in consideration of
        a quorum.

        Hearing – An official investigative function of the Medical Staff.

        Hospital – Lake Health and its divisions.

        Hospital Staff or Staff – Health professionals privileged to attend patients.

        Interview – A non-official investigative function of the Medical Staff.

        Majority – More than one half of legal votes cast.

        Medical Staff – Health professionals holding an MD, DO, DDS, DMD, DPM or
        PhD/Psych. degree who have been granted privileges to attend patients in the
        Lake Health.

        Membership – A privilege granted to practitioners by the Board of Trustees to
        participate in functions of the Hospital Staff.

        Official Notice – Written notification by either certified mail, return receipt
        requested or personal delivery two active members of the Medical Staff appointed
        by the President.

        Patient Care Days – Days hospitalized patient is actually under the care or
        responsibility of Staff member. An isolated consultation shall equal one day of
        care.

        Peer Recommendation – A statement of support, by a member of the same
        specialty or sub-specialty, in connection with an applicant’s request for
        membership and/or reappointment.




Lake Health Medical Staff Bylaws              3                               October 26, 2009
        Physicians: MD, DO – Those health professionals holding the degree of Medical
        Doctor or Doctor of Osteopathy.

        Plurality – Largest number or more numbers, i.e., greater than the next largest
        number.

        Podiatrist: DPM – Individuals holding a degree of Doctor of Podiatric Medicine.

        President of the Hospital – The Administrator of the Hospital.

        Privileges – Those specific clinical processes, procedures or functions granted to a
        practitioner by the Board of Trustees.

        Professional Review Action means an action or recommendation of a professional
        review body which is taken or made in the conduct or professional review
        activity, which is based on the competence or professional conduct of an
        individual practitioner, which affects or could adversely affect the health or
        welfare of a patient or patients, and which affects (or may affect) adversely the
        clinical privileges or membership in a professional society of the practitioner.
        Such term includes a formal decision of a professional review body not to take an
        action or make a recommendation described in the previous sentence and also
        includes professional review activities relating to a professional review action.

        Professional Review Activity means an activity of the Hospital and Medical Staff
        With respect to an individual practitioner.

        Professional Review Body means the Hospital and the Governing Body or any
        committee of the Hospital, which conducts professional review activity, and
        includes any committee of the Medical Staff of the Hospital when assisting the
        Governing Body in a professional review activity.

        Any adverse action, including a summary suspension, shall not be a ‘professional
        review action’ until all procedures and appeals in the Medical Staff Bylaws have
        been completed or waived, and there has been a final action by the Hospital
        Board.

        Psychologist – PhD/Psych. – Those health professionals holding the degree of
        clinical psychologist.




Lake Health Medical Staff Bylaws             4                               October 26, 2009
  IV. MEMBERSHIP
        A. NATURE OF MEDICAL STAFF MEMBERSHIP
           Membership on the Medical Staff of Lake Health is a privilege which shall
           be extended only to professionally competent physicians, dentists,
           podiatrists and psychologists who continuously meet the qualifications,
           standards and requirements set forth in these Bylaws, Rules and
           Regulations. Appointment to and membership on the Staff shall confer on
           the appointee or member only such clinical privileges and prerogatives as
           have been granted by the Board in accordance with these Bylaws, Rules
           and Regulations. Neither membership on the Staff nor these Bylaws,
           Rules and Regulations constitute a contract and neither are intended or
           should be construed to confer any contractual rights upon an appointee or
           member.

            B. BASIC QUALIFICATIONS FOR MEMBERSHIP
               1. Physicians, dentists, podiatrists and psychologists currently licensed to
                  practice in the State of Ohio shall be qualified for membership on the
                  Medical Staff if they meet the following conditions:
                  a) They document their experience, background, training to board
                     certification or board certification, recertification, demonstrated
                     ability and physical and mental health status, with sufficient
                     adequacy to demonstrate to the Medical Staff and the Board that
                     any patient treated by them will receive care of the generally
                     recognized professional level of quality and efficiency;
                  b) The applicant demonstrates that he/she will maintain an office
                     within such proximity to the Lake Health facility at which he/she
                     will primarily practice as to assure optimal patient care. The
                     reasonableness of the proximity to a Lake Health facility shall be
                     determined by the clinical department in which the applicant seeks
                     clinical privileges.
                  c) The applicant demonstrates by providing documented references,
                     attesting to his/her ethical practice of medicine, dentistry, podiatry
                     or psychology, the ability to work with others and the willingness
                     to participate in the discharge of staff responsibilities;
                  d) Board certification must be obtained within seven years of the
                     completion of their residency or fellowship training; or the
                     Credentials Committee shall consider special circumstances of said
                     physician’s clinical competence on an annual basis.
                  e) They shall hold current board certification or recertification in a
                     specialty recognized by the American Board of Medical
                     Specialties, the American Osteopathic Association, or the
                     American Podiatric Medical Association or the Credentials
                     Committee shall consider special circumstances of said physician’s
                     clinical competence on an annual basis.




Lake Health Medical Staff Bylaws             5                              October 26, 2009
                        If board certification is not available for that particular class of
                        practitioner, (e.g. general dentists, psychologists) documented
                        experience of at least two years may be accepted in lieu of board
                        certification.

                        Physicians, dentists, podiatrists and psychologists who are
                        members of the Medical Staff and who are not Board Certified by
                        June 27, 1994 shall not be required, either then or in the future, to
                        attain Board Certification as a condition of reappointment to the
                        Medical Staff. Provided, however, that if any such person’s
                        membership on the Medical Staff shall terminate, such person shall
                        be required to meet all requirements, including those set forth
                        above, as a condition of being appointed again to the Medical
                        Staff.

                    f) They shall present evidence of professional liability insurance
                       coverage through a company authorized to sell malpractice policies
                       in the State of Ohio, or through an entity, such as a hospital, which
                       has an acceptable self-insurance program in place. The minimum
                       level of coverage and the acceptable level of carrier rating shall be
                       set by the Board of Trustees; this amount shall be equal for all
                       Medical Staff members, and Allied Health Professionals.

                    g) A practitioner may petition the Board for an exception to the
                       Medical Staff malpractice insurance requirements. Any exception
                       shall be at the sole discretion of the Board. It will be the
                       responsibility of the practitioner to demonstrate that the
                       practitioner’s proposed insurance arrangement is an acceptable,
                       reasonable equivalent means of meeting the Medical Staff
                       malpractice insurance requirement. The Board may, from time to
                       time, adopt policies to assist in the evaluation of exception
                       requests.

                2. Medical Staff membership or clinical privileges shall not be denied on
                   the basis of sex, race, creed, color or national origin. Criteria related
                   to the delivery of quality patient care in the hospital and to
                   professional ability and judgment may be used as a basis for denial of
                   membership.

                3. Effect of Other Affiliations
                   No physician, dentist, podiatrist or psychologist is automatically
                   entitled to membership on the Medical Staff or to the exercise of
                   particular clinical privileges, merely because he/she is licensed to
                   practice in this or any other State, or because he/she is a member of
                   any professional organization, or because he/she is certified by any
                   clinical board, or because he/she had or presently has Medical Staff



Lake Health Medical Staff Bylaws               6                               October 26, 2009
                    membership or privileges at another health care facility or in another
                    practice setting, or because he/she had previously held Medical Staff
                    membership or privileges at this institution.

                4. Medico-Administrative Personnel
                   A physician, dentist, podiatrist or psychologist with medico-
                   administrative responsibilities must be a member of the Medical Staff
                   and his/her privileges shall be delineated in accordance with
                   mechanisms as defined in these Bylaws, Rules and Regulations.

                5. Health Status
                   When the Medical Executive Committee or Board has reason to
                   question the physical and/or mental health status of a practitioner, the
                   practitioner shall be required to submit an evaluation of his/her
                   physical and/or mental health status by a physician or physicians
                   mutually acceptable to all parties as a prerequisite to further
                   consideration of his/her application for appointment or reappointment,
                   or to the continued exercise previously granted privileges, or to
                   maintenance of his/her staff appointment. If, after thirty (30) days has
                   elapsed, a physician or physicians mutually acceptable to all parties
                   has not been identified, such selection will be made by the Medical
                   Executive Committee.

C. BASIC RESPONSIBILITIES OF STAFF MEMBERSHIP
   Each member of the Staff and each Practitioner granted temporary privileges,
   including temporary privileges as a locum tenens physician, shall:

    1. Provide his/her patients with continuous care at the generally recognized
       professional level of quality and efficiency;
    2. Abide by the Medical Staff Bylaws, Rules and Regulations, and by the standards,
       policies and rules of the Hospital which will be available to all members of the
       Medical Staff.
    3. Discharge such staff, department and division committee and Hospital functions
       for which he/she is responsible by appointment or election.
    4. Prepare and complete in timely and legible manner the medical records for all
       patients he/she admits or in any way provides care to in the Hospital.
       a. All Staff members shall be responsible for the preparation of a complete
           legible medical record on patients they attend. Dental and Podiatric patients
           must have an admission history and physical performed by a physician, who is
           a member of the medical staff, and the dental or podiatric portion of the
           history and physical recorded in the record by the dentist or podiatrist. This
           record shall include a history, physical examination and provisional diagnosis
           within 24 hours of admission. All admissions by dentists must have medical
           consultation before the patient goes to surgery, except in the case of patients
           without medical problems admitted by oral surgeon with privileges to
           complete an admission history and physical examination and to assess the
           medical risks of the procedure to the patient.




Lake Health Medical Staff Bylaws              7                              October 26, 2009
        b. A History and Physical must be completed on all Inpatient, Geropsych,
            Comprehensive Rehab, SNRU and Observation patients with 24 hours of
            admission. A History and Physical must be completed and present on the chart
            before any invasive procedure. For outpatient status, refer to Administrative Policy
            H-11-1.
            The elements that must be present in a History and Physical are:
                Chief complaint
                Details of present illness
                Social, past and family history
                Review of systems (inventory of body system)
                Relevant physical findings from examination
                Reason for admission
                Statement of the course of action planned for this episode of care
                Conclusions or impressions drawn from the medial history and physical
                   exam.
    5. Abide by the ethical principles of his/her profession.
    6. Promptly notify the President of the Hospital and President of the Medical Staff
       of the revocation or suspension of his/her professional license, whether voluntary
       or involuntary, or the imposition of terms of probation or limitation of practice by
       any state licensing agency; or of his/her loss of Staff membership or loss or
       restriction of privileges at any hospital, or other health care institution, as a
       consequence of a medical disciplinary proceeding, or of the cancellation or
       restriction of his/her professional liability coverage, or the revocation, suspension
       or voluntary relinquishment of his/her DEA number, or the adverse results of a
       formal investigation by the Department of Health and Human Services or any law
       enforcement agency or health regulatory agency, or of the imposition of sanctions
       by a Peer Review Organization or a final adverse judgment or settlement against
       a practitioner in a professional liability action.
    7. Provide emergency services to medical assistance patients and other patients
       without personal physicians, in accordance with the protocol adopted by the Staff
       and approved by the Board of Trustees, delineating responsibilities for services to
       such patients.
    8. Abide by the terms of the Lake Health Notice of Privacy Practices prepared and
       distributed to Lake Health patients, as required by the federal patient privacy
       regulations.




Lake Health Medical Staff Bylaws               8                                October 26, 2009
   V. STAFF CATEGORIES
      A. Change in Category of Staff Membership
         Advancement in category of Staff membership shall be by the member’s
         written request to his/her department chairman who shall forward the request
         to the Credentials Committee with recommendations based upon his
         knowledge of the member’s qualifications and performance. Thereafter, the
         request shall follow the established line of communication to the Board of
         Trustees for action.

            To be eligible for advancement from Provisional category, a member shall
            have service on that level for the preceding twelve (12) months.

        B. Categories of Membership
           The categories of membership shall be Active, Courtesy, Provisional,
           Consulting and Affiliate.
           1. Active Staff
              The Active Medical Staff members shall transact all business of the
              Medical Staff. The right to vote and the privilege to hold Staff office shall
              be restricted to this category. To be eligible for this category a Staff
              member shall:
              a. Do plurality of work and/or commitment to care within the Lake
                  Health. In the interest of achieving full service capability in providing
                  comprehensive patient care in this hospital, this requirement may be
                  waived upon the written recommendation of a department chairman
                  through the usual line of communication to the Board of Trustees for
                  approval.
              b. Maintain all Staff obligations and requirement.
              c. Fulfill all the requirements of Active Staff membership for a period of
                  one year (12 months) to be eligible to advance in Staff category to
                  Active.
              d. A member shall hold current certification or recertification by a
                  specialty board as defined in Article IV. This requirement may be
                  waived or modified to accommodate special circumstances of a
                  medical staff member upon written request of the affected member to
                  their department chairman, who shall forward it with their
                  recommendations to the Medical Executive Committee. The request
                  shall then follow the established line of communication to the Board of
                  Trustees for action. If certification is not offered in the member’s
                  specialty, the member shall document competence equivalent to board
                  certification.
              e. Have satisfactorily completed any period of observation and/or
                  evaluation, which may have been undertaken as a part of that
                  physician’s departmental protocol.




Lake Health Medical Staff Bylaws             9                              October 26, 2009
           2. Provisional Staff
              All initial appointments to the Medical Staff (except Honorary) shall be to
              the Provisional membership category for a 12-month period.
              Reappointment to the Provisional Staff shall not exceed two years.

               Each Provisional Staff member shall be assigned to a department where
               their performance shall be observed and evaluated by the department
               chairman, or the chairman’s designee, in order to determine the eligibility
               of the Provisional member for advancement to another Staff category and
               to exercise the clinical privileges granted to him/her.

           3. Courtesy Staff
              The Courtesy Staff shall consist of those staff members who for various
              reasons are not eligible for Active membership.
               a. Courtesy member shall not serve as an officer in his/her department,
                  but shall on all committees to which he/she is appointed.
               b. Elective admissions by a Courtesy Staff member shall be subordinate
                  to those of Active or Provisional Staff members at times of restricted
                  admissions.

           4. Consulting Staff
              The Consulting Staff shall consist of practitioners of recognized skills and
              knowledge who offer a service, which may be required for comprehensive
              patient care. Privileges shall be limited to consultation within a designated
              specialty.

            5. Affiliate Staff
               Physicians credentialed for work in the Urgent Care Walk-in Centers and
               telemedicine physicians will be considered affiliate staff. They will not be
               required to pay dues or attend meetings.

        C. Leave of Absence
           A member of the Staff may be granted a leave of absence by the Medical
           Executive Committee with the approval of the Board of Trustees. A written
           request, specifying the purpose and duration of such leave of absence, shall be
           submitted by the staff member. A leave of absence shall not be granted for a
           time period greater than 24 months.

            During a leave of absence, all clinical and non-clinical responsibilities and
            privileges shall be suspended; the Staff member shall be relieved of his/her
            obligation to pay Staff dues and assessments.

            Upon written request at least 30 days prior to the date of termination of the
            leave of absence, reinstatement of full privileges and responsibilities may be
            granted by the Medical Executive Committee. Following the written request
            for reinstatement to the Medical Staff, the member must complete the
            reappointment process as defined in Section X. Reappointment and



Lake Health Medical Staff Bylaws             10                              October 26, 2009
            Recredentialing. Dues and assessment must be paid at the time of request for
            reinstatement of full privileges. Failure to request reinstatement within two
            years (24 months) from the date the leave of absence began shall constitute a
            termination of Staff Membership. Thereafter, a member must reapply for
            membership and be processed in the same manner specified for initial
            appointments.

  VI. HONORARY STATUS
      Honorary Status may be conferred upon retired or emeritus Active Staff Members
      or others of reputation when it is desired to honor them, subject to the approval of
      the Medical Executive Committee and the Board of Trustees. Those receiving
      honorary status shall not be considered members of the Medical Staff for purposes
      of rights to vote in Medical Staff elections, holding office, rights to any hearing or
      appeal pursuant to the Fair Hearing Plan contained within Article XII, privileges
      to admit patients or accept referral of patients, the requirements of meeting
      attendance or the assessment of dues.

 VII. ALLIED HEALTH PROFESSIONALS
      A. QUALIFICATIONS
         The Medical Staff may recommend to the Board of Trustees the granting of
         clinical privileges to Allied Health professionals based upon investigation and
         evaluation of the education, training, experience, demonstrated ability and
         judgment of individuals requesting privileges as Allied Health Professionals,
         according to the procedures established in these Bylaws or in other documents
         approved by the Board of Trustees.

            Privileges shall be granted only to those individuals holding a license,
            certificate or other legal credential, as required by State law, and who are
            determined, on the basis of documented references, to adhere to the ethics of
            their respective professional disciplines, as applicable, and to work
            cooperatively with others.

            From time to time, the Medical Executive Committee, in conjunction with the
            Credentials Committee, may establish particular qualifications required of
            members of a specific Allied Health Professional category, provided such
            qualifications shall not be founded upon any arbitrary or discriminatory basis,
            and shall be in conformance with all applicable laws.

            They shall present evidence of professional liability insurance coverage
            through a company licensed in the State of Ohio, or through an entity, such as
            a hospital, which has an acceptable self-insurance program in place. The
            minimum level of coverage and the acceptable level of carrier rating shall be
            set by the Board of Trustees; this amount shall be equal for all Medical Staff
            members, and Allied Health Professionals.

        B. CATEGORIES
           This designation shall include the following categories, which categories may
           be revised from time to time by the Medical Executive Committee, as it deems



Lake Health Medical Staff Bylaws             11                              October 26, 2009
            necessary or appropriate. Any such revision of these categories by the
            Medical Executive Committee shall be submitted to the Active Medical Staff
            for consideration and ratification at the next meeting of the General Staff.
            Advanced Practice Nurse
            Anesthesiology Assistants
            Cardiovascular R.N.
            Certified Cardiovascular Perfusionist
            Certified Registered Nurse Anesthetist
            Licensed Independent Social Worker
            Licensed Social Worker
            Licensed Professional Clinical Counselor
            Certified Nurse Midwife
            Neonatal Nurse Practitioner
            Certified Nurse Practitioner
            Orthopedic Technologist – Certified
            Physician Assistant – Certified
            Registered Nurse First Assistant
            Social Worker
            Staff Assistants employed at the Pre-Admission Testing Facilities
            Surgical Assistants
            Surgical Technician

        C. STATUS
           Allied Health Professionals shall not be granted membership on the Medical
           Staff. However, they will be required to pay an application fee, as determined
           by the Medical Executive Committee. They will not be required to pay dues
           or attend Medical Staff, Departmental or Committee meetings, but may attend
           such meetings by invitation.

            A recommendation by, or on behalf of the Medical Staff not to grant
            privileges to an applicant as an Health Professional, or a decision to suspend,
            terminate or discontinue such privileges, shall not give rise to any procedural
            rights of the Fair Hearing Plan as set forth within Article XII of these Bylaws.

            However, any adverse recommendation shall give rise to a separate fair
            hearing process including a right of appeal, in accordance with a policy
            established and maintained within each clinical department, which process
            shall include the right of the Allied Health Professionals:

               To receive notice of the adverse recommendation, along with a statement
                of the basis for the adverse recommendation.
               To request a hearing before a Hearing Committee
               To call witnesses and present other evidence at such hearing
               To be represented by counsel or other person at such hearing
               To appeal to the Executive Committee of the Medical Staff from any
                adverse decision of the Hearing Committee




Lake Health Medical Staff Bylaws             12                              October 26, 2009
        D. DEPARTMENTAL ASSIGNMENTS AND PRIVILEGES
           Each Allied Health Professional shall be individually assigned to a clinical
           department appropriate to his or her professional training, and shall be subject
           to any rules and regulations of that department. Clinical privileges shall be
           delineated for each Allied Health Professional by the department to which he
           or she is assigned, and by which he or she will be supervised.

        E. QUALITY IMPROVEMENT REVIEW
             Generally, an Allied Health Professional shall be subject to quality
             improvement review by the clinical department to which he or she is
             assigned. Physicians practicing at Urgent Care Centers shall be subject
             to quality improvement review by the Department of Medicine. Staff
             Assistants employed at the Pre-Admission Testing facilities shall be
             subject to quality improvement review by the Department of Surgery.

VIII. APPOINTMENT

        A. Requests for Appointment
           All requests for appointment to the Staff shall be initiated by the completion
           of an Application Form, prescribed by the Credentials Committee and
           forwarded to the Practitioner by the President of the Hospital for completion,
           and returned to the Medical Staff Office. A letter outlining the basic
           qualifications of membership, including board certification, as set forth in
           Article IV., Section B. will be sent to the applicant with the application.

        B. In the event that a former member of the staff who has resigned while in good
           standing requests appointment within one (1) year following his/her
           resignation, such applicant shall submit proof that he/she continues to meet
           the basic qualifications for membership, and shall submit evidence of his/her
           professional activities since the time of resignation However, if a physician’s
           membership has been involuntarily terminated, he/she will need to reapply for
           membership through the normal application process.

        C. Applicant’s Responsibilities
           The applicant shall have the responsibility to provide adequate and accurate
           information for an evaluation of his/her competence, character, ability to work
           cooperatively and effectively with other physicians and employees of the
           hospital, ethics and other qualifications and to submit any additional
           information requested by the Credentials Committee.

            In applying for appointment to the Staff, in order for the application to be
            complete, the applicant signifies that he/she:

            1. Is willing to appear for a personal interview,
            2. Authorizes and consents to consultation with other institutions or
               individuals who may have knowledge regarding his/her competence,
               character and ethics,




Lake Health Medical Staff Bylaws             13                               October 26, 2009
             3. Authorizes and consents to a review of any records and documents
                 necessary for an evaluation of his/her competence and qualifications.
        4.   Release from liability all representatives of the Hospital, the Staff, and all
             individuals or organizations for their acts to obtain or provide information,
             even of a confidential or privileges nature, concerning the investigation of the
             applicant,
        5.   Agrees to utilize and exhaust all administrative remedies afforded by the
             Bylaws, Rules and Regulations prior to initiation of legal action in the event
             of an adverse decision or ruling, and
        6.   Agrees to abide by the Bylaws, Rules and Regulations.
        7.   The applicant must submit:
                 a. Copy of his/her wallet size Ohio Medical License
                 b. Copy of DEA Certificate
                 c. Copy of Board Certificate, if any
                 d. Copy of the face sheet of the malpractice insurance.
                 e. Documentation indicating that the applicant has met the continuing
                     education requirements in accordance with the laws of the State of
                     Ohio, in effect at the time of his/her last license renewal, and that the
                     educational activities relate, at least in part, to the privileges being
                     sought.
                 f. A non-refundable application fee, the amount of which shall be
                     determined by the Medical Executive Committee.

        8. The applicant shall provide information regarding the following, when
            applicable:
                 a. Previously successful or currently pending challenges to any licensure
                    or DEA registration, or the voluntary relinquishing of any of the
                    above.
                 b. Voluntary or involuntary termination of medical staff membership, or
                    voluntary or involuntary limitation, reduction, or loss of clinical
                    privileges.
                 c. At least one letter of recommendation from a professional peer.
                 d. The applicant must inform in writing of any final judgments or
                    settlements arising out of a medical liability action in the past two
                    years.
        9. The applicant must inform in writing of any convictions or felonies within the
            past two years
        10. The applicant must account for all time periods following medical school or
            its equivalent on the application
        11. The applicant must list all hospital membership held at present or in the past
        12. The applicant must document the training program, its location and time spent
        13. The applicant must list all states where presently and/or previously licensed
        14. The applicant must state that he or she does or does not have any physical or
            mental condition that could affect their ability to exercise the privileges
            requested safely and competently.




Lake Health Medical Staff Bylaws               14                              October 26, 2009
        D. Appointment Process
           It is the responsibility of the Medical Staff Office to request information from
           those references listed by the applicant, from the applicant’s training program,
           all hospitals where membership is and/or has been held, all state medical
           boards where license is and/or has been held, specialty boards where
           certification has been granted, and all pertinent state and federal
           clearinghouses and data banks. A criminal background check will also be
           performed on all applicants. The credential file will only be presented to the
           Credentials Committee for approval when it is complete.

            1. The Credentials Committee may request the applicant to provide case
               reports, utilization statistics, and any other relevant data regarding the
               applicant’s previous experience.
            2. It shall be the responsibility of the Credentials Committee to affirm that all
               documents are approved, that all present or previous hospitals and medical
               boards are contacted and that appropriate documentation of previous
               medical experience is obtained and that all pertinent state and federal
               clearinghouses and banks have been contacted. Only the five (5) most
               recent affiliations will be verified for teleradiologists, telemedicine and
               locum tenens physicians.
            3. Within ninety (90) days following the receipt of the completed application
               and the verification of all supporting documentation, the Credentials
               Committee shall make a recommendation regarding the application and
               forward that recommendation to the applicable Department for review and
               privileging. The Department may therefore conduct such further
               investigation as it deems appropriate, and, within sixty (60) days following
               receipt of the recommendation of the Credentials Committee, shall
               forward its recommendations with respect to the application to the
               Medical Executive Committee and the Board of Trustees.
            4. The final decision regarding application for membership will be made by
               the Board of Trustees within 60 days.
            5. In the event that the Medical Executive Committee recommends to the
               Board of Trustees that the application for appointment be denied, the
               applicant shall be entitled to the Notice and Hearing provisions set forth in
               Article XII.
            6. For initially appointed practitioners and newly granted privileges a period
               of focused professional practice chart review will be performed (per
               Medical Staff Policy MS-27-1).

        E. Expedited Appointment
           1. In the event that is demonstrated to the satisfaction of the Chairman of the
              Credentials Committee, or his/her designee, through a written request
              from an applicant and a written statement provided by the chairman of a
              clinical department or his/her designee, that there is a good cause for an
              applicant to receive an expedited and processing of his/her completed
              application for membership and request for delineation of clinical
              privileges, then, at the discretion of the Chairman of the Credentials
              Committee, or his/her designee, such application and request for



Lake Health Medical Staff Bylaws             15                               October 26, 2009
                delineation of clinical privileges shall be referred immediately to the
                Medical Executive Committee for processing. For purposes of this
                expedited appointment process, “applicant” shall include both
                practitioners seeking membership on the Medical Staff and those seeking
                Allied Health Professional status.
                Applicants are ineligible for expedited appointment if any of the following
                items are present:

                a. A current challenge or a previously successful challenge to licensure or
                   registration;
                b. An involuntary termination of medical staff membership at another
                   institution:
                c. An involuntary limitation, reduction, denial, or loss of clinical
                   privileges at any institution; or
                d. An unusual pattern of, or an excessive number of, professional liability
                   actions resulting in a final judgment against the applicant.

            2. The Medical Executive Committee will consider the application as soon as
               possible. A personal interview with the applicant may be scheduled at the
               discretion of the Medical Executive Committee.

                In the event that the Medical Executive Committee finds the application
                and request for delineation of clinical privileges to be complete, including
                all necessary supporting documentation, and that the applicant has been
                deemed an appropriate and qualified addition to the Medical Staff, then
                the Committee shall conduct a vote and either (1) recommend membership
                and/or requested privileges be granted to the applicant, effective
                immediately, or (2) refer the application and request for delineation of
                clinical privileges back to the Credentials Committee for completion of the
                regular appointment process as set forth in VIII.C. herein.

                There must be a majority vote in favor of recommending that membership
                and/or requested privileges be granted in order for further expedited
                review by the Executive Committee of the Hospital Board of Trustees. If
                the vote is less than a majority in favor of such a recommendation, the
                application and request for delineation of clinical privileges shall be
                referred back to the Credentials Committee for completion of the regular
                appointment process as set forth in VIII.C. herein.

                If the vote of the Committee has been unanimous in favor of
                recommending that membership and/or requested privileges be granted,
                that recommendation shall be forwarded to the Executive Committee of
                the Hospital Board of Trustees, for timely review and consideration within
                seven (7) days following receipt of the decision of the Medical Executive
                Committee. In the event that the Executive Committee of the Hospital
                Board of Trustees adopts the recommendation of the Medical Executive
                Committee, then membership and the requested privileges shall be
                granted, effective immediately.



Lake Health Medical Staff Bylaws             16                              October 26, 2009
                In the event that the Executive Committee of the Hospital Board of
                Trustees decides not to adopt the recommendation of the Medical
                Executive Committee, then such decision shall constitute an adverse
                action which will be governed by the Fair Hearing Plan set forth in Article
                XII and which will be referred, within seven (7) days, to the Joint Review
                Committee, as mandated in XII.B.

  IX. DETERMINATION OF CLINICAL PRIVILEGES

        A. Exercise of Clinical Privileges
           Every member of the Medical Staff or the Allied Practitioner Staff
           Providing direct clinical services at the Hospital by virtue of Staff
           membership shall, in connection with such practice and except as provided in
           G. of this article, be entitled to exercise only those clinical privileges or
           provide patient care services as are specifically granted pursuant to the
           provisions of these Bylaws and the Staff Rules and Regulations.

        B. Delineation of Privileges in General
           1. Requests
              Each application for appointment and reappointment to the Staff must
              contain a request for the clinical privileges desired by the applicant. A
              request by a Staff member for additional privileges must be supported by
              documentation of training and/or experience.
           2. Basis for Privileges Determination
              Requests for clinical privileges shall be evaluated on the basis of the
              practitioner’s education, training, experience and demonstrated
              competence and judgment. The bases for privileges determinations to be
              made in connection with periodic reappointment or otherwise shall include
              observed clinical performance, whether the frequency of exercise of
              clinical privileges is sufficient to indicate current proficiency, and the
              documented results of the quality/utilization management activities
              required by these Bylaws. Privileges determinations shall also be based
              on pertinent information concerning clinical performance obtained from
              other sources including, but not limited to, other health care facilities,
              health maintenance organizations, preferred provider organizations, or
              health care facility where a practitioner exercises clinical privileges. This
              information shall be added to and maintained in the Staff file established
              for a Staff member, which file shall be available for review by the Staff
              member during normal business hours.
           3. Procedure
              All requests for clinical privileges shall be processed pursuant to the
              procedures outlined in Article VIII. C.

        C. Special Conditions for Dental Privileges
           Requests for clinical privileges from dentists shall be processed in the manner
           specified in IX. B.1. Surgical procedures performed by dentists shall be under
           the supervision of the Chairman of the Department of Surgery. All dental



Lake Health Medical Staff Bylaws             17                             October 26, 2009
            patients shall receive the same basic medical appraisal as patients admitted to
            other surgical services. A physician member of the Staff shall co-admit any
            patients whom a dentist requests to be admitted, and 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 on the total health status of the patient.
            The dentist is responsible for the dental care of the patient, including the
            dental history and examination, discharge summary, and all other appropriate
            elements of the patient’s record. Except in the event of an emergency, the
            responsible physician member of the Staff shall be identified prior to the
            admission of the patient for surgery to be performed by a dentist member of
            the Staff.

        D. Special Conditions for Podiatric Privileges
           1. Admissions
              Podiatrists who are members of the Medical Staff may, according to their
              medical staff privileges, independently admit patients solely for the
              purpose of receiving podiatric services. It is the responsibility of the
              podiatrist to make sure a patient is medically cleared for surgery. If the
              patient requires additional non-podiatric services, the podiatrist must
              request a consult with a member of the hospital’s medical staff who is an
              M.D. or D.O. and who will provide non-podiatric treatment.
           2. Surgery
              Surgical procedures performed by podiatrists will be under the overall
              supervision of the Chair of the Department of Surgery or his/her designee.
           3. Medical Appraisal
              All patients admitted for podiatric care in the Hospital by a podiatrist will
              receive the same basic medical appraisal as patients admitted to other
              services. The podiatrist shall provide a history and physical in accordance
              with guidelines in the Administrative policy, H-11-1, and all podiatrists
              performing history and physicals shall document training in these
              procedures.

                If the patient requires additional non-podiatric services, the podiatrist must
                request a consult with a member of the hospital’s medical staff who is an
                M.D. or D.O. Where a dispute exists regarding proposed treatment
                between a physician member and podiatrist based upon medical or
                surgical factors outside of the scope of licensure of the podiatrist, the
                treatment will be suspended insofar as possible while the dispute is
                resolved by the appropriate department, division, or section.

        E. Special Conditions for Psychologists
           Requests for clinical privileges from psychologists shall be processed in the
           manner specified in IX.B-1. Procedures performed by psychologists shall be
           under the supervision of the Chairman of the Department of Medicine. All
           psychological patients shall receive the same basic medical appraisal as
           patients admitted to other medical services. The working relationship
           between the physician involved in any patient’s treatment and the



Lake Health Medical Staff Bylaws              18                               October 26, 2009
            psychologist involved in cases when psychological treatment is being offered
            shall be a collaborative relationship. Psychologists may co-admit patients
            with the collaboration of a physician. Psychologists are independent
            practitioners within the scope of their licensure and privileges. 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. Except in the event of an emergency, the responsible
            physician shall be identified prior to the admission of the patient. The
            psychologist is responsible for the psychological care of the patient, including
            the psychological history and examination, discharge summary, and all other
            appropriate elements of the patient’s record.

        F. Special Conditions for Telemedicine Practitioners
           Prior to a Practitioner providing telemedicine services (including the
           rendering of a diagnosis or other provisions of clinical treatment) to patients
           of Lake Health, the practitioner must be appropriately credentialed and
           granted appropriate privileges by the Hospital. Such Practitioner may be
           credentialed in accordance with Article IV. B, or at the Hospital’s discretion,
           the Hospital may rely upon credentialing information (including any
           supporting documentation required by Hospital) supporting and evidencing
           the Practitioner’s current medical staff appointment at a JCAHO accredited
           facility provided that such documentation is accompanied by a positive
           recommendation from the Medical Executive Committee. Delineation of
           privileges for the provision of telemedicine services shall be in accordance
           with this Article.

        G. Temporary Privileges
           1. Circumstances
              Upon the written concurrence of the chairman of the department in which
              the privileges will be exercised, the President of the Staff, and the
              President of the Hospital, temporary privileges may be granted in the
              following circumstances:

                a. New Physicians
                   Upon receipt of completed application with required documentation
                   and the review and approval by the Credentials Committee; and there
                   is a delay in the department meeting review, new physicians may
                   receive temporary privileges.

                b. Care of Specific Patients:
                   Upon receipt of a written request, an appropriately licensed
                   practitioner, who is not an applicant for membership, when clinical
                   expertise is not available, may be granted temporary privileges for the
                   care of one or more specific patients. In no instance may privileges be
                   granted for a practitioner for the care of more than ten (10) patients in
                   a time period limited to six months.




Lake Health Medical Staff Bylaws             19                              October 26, 2009
                c. Locum Tenens:
                   Upon receipt of a completed application form which indicates that
                   such practitioner meets the basic qualifications for membership,
                   including board certification, as set forth within Article IV. Section B.,
                   an appropriately licensed practitioner who is serving as a locum tenens
                   physician for a member of the Staff, may, without applying for
                   membership on the Staff, be granted temporary privileges for a period
                   not to exceed ninety (90) days. Privileges extended pursuant to this
                   section shall automatically expire upon the expiration of the
                   practitioner’s service as a locum tenens physician.

            2. Conditions for Temporary Privileges
               Temporary privileges shall be granted only when the information available
               reasonably supports a favorable determination regarding the requesting
               practitioner’s qualifications, current competence and judgment to exercise
               the privileges requested, and only after the practitioner has provided
               evidence of professional liability insurance coverage, current state
               licensure, current DEA registration and current TB status, all temporary
               privileges are granted under the supervision of the Chairman of the
               Department.

            3. Before temporary privileges are granted, the practitioner must
               acknowledge in writing that he/she has received and read the Medical
               Staff Bylaws and Staff Rules and Regulations, and agrees to be bound by
               the terms thereof, in all matters relating to temporary privileges, and to
               observe all of the basic responsibilities of Medical Staff membership as set
               forth within Article IV. Section C.

            4. Time Limits
               Temporary privileges may be granted for a limited period of time, not to
               exceed 120 days, by the CEO upon recommendation of either the
               applicable clinical department chairman or the President of the Medical
               Staff.

            5. Termination
               On the discovery of any information, or the occurrence of any event of a
               professionally questionable nature, pertinent to a practitioner’s
               qualifications or ability to exercise any or all of the temporary privileges
               granted, the department chairman responsible for supervision, or the
               President of the Hospital, after consultation with the department chairman
               responsible for supervision, or the President of the Medical Staff, may
               terminate any or all of such practitioner’s temporary 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 suspensions
               under Article XI. B. In the event of any such termination, the
               practitioner’s patients then in the Hospital shall be assigned to another
               physician by the department chairman responsible for supervision. The



Lake Health Medical Staff Bylaws             20                               October 26, 2009
                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.

        H. Residents
           1. The Senior Vice President of Medical Affairs should consult with the
              chairman of the residency program and determine what the scope of
              practice expectations are for each year of the program and for each
              resident.
           2. For each medical resident the facility must document the following
              information:
              a. Verification of the license expiration date if the resident is a licensed
                  physician;
              b. The year of residency in which they are enrolled;
              c. A statement from the medical residency program director attesting to
                  the resident’s ability to perform based on the criteria the program has
                  defined.
              d. Documentation of malpractice coverage.
              e. If the resident is not a licensed physician, then their scope of practice
                  must be determined by the individual(s) providing supervision.
              f. Documentation of orientation with mandatory training in Blood Borne
                  Pathogens HIPAA Compliance, Environment of Care and a TB Test.
           3. Copies of each resident’s formal performance review from sponsoring
              program on file by supervising physician in the Lake Health Medical Staff
              Office. The quality data shall be reviewed by the appropriate Department
              and the MEC.

        I. Medical Students & Allied Health Professional Students & Others
           Students are not privileged at Lake Health; however, they may accompany a
           physician in conjunction with a mentorship program.

        J. Emergency Privileges
           For the purposes of this Section, an “emergency” is defined as a situation in
           which there is an imminent risk of serious or permanent harm, or of death, to a
           patient, and any delay in administering treatment would add to that risk. In
           the case of an emergency, any practitioner, to the degree permitted by his
           license, regardless of department, 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 document in
           the patient’s medical record the circumstances of the emergency treatment.




Lake Health Medical Staff Bylaws            21                              October 26, 2009
        K. Disaster Privileges
           1. In the event of a disaster, non-member physicians may volunteer their
              services. Verification of licensure and identification by viewing the
              physician’s medical license and driver’s license/photo identification will
              be considered adequate. The physician’s name and medical license
              number shall be documented in the Medical Record.
           2. In such instance, the Lake Health Medical Staff Policy Plan for Disaster
              Privileging will be followed (approved by MEC, March 24, 2003). After
              the disaster is over, full verification as in the normal credentialing process
              will be completed.




Lake Health Medical Staff Bylaws             22                              October 26, 2009
   X. REAPPOINTMENT AND RECREDENTIALING
      A. Requests for Reappointment
         All requests for reappointment to the Staff shall be submitted to the Staff
         Office on a form prescribed by the Credentials Committee and provided by
         the President of the Hospital at least 90 days prior to the expiration of the
         member’s current term of appointment.

        B. Applicant’s Responsibilities
           The applicant shall have the responsibility to provide adequate and accurate
           information with respect to each of the items requested on the reappointment
           form, and to submit any additional information. Information requested shall
           include:
           1. Requirements for Reappointment
               a. Copy of current Ohio license, which will be verified through primary
                  source.
               b. Copy of current DEA certificate (if applicable)
               c. Copy of face sheet of professional liability insurance coverage
               d. Staff member must inform in regard to any previous revocations,
                  limitation of medical licensure, medical staff privileges, medical staff
                  membership, or DEA license or the voluntary/involuntary
                  relinquishing of any of the above since the last appointment.
               e. Staff member must inform in writing of any final judgments or
                  settlements arising out of a medical liability action in the past two
                  years.
               f. Staff member must inform in writing of any convictions or felonies
                  within the past two years.
               g. At least one letter of recommendation from a professional peer.
               h. Proof that Staff member has met the continuing medical education
                  requirements in accordance with the laws of the State of Ohio in effect
                  at the time of his/her last license renewal, and that the educational
                  activities relate, at least in part, to the privileges previously granted or
                  to additional privileges being sought by the staff member.
               i. Additional information may be requested.

        C. Criteria for Reappointment
           Evaluation for reappointment will be based on competence, character, ability
           to work cooperatively and effectively with other physicians and employees of
           the hospital, ethics and other qualifications, as determined from a review of
           the reappointment form, quality assessment, utilization review and any other
           disciplinary actions including information from the National Practitioner Data
           Bank and the State Medical Board of Ohio.

            In addition, the medical staff departments will also evaluate the competence of
            their practitioners through selected quality criteria identified by their
            departments. This process will occur on an ongoing basis with data review
            (per Medical Staff Policy MS-27-1).




Lake Health Medical Staff Bylaws              23                               October 26, 2009
        D. The completed reappointment form will be reviewed by the department
           chairman. Within sixty (60) days, the Department Chairperson will then make
           reappointment recommendations to the Medical Executive Committee, which
           may thereafter conduct such further investigation as it deems appropriate. The
           Medical Executive Committee shall then forward its recommendations with
           respect to the application to the Board of Trustees. The final decision
           regarding reappointment and recredentialing will be made by the Board of
           Trustees.
        E. Request for continuation of privileges will be part of the reappointment
           process and will be based on information that may be appropriate.
        F. Reappointment to the Medical Staff shall be for a period no longer than two
           (2) years. In the instance that a practitioner may have a pending disciplinary
           action, and the reappointment expires in the interim, temporary privileges may
           be granted, if requested, on a time-limited basis until the fair hearing process
           is completed.




Lake Health Medical Staff Bylaws            24                              October 26, 2009
  XI. CORRECTIVE ACTION
        A. Routine Corrective Action
           1. Criteria for Initiation
              Whenever the activities or professional conduct of any practitioner are
              believe to be 1) detrimental to the care or safety of a patient or any
              other person in the Hospital; 2) contrary to the Medical Staff Bylaws
              and Rules or 3) below applicable professional standards, a request for
              an investigation against such member may be initiated by any officer
              of the Staff, by the Chairman of any department, the President of the
              hospital, or by the Board of Trustees. Initiation of corrective action
              pursuant to this section does not prelude imposition of summary
              suspension as provided for in Article XI.B, nor does it require the prior
              imposition of such a suspension.
                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 practitioner who is the subject of the request for
                    corrective action shall be notified by certified mail or written notice in
                    person from the Medical Executive Committee within 48 hours of
                    receipt by the Medical Executive Committee of the request for
                    corrective action. The President of the Medical Staff shall notify the
                    President of the Hospital in writing within seven (7) days of all
                    requests for corrective action received by the Medical Executive
                    Committee and shall continue to keep the President of the Hospital
                    fully informed of all action taken in connection therewith.

                    The Medical Executive Committee and each and every committee
                    designated or established by the Medical Executive Committee to
                    investigate and make recommendations with respect to requests for
                    corrective action shall be termed a “professional review body” as
                    defined in the definitions section of these Bylaws.

                    The activities of each professional review body shall be a
                    “professional review activity” as defined in the definitions section of
                    these Bylaws.
                    The action or recommendation of each professional review body shall
                    be a “professional review action” as defined in the definitions section
                    of these Bylaws.
                3. Investigation
                    After consideration of the request, the Medical Executive Committee,
                    shall within fourteen (14) days either reject the request and report the
                    reasons for its decision to the President of the Hospital, or forward the
                    request either to the Chairman of the department of which the
                    practitioner is a member or in which the practitioner has been



Lake Health Medical Staff Bylaws              25                               October 26, 2009
                    credentialed, or to an Ad Hoc Committee appointed by the Medical
                    Executive Committee, to conduct an investigation. The Ad Hoc
                    Committee will be composed of active members of the Medical Staff.
                    None of these members shall be in direct economic competition with
                    the individual under investigation. The practitioner who is under
                    investigation shall have the opportunity to meet with the department
                    chairman or the Ad Hoc Committee within 14 days of receipt of
                    written notification. Any such appearance shall be informal in nature
                    and not constitute a hearing. Within thirty (30) days after the receipt
                    of the request, the department chairman or the Ad Hoc Committee
                    shall forward a written report of the investigation to the Medical
                    Executive Committee.

                4. Medical Executive Committee
                   Within fourteen (14) 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 or reprimand,
                   c. Recommending terms of probation or requirements of consultation,
                   d. Recommending suspension or revocation of Staff appointment,
                   e. Recommending referral to an Impaired Physician Program.
                   f. Recommending the satisfaction of certain educational, treatment or
                       counseling requirements.

                5. Board Option
                   When the Medical Executive Committee, after review of the
                   investigative report, determines that no corrective action be taken, the
                   President of the Medical Staff shall report such determination to the
                   Board. The Board, in its discretion, may accept the recommendation
                   of the Medical Executive Committee or initiate further action
                   according to its bylaws.

                6. Procedural Rights
                   Any action by the Medical Executive Committee pursuant to XI.A.
                   4.c, d, e or f, or any combination of such actions, or action by the
                   Board pursuant to Article XI, shall entitle the Staff member to the
                   procedural rights as provided in Article XII (Fair Hearing Plan).

            B. Summary Suspension
               1. Criteria and Initiation
                  Whenever the conduct of a practitioner requires that prompt action be
                  taken to protect the life or well being of any patient or to reduce the
                  substantial likelihood of immediate injury or damage to the health or
                  safety of any patients, employees or other persons present in the
                  Hospital, or whenever the conduct of the practitioner materially
                  disrupts the operation of any department or unit of the Hospital, the
                  Medical Executive Committee, or the Board of Trustees, or the



Lake Health Medical Staff Bylaws             26                              October 26, 2009
                    President of the Medical Staff, shall have the authority to suspend
                    summarily the Staff appointment of all or any portion of the clinical
                    privileges, of such staff member. The body which imposes the
                    suspension shall notify the President of the Medical Staff, who shall
                    notify the President of the Hospital of such action. Such summary
                    suspension shall become effective immediately upon imposition, and
                    the President of the Hospital shall promptly give special notice of the
                    suspension to the practitioner, and notice to the Medical Executive
                    Committee and Board of Trustees.
                2. Medical Executive Committee Action
                    As soon as reasonably possible, but no later than one (1) week, after
                    such summary suspension, a meeting of the Medical Executive
                    Committee shall be convened to review and consider the action taken.
                    Within three days after this meeting, the Medical Executive
                    Committee shall recommend to the Joint Review Committee (as
                    defined in Article XII. B2) modification, continuation or termination
                    of the terms of summary suspension.
                3. Procedural Rights
                    Unless there is immediate termination of the suspension by the Joint
                    Review Committee and cessation of all further corrective action, or in
                    the event that the Medical Executive Committee fails to meet within
                    the time prescribed in Article XI, the practitioner shall be entitled to
                    the procedural rights as provided in Article XII. The terms of the
                    summary suspension either as originally stated, or modified by the
                    Medical Executive Committee, shall remain in effect pending a final
                    decision by the Board. In the event of a requested Hearing pursuant to
                    Article XII, the terms of the summary suspension, as continued or
                    modified by the Joint Review Committee, shall remain in effect
                    pending a final decision by the Board.

            C. Automatic Suspension and Revocation
               1. License
                  If a practitioner’s license to practice his/her profession in the State of
                  Ohio is revoked, voluntarily relinquished, or not renewed, for any
                  reason, such practitioner’s membership and clinical privileges shall
                  immediately be revoked and terminated. In the event that a
                  practitioner’s license to practice his/her profession in the State of Ohio
                  is suspended, such practitioner’s membership and clinical privileges
                  shall immediately be suspended, indefinitely, until such time as
                  practitioner’s license is reinstated in full.

                2. Drug Enforcement Administration (DEA) Number
                   A practitioner whose DEA number is not currently active shall
                   immediately and automatically be suspended from the Medical Staff,
                   until such time as the practitioner’s DEA number is reinstated in full.




Lake Health Medical Staff Bylaws             27                               October 26, 2009
                 3. Conviction of a Felony
                    In the event that a practitioner is convicted of a felony in any court of
                    the United States, either federal or state, upon exhaustion of appeals,
                    the practitioner’s membership and clinical privileges shall be
                    automatically revoked. Such revocation pursuant to this provision
                    shall not preclude the practitioner from subsequently applying for
                    Medical Staff membership and appointment.

            D. Continuity of Patient Care
               Upon the imposition of summary suspension or the occurrence of an
               automatic suspension, the President of the Staff or the Chairman of the
               department in which the suspended practitioner is assigned, shall provide
               for alternative coverage for the patients of the suspended practitioner’s
               patients in the Hospital. The wishes of the patient shall be considered,
               where feasible, in choosing a substitute practitioner to the extent necessary
               to safeguard the patient.

 XII. FAIR HEARING PLAN
      A. DEFINITIONS
         The following definitions, in addition to those stated in other provisions of the
         Medical Staff Bylaws, shall apply to the provisions of this Fair Hearing Plan:

            1.      APPELLATE REVIEW COMMITTEE means the group designated
                    pursuant to Article XII. E-4 to hear a request for appellate review
                    properly filed and pursued by a practitioner.
            2.      HEARING COMMITTEE means the Panel, the Arbitrator or the
                    Hearing Officer appointed pursuant to Article XII. B-3 to hear a
                    request for an evidentiary hearing properly filed and pursued by a
                    practitioner.
            3.      PARTIES means the practitioner who requested the hearing or
                    appellate review and the body upon whose adverse action a hearing or
                    appellate review request is predicated.
            4.      PRACTITIONER means an individual who has been granted
                    membership or is an applicant to the Medical Staff.
            5.      JOINT REVIEW COMMITTEE means the group designated in
                    accordance with Article XII. B-2 to review any recommendation or
                    action enumerated in Article XII B-1 prior to the issuance of notice to
                    the practitioner.

        B. INITIATION OF HEARING
           1. Recommendations or Actions
              The following recommendations or actions shall be deemed actual or
              potential adverse actions and shall entitle the practitioner affected thereby
              to a Fair Hearing:
              a. Denial of initial staff appointment except when the denial is based
                  upon a practitioner’s failure to meet the basic qualifications for
                  membership, as identified in Article IV. B. or upon a failure to provide




Lake Health Medical Staff Bylaws               28                              October 26, 2009
                     information or documentation required for the processing of the
                     application for appointment.
                b.   Denial of reappointment, except when the denial is based upon a
                     failure to meet basic qualifications for reappointment.
                c.   Any suspension of Staff appointment and/or clinical privileges
                d.   Revocation of Staff appointment
                e.   Denial of requested modification of Staff category
                f.   Reduction in Staff category
                g.   Limitation of admitting prerogatives
                h.   Denial of requested department assignment
                i.   Denial of requested clinical privileges
                j.   Reduction in clinical privileges
                k.   Limitation of clinical privileges
                l.    Revocation of clinical privileges
                m.   Involuntary imposition of consultation, co-admission or monitoring
                     requirements (excluding monitoring incidental to Provisional Status as
                     provided in Article V. B-2) or involuntary imposition of requirements
                     of additional education or personal counseling.

                2. Review by Joint Review Committee
                   Whenever an adverse recommendation, action or proposed action
                   identified in Article XI1. B-1 other than a summary suspension, is
                   proposed, prior to any official notice to the practitioner of such
                   recommendation, action or proposed action, the person or body
                   making such recommendation or taking or proposing such action shall,
                   within seven (7) days, arrange for a meeting of the Joint Review
                   Committee to review the proposed recommendation or action.

                     Whenever a summary suspension is imposed, the person or body
                     imposing the summary suspension shall arrange for immediate official
                     notice to the practitioner and shall, within seven (7) days, thereafter
                     arrange for a meeting of the Joint Review Committee to review the
                     summary suspension. However, the summary suspension shall be
                     effective immediately upon its imposition and notice to the
                     practitioner, and shall continue in effect pending the meeting of the
                     Joint Review Committee and any subsequent hearing and appellate
                     review.

                     The Joint Review Committee shall consist of the President of the
                     Medical Staff, the Chairpersons of the Board of Trustees, and the
                     President of the Hospital, or their designees.

                     The Joint Review Committee shall consider the recommendation,
                     action or proposed action and shall determine whether or not there
                     exists a sufficient factual basis for the proposed action or
                     recommendation or summary suspension, and whether or not there
                     exist any factors which might mandate a modification of the proposed
                     action or recommendation or summary suspension.



Lake Health Medical Staff Bylaws              29                              October 26, 2009
                    If the Joint Review Committee determines that there exists a sufficient
                    factual basis for the recommendation, action, proposed action or
                    summary suspension, the Joint Review Committee shall so notify the
                    President of the Hospital who shall promptly issue to the practitioner
                    official notice, as specified in Article XI. of the adverse
                    recommendation or action. In the instance of summary suspension, no
                    additional official notice to the practitioner shall be required, as
                    official notice shall have been previously issued to the practitioner
                    immediately upon the imposition of the summary suspension.

                    If the Joint Review Committee determines that there exists an
                    insufficient basis for the recommendation, action, proposed action or
                    summary suspension, or that there exist factors which mandate a
                    modification of the recommendation, action, proposed action or
                    summary suspension, the Joint Review Committee shall issue a report
                    of its decision, together with a statement of the basis for such decision,
                    to the person or body which has made the recommendation or taken
                    the action or imposed the summary suspension. The decision of the
                    Joint Review Committee shall be conclusive. In the event of a
                    modification of the recommendation, action, proposed action, or
                    summary suspension, the Joint Review Committee shall also direct
                    the President of the Hospital to promptly issue to the practitioner
                    official notice as specified in Article XI. I, of the adverse
                    recommendation, action or proposed action as modified, or of any
                    termination or modification which may have been made with respect
                    to a summary suspension previously imposed.

                3. Notice of Recommendation of Adverse Action
                   A practitioner against whom a recommendation has been made or
                   against whom an adverse action has been taken pursuant to Article XI.
                   H. shall promptly be given official notice by the President of the
                   Hospital.

                    The notice shall state:
                    a. That a recommendation has been made or that an action has been
                       taken or proposed to be taken against the practitioner, together
                       with a description of the recommendation or any subsequent
                       modification of the proposed action;
                    b. The basis for the recommendation, action or proposed action,
                       including the acts or omissions with which the member is charged
                       and a list of medical records in question, where applicable;
                    c. That the practitioner has the right to request a hearing on the
                       recommendation, action or proposed action, and has thirty (30)
                       days from the receipt of the notice of the recommendation, action
                       or proposed action during which to request a hearing;
                    d. That, in the hearing, the practitioner involved has the right:




Lake Health Medical Staff Bylaws              30                               October 26, 2009
                        i.         To representation by an attorney or other person of the
                                   practitioner’s choice;
                        ii.        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;
                        iii.       To call, examine and cross-examine witnesses;
                        iv.        To present evidence determined to be relevant by the
                                   Presiding Officer, regardless of its admissibility in a court
                                   of law, and;
                        v.         To submit a written statement at the close of the hearing.

                4. Request for Hearing
                   A practitioner shall have thirty (30) days following receipt of notice of
                   such recommendation, action or proposed action, during which to
                   request a hearing. The request shall be in writing and addressed to the
                   President of the Medical Staff, with a copy forwarded to the President
                   of the Hospital. In the event that a practitioner does not request a
                   hearing within the thirty (30) day period specified, or fails to request a
                   hearing in the manner specified, the practitioner shall be deemed to
                   have waived any right to a hearing or appellate review, and shall be
                   deemed to have accepted the recommendation or proposed action.

        C. HEARING PREREQUISITES
             1. Notice of Hearing
                Upon receipt of a timely request for a hearing, and, following receipt
                of a determination by the Joint Review Committee, the President of the
                Medical Staff shall schedule and arrange for a hearing, and within
                fifteen (15) days following receipt of the request for a hearing, shall
                send the practitioner official notice of the time, place and date of the
                hearing, together with a list of names and addresses of any persons
                who, at that time, are expected to be called as witnesses to give
                testimony or other evidence on behalf of the Medical Staff.

                  2. Time for Hearing
                    Unless extended by the Hearing Officer for good cause, or upon
                    agreement of the parties with a written waiver of this time limitation
                    by the practitioner, the date for commencement of the hearing shall be
                    set not sooner than thirty (30) days, and not later than sixty (60) days
                    from the date of receipt by the President of the Medical Staff of the
                    request for a hearing. However, when the request for a hearing is
                    received from a practitioner under summary suspension, the hearing
                    shall be held as soon as arrangements may reasonably be made, but the
                    date for commencement of the hearing shall be set not later than forty-
                    five (45) days from the date of receipt of the request for a hearing.

                3. Failure to Appear or Proceed at Hearing
                   The failure of the practitioner to appear or to proceed at the hearing,
                   without good cause shown, shall be deemed a voluntary acceptance by



Lake Health Medical Staff Bylaws                 31                              October 26, 2009
                    the practitioner of the recommendation or the proposed action which
                    occasioned the hearing, and a waiver of the right to any further hearing
                    or appellate review.

               4. Postponements and Extensions
                  Once a request for a hearing has been received and a hearing scheduled,
                  postponements and extensions beyond the time limits set herein shall be
                  permitted by the Hearing Committee Arbitrator or Hearing Officer, at
                  the discretion of the Hearing Committee Arbitrator, or Hearing Officer,
                  but only upon a showing of good cause.

        D. HEARING PROCEDURE
           1. Appointment of Hearing Committee
                 Once the hearing requested by a practitioner has been scheduled, the
                 President of the Medical Staff shall appoint a Hearing Committee to
                 consider evidence and render a decision at the hearing. The Hearing
                 Committee shall consist of at least three (3) members of the Active or
                 Courtesy Staff, none of whom is in direct economic competition with
                 the practitioner. One of the members of the Hearing Committee shall
                 be designated as Chairperson.

                    In the alternative, the President of the Medical Staff, after consultation
                    with the Medical Executive Committee, may appoint, in place of a
                    Hearing Committee, an Arbitrator mutually acceptable to the
                    practitioner and to the Medical Executive Committee, or a single
                    Hearing Officer who is an Arbitrator or member of the Active or
                    Courtesy Staff, and who is not in direct economic competition with the
                    Practitioner.

                    A member of the Active or Courtesy Staff shall not be disqualified
                    from serving on a Hearing Committee or as a Hearing Officer solely
                    because such member has heard the allegations or has knowledge of
                    the facts or circumstances which led to the recommendation or
                    proposed action. However, no member shall serve on a Hearing
                    Committee or as a Hearing Officer if that member served on the
                    Executive Committee when the Executive Committee made the
                    recommendation or proposed the action, which occasioned the hearing,
                    or served on the Joint Review Committee which considered the
                    recommendation or proposed action.

            2. Presiding Officer
                  In addition to the Hearing Committee, the President of the Medical
                  Staff shall appoint a Presiding Officer, who shall be an attorney
                  actively engaged in the practice of law or affiliated with an academic
                  institution.

                    The Presiding Officer shall act to maintain decorum and to assure that
                    all participants in the hearing have a reasonable opportunity to present



Lake Health Medical Staff Bylaws              32                               October 26, 2009
                    relevant oral and documentary evidence. The Presiding Officer shall
                    rule upon, decide, and advise the Hearing Committee or Arbitrator or
                    Hearing Officer on all procedural matters and evidentiary issues which
                    may arise during the hearing.

                    The Presiding Officer shall be impartial and shall not act as an
                    advocate for the practitioner, the Medical Staff, the Hospital or the
                    Board of Trustees.

                    If requested by the Hearing Committee, the Presiding Officer may
                    participate in the Hearing Committee’s deliberations, and provide legal
                    advice during such deliberations, but shall not be entitled to vote.

            3. Rights of Parties
                  During the hearing, each of the parties shall have the right to:
                  a. Be represented by an attorney or other person of the party’s choice;
                  b. Call, examine and cross-examine witnesses on any matter relevant
                      to the issues.
                  c. Present evidence and introduce exhibits determined to be relevant
                      by the Presiding Officer, regardless of their admissibility in a court
                      of law;
                  d. Impeach any witness;
                  e. Rebut any evidence;
                  f. Record the hearing by use of a court reporter or an electronic
                      recording device, and
                  g. Submit a written statement at the close of the hearing;
                  h. Receive a written recommendation of the Hearing Committee
                      Arbitrator or Hearing Officer, including a statement of the basis for
                      the recommendation, following deliberation and decision.
                If the practitioner who requested the hearing does not testify in his or her
                own behalf, he or he may be called and examined as if under cross-
                examination.

            4. Pre-Hearing Procedure
               a. Each party shall give notice, at least fifteen (15) days prior to the
                  hearing, of an intention to be represented by counsel, and of the name,
                  address and telephone number of such counsel.
               b. Further, at least fifteen (15) days prior to the hearing, the practitioner
                  or the practitioner’s counsel shall furnish a written list of the names
                  and addresses of all witnesses who may be called to give testimony or
                  other evidence in support of the practitioner at the hearing. If such
                  witnesses are expected to give expert opinion testimony, the
                  practitioner or the practitioner’s counsel shall also provide the Medical
                  Executive Committee or its counsel, at the time of furnishing the
                  witness list, with either a written report prepared by such expert, or a
                  written summary of the opinions expected to be offered by such
                  expert.




Lake Health Medical Staff Bylaws              33                              October 26, 2009
                c. While neither party shall have a legal right to the discovery of
                   documents or other evidence of the opposing party in advance of the
                   hearing, the Presiding Officer shall confer with both parties, or their
                   counsel, prior to the hearing and shall encourage a mutual exchange of
                   documents and other evidence expected to be presented by the parties
                   at the hearing.
                d. It shall be the duty of each of the parties, or their counsel, to notify the
                   Presiding Officer of any existing or anticipated procedural or
                   substantive disputes or issues, as far in advance of the hearing as
                   possible, so that decisions concerning such disputes or issues may be
                   made in advance of the hearing. Objectives to any pre-hearing
                   decision of the Presiding Officer may be stated at the time of
                   commencement of the hearing.
            5. Miscellaneous Rules of Procedure and Evidence
                a. The hearing shall not be conducted strictly according to rules of law
                   relating to the examination or presentation of evidence. Any relevant
                   evidence shall be admitted, if, in the judgment of the Presiding Officer,
                   it is the sort of evidence upon which responsible persons customarily
                   rely in the conduct of serious affairs, regardless of the admissibility of
                   such evidence in a court of law.
                b. Each party shall, prior to or during the hearing, be entitled to
                   submit memoranda concerning any issue of law or fact, and such
                   memoranda shall become part of the Hearing record. The Presiding
                   Officer may require one or both parties to prepare and submit to him
                   or her, written statements of their positions on the issues, prior to,
                   during, or after the hearing.
                c. 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 lawfully authorized to administer such oath. The Hearing
                   Committee Arbitrator or Hearing Officer shall be entitled to consider
                   any pertinent material contained in any medical record or in any
                   Credentials Committee file for the practitioner, or other file in the
                   Hospital, and all other information which may be considered pursuant
                   to these Bylaws, in connection with applications for appointment or
                   reappointment to the Medical Staff and for clinical privileges.

            6. Burden of Presenting Evidence and Proof
               At the hearing, unless otherwise determined for good cause, the Medical
               Executive Committee shall have the initial duty to present evidence in
               support of its recommendation or proposed action. The practitioner shall
               be obligated to present evidence in response to the evidence of the
               Executive Committee. The practitioner shall, thereafter, bear the burden
               of persuasion of the Hearing Committee Arbitrator or Hearing Officer by a
               preponderance of the evidence, that the recommendation or proposed
               action is arbitrary, capricious or unreasonable, or without any basis in fact.




Lake Health Medical Staff Bylaws              34                                October 26, 2009
            7. Recesses, Adjournment and Deliberations
               The Presiding Officer may adjourn the hearing for a period not to exceed
               ten (10) days, and reconvene the hearing without special notice, at such
               times as may be reasonable and warranted, for the purpose of obtaining
               new or additional evidence or consultation, but with due consideration for
               reaching an expeditious conclusion to the hearing. Upon conclusion of the
               presentation of oral and written evidence and the receipt of closing
               arguments, oral or written, if any, the hearing shall be closed.

                The Hearing Committee shall then, or at some convenient time within
                fourteen (14) days following conclusion of the hearing, conduct its
                deliberations outside the presence of the parties. If the hearing is
                conducted by an Arbitrator or Hearing Officer, he or she shall reach a
                decision within fourteen (14) days following the conclusion of the hearing.
                The Hearing Committee Arbitrator or Hearing Officer shall not engage in
                any discussions with any of the parties to the hearing following the
                conclusion of the hearing.

        E. REPORT OF DECISION AND FURTHER ACTION
           Within fourteen (14) days after final adjournment of the hearing, the Hearing
           Committee Arbitrator or Hearing Officer shall make a written report of
           findings and recommendations in the matter, including a statement of the basis
           for the recommendations, and shall forward same, together with the hearing
           record and all other documentation considered, to the Medical Executive
           Committee, to the President of the Hospital, and to the Board of Trustees.
           The President of the Hospital shall transmit a copy of the report to the
           practitioner. The Medical Executive Committee shall review the report and
           submit any comments on the report to the Board of Trustees.


        F. ACTION ON RECOMMENDATIONS AND REPORT
           After receipt of the recommendation and report of the Hearing Committee
           Arbitrator or Hearing Officer, the Board of Trustees shall consider the
           recommendation and report at its next scheduled meeting, and shall affirm,
           modify or reverse the recommendation. The Board of Trustees shall transmit
           a written report of its determination, including a statement of the basis for its
           determination, together with the hearing record, the recommendation and
           report, and all other documentation considered, to the Medical Executive
           Committee and to the President of the Hospital.

            If the determination by the Board of Trustees is a reversal of a
            recommendation of the Hearing Committee Arbitrator or Hearing Officer, and
            is thus favorable to the practitioner, the determination by the Board of
            Trustees shall be a final decision and the matter shall be considered closed.

            If, however, the determination by the Board of Trustees, upholds the
            recommendation of the Hearing Committee or modifies the recommendation
            to the effect that the determination continues to be adverse to the practitioner,



Lake Health Medical Staff Bylaws              35                               October 26, 2009
            then the practitioner shall have the right to request an appellate review by the
            Appellate Review Committee of the Board of Trustees.

            The President of the Hospital shall promptly forward a copy of the
            determination by the Board of Trustees to the practitioner. In the event that
            the determination continues to be adverse to the practitioner, the President of
            the Hospital shall also inform the practitioner of the right to appellate review
            by the Appellate Review Committee of the Board of Trustees, and of the
            mechanism for requesting such appellate review.

        G. INITIATION AND PREREQUISITES OF APPELLATE REVIEW
           1. Request for Appellate Review
              A practitioner shall have ten (10) days following receipt of the
              determination by the Board of Trustees to request an appellate review.
              The request shall be in writing and addressed to the Chairman of the
              Board of Trustees, with a copy forwarded to the President of the Medical
              Staff and to the President of the Hospital. Such request shall be deemed to
              have been made when delivered to the Chairman of the Board of Trustees
              in person or when sent by registered mail to the Chairman of the Board of
              Trustees, properly addressed and postage prepaid. The request may
              include a request for a copy of the record of the Hearing Committee
              Arbitrator or Hearing Officer and all other material, favorable or
              unfavorable, that was considered in making the adverse action or result.

                A practitioner who fails to request an appellate review within the ten (10)
                day period specified, and in the manner specified herein, shall be deemed
                to have waived any right to such review, and shall be deemed to have
                accepted the determination by the Board of Trustees, which shall be
                deemed a final decision.

            2. Notice of Time and Place for Appellate Review Hearing
               Upon receipt of a timely request for appellate review, the Chairman of the
               Board of Trustees shall deliver such request to the President of the
               Hospital and the President of the Medical Staff. The Chairman of the
               Board of Trustees shall promptly schedule and arrange for an Appellate
               Review Hearing which shall be held not less than ten (10) days nor more
               than twenty-one (21) days from the date of receipt of the request; provided
               however, that an Appellate Review Hearing for a practitioner who is under
               a suspension then in effect shall be held as soon as the arrangement for it
               may reasonably be made, but not later that twenty-one (21) days from the
               date of receipt of the request for appellate review. At least ten (10) days
               prior to the Appellate Review Hearing, the Chairman of the Board of
               Trustees shall send the practitioner notice of the time, place and date of the
               Hearing. The time limits for conducting the Appellate Review Hearing
               may be extended by the Appellate Review Committee for good cause.




Lake Health Medical Staff Bylaws              36                              October 26, 2009
            3. The Appellate Review Committee shall be appointed by the Chairman of
               the Board of Trustees, and shall include at least one member of the Board
               of Trustees who is also an active member of the Medical Staff.

        H. APPELLATE REVIEW PROCEDURE

            1.    Nature of Proceedings
                 The proceedings by the Appellate Review Committee shall be in the
                 nature of an appellate review based upon the record of the Hearing before
                 the Hearing Committee, Arbitrator or Hearing Officer and all subsequent
                 determinations and actions thereon. The Appellate Review Committee
                 shall also consider any written statement submitted pursuant to Article
                 XII. H-2 and such other materials as may be presented and accepted
                 pursuant to Article XII. H-5.

            2. Written Statements
               The practitioner seeking the review shall submit a written statement
               detailing the findings of fact, conclusion and procedural matters which he
               or he disagrees, and his or her reasons for such disagreement. This written
               statement may cover any matters raised at any step in the Fair Hearing
               process, and may contain legal arguments of counsel. The statement shall
               be submitted to the Appellate Review Committee through the Chairman of
               the Board of Trustees at least five (5) days prior to the scheduled date of
               the Appellate Review Committee hearing. Copies shall be provided to the
               Medical Executive Committee and the President of the Hospital. A
               written statement in reply may be submitted by the Medical Executive
               Committee or by representatives of the Board chosen by the Chairman of
               the Board. If a reply statement is submitted, the Chairman of the Board
               shall provide a copy thereof to the practitioner prior to the scheduled time
               of the Appellate Review Committee hearing. If the practitioner fails to
               submit such a written statement by the time specified above, the Appellate
               Review Committee may treat such failure as a waiver of Appellate review
               by the practitioner, and the previous action of the Board shall be deemed
               the final action of the Board.

            3. Presiding Officer
               The Chairman of the Appellate Review Committee shall be the Presiding
               Officer. He or he shall determine the order of procedure during the
               review, make all required rulings, and maintain decorum. He or she may
               be assisted by counsel.

            4. Oral Statement
               The Appellate Review Committee, at its sole discretion, may allow the
               parties or their representatives to appear personally and make oral
               statements in favor of their positions. Any party or representatives so
               appearing shall be required to answer questions put to him by any member
               of the Appellate Review Committee.




Lake Health Medical Staff Bylaws             37                             October 26, 2009
            5. Consideration of New or Additional Matters
               New or additional matters or evidence not raised or presented during the
               original hearing and not otherwise reflected in the record, shall be
               introduced at the Appellate Review Committee hearing only under
               unusual circumstances. The Appellate Review Committee, at its sole
               discretion, shall determine whether such matters or evidence shall be
               considered or accepted.

            6. Powers
               The Appellate Review Committee shall have all power granted to a
               Hearing Committee Arbitrator or Hearing Officer and such additional
               powers as are reasonably appropriate to the discharge of its
               responsibilities.

            7. Recesses and Adjournment
               The Appellate Review Committee may recess the review proceedings for
               up to ten (10) days and reconvene the same without additional notice.
               Upon the conclusion of the review of all evidence and written statements,
               as well as oral statements, if allowed, the Appellate Review Committee
               hearing shall be closed. The Appellate Review Committee shall, within
               seven (7) days, conduct its deliberations outside the presence of the
               parties. Upon the conclusion of those deliberations, the Appellate Review
               Committee hearing shall be declared finally adjourned.

            8. Action Taken
               Within seven (7) days of final adjournment, the Appellate Review
               Committee shall issue its report to the Medical Executive Committee and
               to the Board, in which report it shall recommend either that the Board
               affirm, modify or reverse the adverse result or decision of the Board taken
               pursuant to Article XII. G.

        I. FINAL DECISION OF THE BOARD
           Within fourteen (14) days after receipt of the report of the Appellate Review
           Committee, the Board shall render its decision in the matter.

            The President of the Hospital shall send official notice of the Board’s final
            decision, which shall include a statement of the basis for the decision, to the
            practitioner, and shall provide a copy to the President of the Medical Staff.

        J. GENERAL PROVISIONS
           1. Waiver
              If at any time after receipt of official notice of an adverse
              recommendation, action or result, a practitioner fails to make a request or
              appearance or otherwise fails to comply with this Fair Hearing Plan, he
              will be deemed to have consented to such adverse recommendation, action
              or result and to have voluntarily waived all rights to which he 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.



Lake Health Medical Staff Bylaws             38                               October 26, 2009
                If an adverse action is proposed or taken, or an adverse recommendation is
                made, in connection with a practitioner’s application for an initial staff
                appointment or application for reappointment, and the practitioner fails to
                avail himself of rights to which he may have been entitled pursuant to this
                Fair hearing Plan, such practitioner shall not be permitted to file a new
                application for initial staff appointment or reappointment and thereby avail
                himself of rights previously waived.
            2. Number of Reviews
               Notwithstanding any other provision of the Medical Staff Bylaws or of
               this Plan, no practitioner shall be entitled to more than one evidentiary
               Fair Hearing or Appellate Review Committee hearing with respect to an
               adverse recommendation or action.

            3. Extensions
               Stated periods and limits for actions, notices, requests, submissions of
               material and scheduling in Article XII may be extended in unusual
               circumstances upon the agreement of the parties, or, when necessary, by
               the Hearing Committee Arbitrator, Hearing Officer or Appellate Review
               Committee.

            4. Release
               By requesting a Hearing or Appellate Review Committee hearing under
               this Fair Hearing Plan, a practitioner agrees to be bound by the provisions
               of the Medical Staff Bylaws in all matters relating thereto.

        K. REPORTING PROFESSIONAL REVIEW ACTIONS
           1. Reportable Actions
              a. Within fifteen (15) days of:
                    i. A final decision as identified in Article XII. I. of an adverse
                       professional review action against a practitioner;
                   ii. The voluntary surrender of Medical Staff membership or clinical
                       privileges by a practitioner under investigation for possible
                       incompetence or improper professional conduct;
                  iii. The voluntary surrender of clinical privileges or medical staff
                       membership in lieu of conducting an investigation; or
                  iv. Revision to professional review actions previously conducted
                       and reported to the National Practitioner Data Bank;The
                       President of the Hospital shall report the decision, surrender or
                       revision to the State Medical Board of Ohio and to the National
                       Practitioner Data Bank.
                   v. Professional review actions not based on professional
                       competence or conduct will not be reported to the State Medical
                       Board of Ohio or the National Practitioner Data Bank. Actions
                       which are not reportable include:
                  vi. Suspension of practitioner’s clinical privileges or medical staff
                       membership based solely on a failure to complete medical
                       records in a timely manner;



Lake Health Medical Staff Bylaws             39                              October 26, 2009
                     vii. Denial of clinical privileges or medical staff membership based
                          on a closed medical staff or exclusive contract arrangement
                          which would foreclose the practitioner from providing those
                          services within the hospital;
                    viii. Suspension, denial or non-renewal of clinical privileges or
                          medical staff membership due to a failure to obtain or maintain
                          professional liability insurance at a specified level;
                      ix. Reduction, non-renewal or denial of clinical privileges or
                          medical staff membership based on failure to comply with
                          threshold eligibility requirements such as board certification,
                          geographic proximity to the facility, or failure to comply with
                          committee attendance requirements;
                       x. Reduction or non-renewal of clinical privileges or medical staff
                          membership due to a practitioner’s failure to meet new threshold
                          requirements or bylaws requirements; or
                      xi. Voluntary admission into an approved impaired physician
                          program.

            2. Review of Adverse Action Report
               a. The affected practitioner shall be provided an opportunity to review an
                  adverse action report concerning a professional review action for
                  factual accuracy.
               b. Disputes with the affected practitioner with respect to an adverse action
                  report shall be resolved using a fair procedure agreeable to the
                  practitioner and the medical staff.


XIII. OFFICERS
      A. Officers
         1. The officers of the Staff shall be President, Vice President and Secretary-
            Treasurer. They shall be members of the Active Staff, qualified by
            training, experience and demonstrated ability for the position, and shall
            have served on two or more standing Staff committees or as a department
            officer. They shall hold office for two (2) calendar years. No one shall be
            elected to the office of President for more than two (2) consecutive terms.
         2. There shall be a medical staff representative and alternate to the Hospital
            Medical Staff Section of the AMA, who shall be elected by the Medical
            Staff.
      B. Election of Officers
         1. The officers shall be elected by the Active Medical Staff at the Annual
            meeting.
         2. A Nominating Committee (See Article XV.E.) shall publish a list of
            candidates for the offices at least two weeks prior to the Annual meeting.
            Nominations also may be made from the floor at that meeting.
         3. If there are more than two candidates for an office and none receives a
            majority of votes cast, the candidate receiving the fewest votes is omitted
            from each successive slate and voting is repeated until one candidate
            receives a majority of votes cast.



Lake Health Medical Staff Bylaws             40                             October 26, 2009
        C. Term of Office
           1. The officers shall assume their duties on January first, next, and shall hold
              office for two calendar years or until their successors are elected.
        D. Vacancies
           1. The Medical Staff may, by a 2/3 majority vote of the Active Staff, remove
              any medical staff officer for failure to fulfill his/her responsibilities,
              malfeasance while in office, physical or mental infirmity to a degree that
              renders him/her incapable of fulfilling the duties of the office, or conduct
              detrimental to the interests of the hospital and/or medical staff. No such
              removal shall be effective unless and until it has been ratified by the
              Medical Executive Committee and by the Board of Trustees.
           2. Failure of an officer to maintain Active Staff status shall result in
              automatic removal from office, creating a vacancy in that office.
           3. If there is a vacancy in the office of President for any reason, the Vice
              President shall serve out the remaining term.
           4. Vacancy in the Office of Secretary-Treasurer shall be filled by
              Medical Executive Committee action.

        E. Duties of the Officers
           1. Staff officers shall serve on the Joint Conference Committee.
           2. President
              a. The President shall serve as chief administrative officer of the Staff,
                  shall preside at all Staff and Medical Executive Committee meetings,
                  and shall be an ex-officio member, without vote, of all committees
                  except the Nominating Committee. He shall be responsible for the
                  clinical organization of the Hospital and shall have the authority to
                  supervise all clinical work done in the Hospital.
              b. He shall represent the Staff at all meetings of the Board of Trustees.
              c. Should circumstances arise in which enforcement of the Staff Bylaws,
                  Rules and Regulations or any section thereof would be harmful to a
                  patient, the President of the Staff may modify such action and shall
                  report these variances to the Medical Executive Committee and to the
                  Board of Trustees within 72 hours. Either the Medical Executive
                  Committee or the Board of Trustees may overturn the action of the
                  President of the Medical Staff.
              d. He shall appoint members to any standing or special committee of the
                  Staff except the Nominating Committee and the Credentials
                  Committee.
              e. The former President of the Medical Staff shall be an ex-officio of the
                  Medical Executive Committee for a period of two (2) years following
                  his term as President.

            3. Vice President
               a. The Vice President shall assume the duties of the President, upon his
                  request or when absent, or upon resignation, inability or refusal to act,
                  or death of the President. Vacancy which may occur due to
                  progression of the Vice President into the position of President before




Lake Health Medical Staff Bylaws             41                              October 26, 2009
                    term expiration shall be filled, for the remainder of that term, by vote
                    of the Medical Executive Committee.

            4. Secretary-Treasurer
                a. The Secretary-Treasurer shall be responsible for the minutes of Staff
                    meetings, shall attend to official correspondence, and shall perform
                    those functions associated with the office. He shall act as custodian
                    of all funds and properties of the organization.
                b. In conjunction with the President of the Hospital, he shall keep the
                    Staff and the Board of Trustees informed of the various accreditation
                    programs affecting the Hospital.

XIV. STAFF DEPARTMENTS
     A. Organization of Staff Departments
        1. Staff Departments shall include the Departments of Anesthesiology,
           Emergency Medicine, Family Practice, Medicine, Obstetrics and
           Gynecology, Pathology, Radiology and Surgery.
        2. Each Department shall be organized as a separate part of the Staff and
           shall have a chairman who shall be responsible for the overall supervision
           of the clinical and administrative work within his department.

        B. Qualifications, Selection and Tenure of Department Chairman
           1. Each chairman shall be a board certified member of the Active Staff
              qualified by training, experience and demonstrated ability for the position,
              shall have served on two or more Staff committees and shall be elected at
              the last departmental meeting of the year by a majority of the Active
              members present.
           2. Each chairman shall be elected for a two-year term subject to the approval
              of the Board of Trustees, and may serve no more than two consecutive
              terms. In the event that any department has only one member eligible to
              hold the office of chairman, this restriction shall not apply.
           3. A chairman may be removed from office by a majority vote of all Active
              Staff members of the department, but no such removal shall be effective
              unless and until it has been ratified by the Medical Executive Committee
              and by the Board of Trustees.
           4. A vacancy in the office of the chairman of a department shall be filled by
              election at the next meeting in accordance with the Bylaws of the
              Department.

        C. Functions of the Department Chairman
           The department chairman shall:
           1. Be accountable for all professional and administrative and disciplinary
              activities within his/her department,
           2. Be a member of the Medical Executive Committee, provide guidance on
              the overall medical policies of the Hospital and make specific
              recommendations and suggestions regarding his/her own department to
              assure quality patient care,




Lake Health Medical Staff Bylaws              42                               October 26, 2009
            3. Maintain continuing review of the professional performance of all
                practitioners with clinical privileges in his/her department and report
                regularly thereon to the Medical Executive Committee.
            4. Shall access a need for and recommend outside services applicable to their
                specialty that the hospital does not or cannot provide.
            5. Be responsible for the enforcement of the Staff Bylaws, Rules and
                Regulations within his/her department,
            6. Be responsible for implementation of actions taken by the Executive
                Committee of the Medical Staff,
            7. Transmit to the Credentials Committee recommendations concerning Staff
                classification, reappointment, and delineation of clinical privileges for all
                practitioners in his department,
            8. Be responsible for the teaching, education and research programs in his
                department,
            9. Participate in every phase of administration of his/her department through
                cooperation with the nursing service and the Hospital administration in
                matters affecting patient care including personnel, supplies, special
                regulations, standing orders and techniques.
            10. Assist in the preparation of annual reports including budgetary planning as
                may be required by the Medical Executive Committee, the President of the
                Hospital or the Board of Trustees;
            11. Appoint a department secretary;
            12. Appoint a deputy chairman.

        D. Functions of Departments
           1. Each clinical department shall establish its own Bylaws, Rules and
              Regulations consistent with those of the Staff.
           2. Each department shall establish guidelines for the recommendation of
              clinical privileges.
           3. Each department shall meet at least quarterly to review and analyze the
              clinical and administrative work of the department and submit a report to
              the Medical Executive Committee.
           4. The Department Chair may recommend such measures as focused review,
              monitoring, proctoring or required consultations for individuals within
              their department based on results of focused or ongoing professional
              practice evaluation. Such actions do not constitute restriction of
              privileges.

        E. Extra Departmental Privileges
           Members of any department may be granted clinical privileges by one or more
           departments in accordance with their education, training, experience and
           demonstrated competence, and they shall be subject to the rules of the
           department concerned in the exercise of these privileges.

        F. Section of Dentistry of the Department of Surgery
           Dentists accepted to Staff membership shall be assigned to the Department of
           Surgery, Section of Dentistry. They shall be subject to all rules of the
           Department of Surgery and to the jurisdiction of the department chairman.



Lake Health Medical Staff Bylaws             43                               October 26, 2009
            All dental surgical procedures must be under the overall supervision of the
            chairman of the Department of Surgery. A physician who is a member of the
            medical staff, and recorded in the medical record must perform an admission
            history and physical examination on each dental patient.

        G. Section of Podiatry of the Department of Surgery
           Podiatrists accepted to Staff membership shall be assigned to the Department
           of Surgery, Section of Podiatry. They shall be subject to all rules of the
           Department of Surgery and to the jurisdiction of the Department Chairman.
           All podiatric surgical procedures must be under the overall supervision of the
           chairman of the Department of Surgery.

            Podiatry residents of Lake Health will be supervised during surgery and
            follow-up rounds by staff podiatrists, orthopedic and/or plastic surgeons.
            Progress notes written by residents must be co-signed by the attending
            physicians. Podiatry residents do not have order writing privileges.

        H. Section of Walk-in Medical Care of the Department of Medicine
           This section shall:
           a. Recommend to the Department of Medicine privileges for physicians
              practicing in the Walk-in Centers of Lake Health..
           b. Conduct Quality Improvement review of the Walk-in Care Centers under
              the direction of the Department of Medicine.

            There shall be a Director of the Walk-in Care Centers who will chair this
            section (and be responsible to the Department of Medicine). Physicians
            functioning under the auspices of this section shall be either Lake Health
            medical staff members who are members of clinical departments in which
            they qualify, or Walk-in Care Physicians, who are exempt from board
            certification.




Lake Health Medical Staff Bylaws             44                              October 26, 2009
 XV. COMMITTEES
     A. Appointment
        Unless otherwise specifically designated, committees shall be appointed by
        the President of the Staff.

        B. Standing Committees
           1. The Medical Executive Committee
              a. The Medical Executive Committee shall consist of the President, Vice-
                  President, and Secretary-Treasurer of the Staff and the chairmen from
                  the Departments of Anesthesiology, Emergency Medicine, Family
                  Practice, Medicine, Obstetrics and Gynecology, Pathology, Radiology
                  and Surgery.

                b. The President of the Hospital, the Senior Vice President of Medical
                   Affairs, the Vice President Quality Services, and the Chief Nursing
                   Officer shall be members of this committee, ex-officio, without vote.

                c. The President of the Staff shall be the chairman of this committee.

                d. The Vice-President and Secretary-Treasurer shall each have one vote,
                   each department chairman shall have one vote for every 15 Active
                   members, or portion thereof, in that department.

                e. The function of this committee shall be as follows:
                      i. Transact all business for the Staff, subject to such limitations as
                         may be imposed by these Bylaws;
                     ii. Coordinate the activities and policies of the staff;
                    iii. Receive and act on reports from all other committees and
                         departments of the Staff.
                    iv. Enforce the Bylaws, Rules and Regulations of the Staff;
                     v. Serve as the disciplinary body of the Staff;
                    vi. Provide liaison between the Board and the Staff;
                   vii. Keep the Staff and Board informed regarding the current
                         accreditation status of the Hospital and those factors influencing
                         that status.

                f. This committee shall hold regular monthly meetings and special
                   meetings as may be necessary. Any four members of the Medical
                   Executive Committee or the chairman of the Medical Executive
                   Committee may call a special meeting.

                g. Minutes shall be kept and the committee shall present reports of its
                   deliberations and actions to the Staff and the Board of Trustees at their
                   respective regular meetings.




Lake Health Medical Staff Bylaws             45                               October 26, 2009
                h. The Executive Committee of the Medical Staff must review all
                   non-physician patient care contracts on an annual basis.

            2. Credentials Committee

                a. The Credentials Committee shall be composed of a representative
                   from each of the Departments of Anesthesiology, Emergency
                   Medicine, Family Practice, Medicine, Obstetrics and Gynecology,
                   Radiology, Surgery and Pathology. The representative shall be a
                   member of the Active Staff elected for a term of two years by the
                   department concerned.

                b. The committee members shall elect a chairman of the Credentials
                   Committee from their number at the January meeting each year.

                c. This committee shall meet at monthly intervals and hold special
                   meetings on call of the President of the Staff or the chairman of the
                   Credentials Committee.

                d. It shall be the responsibility of this committee to establish and
                   maintain criteria for the granting of Staff membership and privileges in
                   the Hospital.

                e. It shall be the function of this committee to investigate all initial
                   applications or requests for a change in Staff membership or
                   privileges. These investigators may be delegated to the department of
                   the physician concerned.

                f. Following investigation, the Credentials Committee shall submit its
                   recommendation for the approval, deferral or rejection of the
                   application or request to the Medical Executive Committee.

                       i. A recommendation for approval shall include the designation of
                          membership status, department assignment and specific
                          privileges granted.
                      ii. A recommendation of deferral shall be followed by monthly
                          progress reports and a specific recommendation for acceptance
                          or rejection within 90 days.
                     iii. A recommendation for rejection shall be sent to the Medical
                          Executive Committee for action within 60 days.

                g. Minutes of each meeting shall be kept and reports of this committee
                   shall be made monthly to the Medical Executive Committee in
                   sufficient detail to enable the Medical Executive Committee to act.

                h. The Chairman of the Credentials Committee may invite a
                   representative from any Section of the Medical Staff to provide advice




Lake Health Medical Staff Bylaws             46                              October 26, 2009
                    when the Credentials Committee is reviewing an applicant with a
                    degree other than M.D./D.O.

            3. Quality Improvement Coordinating Committee
               a. The Board of Trustees, having established a Board Level Quality
                  Assurance/Risk Management (QA/RM) Committee, shall delegate the
                  working authority to a committee organized according to these bylaws
                  and shall appoint the Senior Vice President of Medical Affairs, or a
                  member of the Active Staff as Chairperson.

                b. The Committee shall be composed of the following members:
                   President of the Medical Staff
                   Medical Staff Quality Chairmen of the Departments of Emergency
                   Medicine, Medicine, Radiology, Obstetrics/Gynecology, Family
                   Practice, Surgery, Anesthesiology, Maternal Child/Health and
                   Pathology
                   Chief Nursing Officer
                   Senior Vice President of Medical Affairs
                   One (1) Senior Vice President of Operations
                   Vice President Quality Services
                   Director of Quality Services
                   Chief Information Officer
                   Director of Research
                   Representative Care Coordination/Utilization Review
                   Chairman or Director of Medical Education or his/her designee

                    The Senior Vice President of Medical Affairs and the Vice President
                    of the Medical Staff shall co-chair the committee.

                c. The committee shall meet at least quarterly and at the request of the
                   chairman.

                d. Clinical Quality Management Structure
                      i. Standing quality committees are identified in the PI Plan, and ad
                         hoc multidisciplinary committees are formed by the QICC as
                         needs are identified. Committee charges are described in the PI
                         Plan.
                     ii. The President of the Medical Staff selects from Active Staff
                         members each chairperson of the quality committees, and the
                         Board of Trustees formally appoints them. The physician
                         members are appointed by the President of the Medical Staff.
                    iii. The PI/Patient Safety Plan shall be examined annually and
                         revised as necessary and approved by the QA/RM Committee,
                         the Medical Executive Committee, and the Board of Trustees.
                    iv. The QICC provides reports to the Board of Trustee’s QA/RM
                         Committee and the Medical Executive Committee.




Lake Health Medical Staff Bylaws             47                             October 26, 2009
            4. Joint Conference Committee
               The Joint Conference Committee shall consist of the President, Vice
               president and Secretary-Treasurer of the Medical Staff. They shall meet at
               least semi-annually with the members of the committee appointed by the
               Board of Trustees in accordance with the hospital bylaws.

            5. Bylaws Committee
               The Bylaws Committee of the Medical Staff is composed of one member
               elected from each clinical department at their first departmental meeting of
               the year when the Officers of the Medical Staff take office. The
               candidates must be experienced, credible, and knowledgeable of the
               Bylaws. The Chair of the Bylaws Committee is elected by the Bylaws
               Committee members at their first meeting. The committee meets regularly
               to write, accept proposals for review, amend Bylaws in order to present to
               the General Staff Meeting for voting.

            6. Cancer Committee
               Goals and membership of the Cancer Committee will be in accordance
               with the standards set forth by the American College of Surgeons
               Commission on Cancer.

                a. The Cancer Committee shall consist of at least one board certified
                   physician representative from Surgery, OB/GYN, Family Practice,
                   Internal Medicine, Medical Oncology, Radiation Oncology,
                   Diagnostic Radiology and Pathology, and must include the cancer
                   liaison physician. Non-physician membership included
                   administration, nursing, social services, cancer registry and quality
                   services. Other physician and non-physician members will be
                   included based on the cancer experience of Lake Health. Physician
                   representatives from the major sites of cancer seen at Lake Health will
                   be included.
                b. The President of the Medical Staff shall appoint the Chairman of this
                   Committee, and the Chairman of the clinical departments shall appoint
                   other physician members.
                c. The duties and responsibilities of the Committee are to:
                       i. Develop and evaluate the annual goals and objectives for the
                          clinical, educational and programmatic activities related to
                          cancer.
                      ii. Promote a coordinated multidisciplinary approach to patient
                          management,
                    iii. Ensure that educational and consultative cancer conferences
                          cover all major sites and related issues.
                     iv. Ensure that an active supportive care system is in place for
                          patients, families and staff;
                      v. Monitor quality management and improvement via studies that
                          focus on quality, access to care, and outcomes;
                     vi. Promote clinical research;




Lake Health Medical Staff Bylaws            48                              October 26, 2009
                     vii. Supervise the cancer registry and ensure accurate and timely
                          abstracting, staging, and follow-up reporting;
                    viii. Perform quality control of registry data;
                      ix. Encourage data usage and regular reporting;
                       x. Ensure appropriateness of content and timely publication of the
                          annual report;
                      xi. Upholds medical ethical standards;
                     xii. Serve as registry physician advisors.

                d. Meet quarterly or more frequently, as needed.

            7. Medical Ethics Committee
               a. The committee shall consist of the Chairman, and representatives from
                  Oncology, Critical Care, Neurology, Surgery, Medicine, OB/GYN,
                  Family Practice, Psychiatry, and the Medical Staff President (Ex
                  Officio) and representatives from the hospital: Nursing representatives
                  from the Intensive Care Unit, representatives from Social Services,
                  Clergy, legal counsel, Ethicist, Lay Person and a representative from
                  Administration (Ex Officio).
               b. Responsibility of the committee will be to review medical decisions or
                  proposals that have ethical implications which have been referred for
                  consideration.
               c. The function of the committee:
                     i. Serve as a consulting body for health professional personnel,
                        patients or families;
                    ii. May develop policies and guidelines for bioethics issues;
                   iii. May conduct and/or coordinate educational programs relevant to
                        bioethics;
                   iv. Observe federal and state requirements regarding ethical issues;
                    v. Observe confidentiality policies;
                   vi. Meets quarterly or more frequently, as needed.

            8. Education Committee
               a. The Education Committee shall consist of seven (7) or more members
                  of the medical staff. All major services should be represented.
               b. The members will be appointed by the President of the Medical Staff
                  with the approval of the Medical Executive Committee.
               c. The Director of Medical Education shall be a member of the
                  Committee and will serve as Chairman.
               d. No more than a maximum of 50% of the committee members will be
                  replaced each year.
               e. The committee will meet as necessary to develop educational
                  programs according to the OSMA Accreditation Body requirements,
                  and submit a report in writing to the Medical Executive Committee. A
                  summary report will be given to the medical staff at appropriate
                  meetings.
               f. The committee will participate in the identification of quality issues
                  and develop continuing medical education programs which are to have



Lake Health Medical Staff Bylaws             49                             October 26, 2009
                   expected outcomes affecting these quality issues, consistent with
                   OSMA accreditation requirements.
                g. The committee will meet as necessary to develop and plan educational
                   activities according to the OSMA Accreditation Body requirements,
                   and submit a report in writing to the Medical Executive Committee.

            9. Practitioners’ Health Committee
               a. The committee shall consist of no less than seven (7) members of the
                  medical staff, a majority of which, including the chairman, shall be
                  physicians. Except for initial appointments, each member shall serve a
                  term of two (2) years, and the terms shall be staggered to achieve
                  continuity. Insofar as possible, members of this committee shall not
                  serve as participants on other peer review or quality assurance
                  committees while serving on this committee.
               b. The Practitioner’s Health Committee may receive reports related to the
                  health, well-being, or impairment of Medical Staff members, and, as it
                  deems appropriate, may investigate such reports. With respect to
                  matters involving individual medical staff members, the committee
                  may, on a voluntary basis, provide such advice, counseling, or referrals
                  as may seem appropriate. Such activities shall be confidential;
                  however, in the event information received by the committee clearly
                  demonstrates that the health or known impairment of a medical staff
                  member poses an unreasonable risk of harm to hospitalized patients,
                  that information may be referred for corrective action to the President
                  of the Medical Staff, and to the Board of Trustees. The committee
                  shall also consider general matters related to the health and well-being
                  of the Medical Staff, and, with the approval of the Medical Executive
                  Committee, develop educational programs or related activities.
               c. The committee shall meet on call of the chairman. It shall maintain
                  records of its proceedings and shall report on its activities on a routine
                  basis to the Medical Executive Committee.
               d. The Practitioner’s Health Committee is deemed a peer review
                  committee whose actions are intended to be confidential and protected
                  from discovery, and whose participants are intended to be covered by
                  the statutory immunity afforded peer review committee participants.

        C. Special Committees
           Special committees shall be appointed by the President of the Staff as
           necessary. Appointment shall be in writing, shall designate the chairman and
           shall state the origin, responsibilities, and the method of reporting to be
           utilized.

        D. Voting
           Voting members of all standing and special committees shall be members of
           the Medical Staff.

        E. Nominating Committee




Lake Health Medical Staff Bylaws             50                              October 26, 2009
            1. The nominating Committee shall consist of five members of the Active
               Staff elected by the Staff at the Interim meeting.
            2. The chairman of this committee shall be elected by the members of the
               Nominating Committee.
               a. It shall be the function of this committee to offer one or more
                   nominees for each office of the Staff, and the AMA Organized
                   Medical Staff Section (OMSS) representative and alternate; however,
                   no physician shall be nominated for more than one office or position.
               b. The committee shall publish a list of candidates at least two weeks
                   prior to the Annual meeting.

        F. Hospital Committees
           The President of the Medical Staff shall appoint representatives from the
           Medical Staff to hospital committees in accordance with requirements of
           applicable licensing bodies and accrediting organizations.




Lake Health Medical Staff Bylaws            51                             October 26, 2009
XVI. STAFF MEETINGS
     A. Regular Meetings
        Meetings of the staff shall be held in April and October at a time and place
        determined by the Medical Executive Committee. The October meeting shall
        be the Annual Staff meeting. The April meeting shall be an Interim meeting.
        The agenda of regular meetings shall include reports from the clinical
        departments and staff committees.
     B. Special Meetings
        Special meetings may be called by the President, the Medical Executive
        Committee, or upon written request of 10 percent of the Active members of
        the Staff. Written notice of such meetings stating the purpose, time and place
        shall be exhibited in the hospital and distributed to all Staff members not less
        than 72 hours in advance of the meeting. No business shall be transacted at
        any special meeting except that that stated in the notice calling the meeting.
     C. Quorum
        Twenty-five (25) percent of the total membership of the Active Staff must be
        in attendance at any meeting to constitute a quorum for the purpose of
        amendment of these Bylaws. Ten (10) percent of the total membership shall
        constitute a quorum for all other actions.
     D. Parliamentary Authority
        Parliamentary Authority Roberts’ Rules of Order shall be the parliamentary
        authority for all staff meetings. In the event of any question or issue of
        procedure at a staff meeting, legal counsel for the Medical Staff shall act as
        parliamentarian.
     E. Agenda
        1. The agenda at any regular staff meeting shall be set by the President of the
            Medical Staff and the Medical Executive Committee.

            2. The agenda at special meetings shall be restricted to:
               a. A reading of the notice calling the meeting, stating what action is to be
                  taken.
               b. The transaction of business for which the meeting was called.
               c. Adjournment.




Lake Health Medical Staff Bylaws             52                             October 26, 2009
XVII. COMMITTEE AND DEPARTMENT MEETINGS
      A. Regular Meetings
         The standing committees of the Staff, with the exception of the Nominating
         Committee shall hold regular meetings. Each department shall hold regular
         meetings, at least quarterly, to review and evaluate the clinical work of its
         members.
      B. Special Meetings
         A special meeting of any committee or department may be called by the
         chairman or by the President of the Staff, or at the request of ten percent of
         the members of the committee or department.
      C. Notice of Meetings
         Written notice stating the place, day and hour of any regular meeting shall be
         published monthly. Notice of special meetings shall be given to each member
         of the committee or department not less than two days prior to the date of the
         meeting.
      D. Quorum
         Fifty (50) percent of the members of a committee shall constitute a quorum
         for any committee meeting (exception: Hearing and Ad Hoc Committees
         require 80%). Twenty five (25) percent of the Active members of the
         department shall constitute a quorum at any department meeting.
      E. Manner of Action
         1. The action of a majority of the members voting at a meeting at which a
             quorum is present shall be the action of the committee or department.
         2. Committee action may be taken without a meeting by unanimous consent
             of the members. The action of a committee shall be by unanimous vote
             signed by each member.
      F. Rights of Ex-Officio Members
         Ex-Officio members of a committee shall not have the right to vote nor shall
         they be counted in determination of a quorum.
      G. Minutes
         Written minutes of each regular and special meeting of a committee or
         department shall include a record of attendance of members, the proceedings
         and a tabulation of the vote taken on each motion. A copy of these minutes
         shall be forwarded to the Medical Executive Committee through the Medical
         Staff office and shall be maintained in a permanent file.




Lake Health Medical Staff Bylaws          53                             October 26, 2009
XVIII. STAFF, DEPARTMENT AND COMMITTEE MEETING ATTENDANCE
       A. Attendance Requirements
          Active members shall be required to attend not less than 50 percent of the staff
          meetings and not less than 50 percent of their department or division
          (Dentistry and Podiatry) meetings during each calendar year. In addition, the
          medical staff members are expected to attend the meetings of each committee
          to which assigned during the calendar year.
       B. Penalty
          Members failing to comply with attendance requirements shall be reported to
          the Medical Executive Committee for corrective action, delineated in Article
          XI.
       C. Excused Absence
          A staff member may be excused from attendance requirements by action of
          the Medical Executive Committee upon written request within one year of the
          absence.
       D. A member whose clinical case is scheduled for presentation at a regular
          department or committee meeting or clinical-pathological-conference, shall be
          notified in advance and may be required to attend that meeting.
       E. Notice
          1. Failure of a member to attend any meeting for which he/she was given
              notice that his/her attendance was mandatory, unless excused by the
              department or committee chairman, upon a showing of good cause, shall
              be referred by such department or committee chairman to the Medical
              Executive Committee for corrective action as in Article XI.
          2. The member may request a postponement of the presentation supported by
              evidence that his absence will be unavoidable.




 Lake Health Medical Staff Bylaws           54                             October 26, 2009
XIX. IMMUNITY FROM LIABILITY
     A. Privileged Acts
        Any act, communication, report, recommendation or disclosure with respect to
        any practitioner performed at the request of an authorized representative or
        this or any other health care facility, shall be privileged to the fullest extent
        permitted by law.
     B. Extent of Privilege
        This privilege shall extend to all individuals working within or cooperating
        with the Bylaws of Lake Health.
     C. Immunity from Liability
        There shall be, to the fullest extent permitted by laws, absolute immunity from
        civil liability for any act, communication, report, recommendations or
        disclosure, that are requested or received, even where the information would
        be otherwise deemed privileged.
     D. Extent of Immunity
        It shall be the responsibility of the hospital to indemnify medical staff
        members for actions taken, as long as the medical staff member has acted in
        good faith in performing these duties:
        1. quality assessment;
        2. review of application for reappointment or determination of clinical
             privileges;
        3. monitoring of health status of practitioners;
        4. corrective actions including summary suspension;
        5. hearings, appellate reviews, and any other hospital departmental service or
             committee activities related to quality patient care and inter professional
             conduct;
        6. utilization review.
     E. Scope of Acts
        The acts, communications, reports, recommendations, and disclosures referred
        to in this article may relate to a practitioner’s professional qualifications,
        clinical competence, character, mental or emotional stability, health and
        physical condition, ethics or any other matter that might directly or indirectly
        have an effect upon patient care.
     F. Releases
        Each practitioner shall, upon request of the Hospital, execute releases in
        accordance with the tenor and import of this article in favor of the individuals
        and organizations specified 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 this state.
     G. Extension of Protection
        The consents, authorizations, releases, rights, privileges, and immunities
        provided Article XIX., A,B,C and D of these Bylaws for the protection of the
        Hospital’s members, other appropriate Hospital officials, personnel and third
        parties in connection with applications for initial appointment shall also be
        fully applicable to the activities and procedures covered by this article.




Lake Health Medical Staff Bylaws           55                             October 26, 2009
 XX. RULES AND REGULATIONS

        A. Adoption of Rules and Regulations
           The Staff shall adopt such Rules and Regulations as may be necessary for the
           administrative and clinical conduct of the Staff.
        B. Amendments
           The Rules and Regulations may be amended by two thirds of the votes cast.

            If an Active Medical Staff member is contractually obligated to be in-hospital
            at the time of the General Staff meeting, he or she must submit in writing the
            name of the person who will cast their proxy vote to the Medical Staff Office
            by noon on the day of the meeting. The voting member present at the meeting
            may receive and cast only one written proxy.

        C. Effective Date of Amendments
           Amendments to the Rules and Regulations become effective only when
           approved by the Board of Trustees.




Lake Health Medical Staff Bylaws            56                             October 26, 2009
XXI. AMENDMENTS
     A. Procedure for Amendment
        These Bylaws may be amended at any regular or special meeting of the Staff.
        Written notice of such proposed amendment shall be given to each member of
        the Active Staff at least two weeks in advance of the regular or special
        meeting. A two-thirds majority of votes cast by Active members shall be
        required for ratification. The amendment becomes effective on approval by
        the Board of Trustees.

            If an Active Medical Staff member is contractually obligated to be in-hospital
            at the time of the General Staff meeting, he or she must submit in writing the
            name of the person who will cast their proxy vote to the Medical Staff Office
            by noon on the day of the meeting. The voting member present at the meeting
            may receive and cast only one written proxy.

        B. Conflict with Bylaws of Lake Health
           Nothing in these Bylaws, Rules and Regulations of the Staff shall supersede
           or be interpreted to be in conflict with the Bylaws of Lake Health, or statutes
           which pertain to the operation of the hospital.




Lake Health Medical Staff Bylaws             57                              October 26, 2009
DATES OF APPROVALS
Amendments approved by the Board of Trustees on April 30, 1990
Amendments approved by the Board of Trustees on November 30, 1990
Amendments approved by the Board of Trustees on May 10, 1993
Amendments approved by the Board of Trustees on June 27, 1994
Amendments approved by the Board of Trustees on May 22, 1995
Amendments approved by the Board of Trustees on October 30, 1995
Amendments approved by the Board of Trustees on April 29, 1996
Amendments approved by the Board of Trustees on April 28, 1997
Amendments approved by the Board of Trustees on October 27, 1997
Amendments approved by the Board of Trustees on June 1, 1998
Amendments approved by the Board of Trustees on November 1, 1999
Amendments approved by the Board of Trustees on April 24, 2000
Amendments approved by the Board of Trustees on October 30, 2000
Amendments approved by the Board of Trustees on April 30, 2001
Amendments approved by the Board of Trustees on October 29, 2001.
Amendments approved by the Board of Trustees on April 29, 2002
Amendments approved by the Board of Trustees on October 26, 2002
Amendments approved by the Board of Trustees on October 27, 2003
Amendments approved by the Board of Trustees on Dec. 8, 2003
Amendments approved by the Board of Trustees on May 14, 2005
Amendments approved by the Board of Trustees on October 31, 2005
Amendments approved by the Board of Trustees on May 31, 2006
Amendments approved by the Board of Trustees on October 7, 2006
Amendments approved by the Board of Trustees on April 30, 2007.
Amendments approved by the Board of Trustees on October 29, 2007.
Amendments approved by the Board of Trustees on April 28, 2008.
Amendments approved by the Board of Trustees on September 29, 2008.
Amendments approved by the Board of Trustees on October 25, 2008.
Amendments approved by the Board of Trustees on May 27, 2009.
Amendments approved by the Board of Trustees on October 26, 2009.

These Bylaws supersede the previous Bylaws adopted by the Medical Staff on September
28, 1978 and amended on March 22, 1980, September 25, 1980, and September 24, 1981.
The previous Bylaws were approved by the Board on July 24, 1983, Oct. 31, 1983, Dec.
3, 1984, June 24, 1985, Oct. 28, 1985, Jan. 6, 1986, Oct. 28, 1986, June 1, 1987, Nov. 30,
1987, June 6, 1988, Oct. 31, 1988, April 26, 1989 and Nov. 27, 1989.




Lake Health Medical Staff Bylaws            58                             October 26, 2009
                         LAKE HEALTH SYSTEM MEDICAL STAFF

                                   RULES AND REGULATIONS

The following comprise certain controls over practice in Lake Health. They may be
altered, deleted, or supplemented by action of the Staff at any regular meeting.

    1. MEETINGS OF THE STAFF
       a. Regular meetings of the Staff shall be held in April and October at a time and
          place determined by the Medical Executive Committee. Written notice of the
          time and place shall be given to the Staff at the preceding Staff meeting and
          again two weeks in advance of the meeting.

    2. ADMISSION OF PATIENTS
       a. No patient shall be admitted without a provisional diagnosis.
       b. Except for routine maternity cases, a physician shall admit no patient to the
          Hospital without a prior examination.
       c. A Staff member shall admit only those patients within the scope of the
          members’ Clinical privileges.
       d. Patients must be seen by either the admitting physician or consultant within 24
          hours following admission to the ICU, or sooner, as the critical situation
          deems appropriate.
       e. All patients admitted to regular floors shall be seen by the admitting
          physician, or his/her designee, within 24 hours following admission.

    3. DISCHARGE OF PATIENTS
       a. Patients shall be discharged only on order of the attending Staff member.
       b. Anticipated discharge of a patient should be noted 24 hours in advance.
       c. A Discharge Summary must be dictated on all Inpatient (excluding normal
          newborns), Geropsych and Comprehensive Rehabilitation with a stay greater
          than 48 hours and on all expired patients. The Discharge Summary should be
          dictated at the time of discharge, and is not to exceed 30 days post discharge.
          Discharge summary must be dictated by the attending physician or appropriate
          designee.
       d. A concise discharge summary providing information to the other caregivers
          and facilitating continuity of care includes the following:
               Reason for hospitalization
               Significant Findings (lab, radiology and other tests)
               Procedures and care, treatment and services provided (hospital course)
               Patient’s condition at discharge
               Instructions to the patient and family as appropriate
          A hand written Discharge summary will suffice for patients with less than 48
          hours stay.

    4. TREATMENT OF PATIENTS
       a. Patients may be admitted and treated only by Staff members who have been
          granted privileges to admit and treat patients in Lake Health, by the Board of
          Trustees



Lake Health Medical Staff Bylaws            59                             October 26, 2009
        b. In the emergency setting, all patients following triage, will undergo an
           appropriate medical screening exam and be offered stabilizing treatment either
           by the ED physician or an attending physician that is a qualified member of
           the medical staff.
        c. In the event that an ED physician requests involvement of an on-call physician
           in a particular specialty, the on-call physician must respond to attend a patient
           with an emergency medical problem in a timely manner and arrange for a
           medical screening examination or provide stabilizing care.
        d. On call physicians who, as a part of their routine responsibilities, are charged
           with the duty to accept patients transferred from other facilities, may not
           refuse any unstable transfer as long as the hospital at which he/she is on-call
           has the capability and capacity to provide treatment.
        e. The on-call physician may, at the patient’s request, transfer stable patients.
        f. In the event that it is determined that a patient must be transferred, the
           transferring physician must discuss the patient’s medical situation with the
           proposed receiving hospital’s authorized representative and obtain an
           agreement to accept the patient in transfer, before the transfer is implemented.
        g. A member of the Medical Staff, or his/her designee, who is authorized to
           write orders on that patient, shall see every patient in the Hospital daily. It is
           the responsibility of the attending physician to ensure that a progress note is
           written daily. Patients on the Comprehensive Center for Rehabilitation
           should be seen by the attending physician according to the severity of their
           condition. This may not require rounding on a daily basis. However, patients
           must be evaluated with documentation a minimum of at least three times a
           week.
        h. There should be a qualified anesthesia provider in addition to the attending
           physician, for delivery, if needed.
        i. The operating surgeon shall be responsible for the daily after care of all his
           surgical patients. The primary physician and the specialist must decide when
           transfer is appropriate. Official transfer of service occurs only with the
           consent of both parties and a written order documented in the patient chart.
        j. Except in a critical emergency, no operation shall be performed without a
           written history and physical examination, and in no case shall an operation be
           performed without a written preoperative diagnosis, and evidence on the chart
           of informed consent. The operating surgeon shall examine the patient before
           the patient enters the surgical suite.
        k. All invasive procedures shall be fully described in a written or dictated report
           by the Staff member performing the procedure immediately after surgery.
        l. The Newborn Nursery shall be under the jurisdiction of the Department of
           Medicine. A chief of the Newborn Nursery shall be appointed by the
           chairman of the Department of Medicine and shall be charged with the
           responsibility and authority for enforcing rules and policies of the Newborn
           Nursery.
        m. When the attending physician is unavailable for patient care, the chairman of
           the department concerned or the deputy chairman shall have the responsibility
           and authority to notify the patient or his legal guardian and assist in the
           disposition of the case.




Lake Health Medical Staff Bylaws             60                               October 26, 2009
        n. When a physician signs out to another physician for coverage, he/she must
           sign out to someone in the same specialty, who is a member of the Lake
           Health Medical Staff.
        o. The department concerned shall establish the qualifications of assistants in
           surgery.
        p. Only the operating surgeon may request a case be placed on the operating
           schedule.
        q. Care for Behavior Health (Psychiatric) Patients:
              i. Patients who meet the admission criteria of the Center for Geriatric
                 Psychiatry (Policy/Procedure Admission Criteria – 02.001) shall be
                 admitted and attended by a psychiatrist who is a member of the Medical
                 Staff.
        r. Any other inpatient or emergency department patient, who exhibits symptoms
           of a psychiatric or substance abuse condition shall be stabilized medically. A
           consult with a contracted licensed independent psychiatrist, psychologist or
           licensed registered nurse, or licensed psychiatrist social worker who
           specialized in mental health disorders, shall be initiated. Care shall be
           provided in accordance with the recommendations of these practitioners
           including transfer, as necessary, to a facility which can provide the
           appropriate psychiatric or substance abuse treatment.
              i. Any patient known or suspected to be suicidal must have consultation
                 with a member of the psychiatry staff or contracted psychiatric
                 evaluation resource. Special nursing care and safety precautions shall be
                 provided as indicated in the Administrative Policy Manual.
             ii. If a patient meets the admission criteria for the Center of Geriatric
                 Psychiatry and the unit is at capacity, the patient will be transferred to
                 another appropriate facility using the established transfer mechanism.

    5. ORDERS
         a. Orders, verbal or written, shall be initiated by the attending physician. In
            addition, Certified Nurse Practitioners, Physician Assistants, Certified
            Nurse Midwives or Advanced Practice Nurses may initiate orders, verbal
            or written, as long as it is consistent with their supervisory agreement
            and/or standard care agreement. All orders must be documented, dated,
            timed and signed. Both Certified Nurse practitioners and PAs without
            prescriptive authority may not initiate medication orders, verbal or written.
         b. All verbal orders may be given to a registered licensed nurse. In addition:
          Verbal orders for medications may be taken by a registered licensed nurse,
            a PA licensed to that physician, or a pharmacist.
          Verbal orders for ordering of laboratory procedures may be given to a
            laboratory technician.
          Verbal orders for ordering x-ray procedures may be given to a radiology
            technician.
          Verbal orders for ordering of physical therapy may be given to a physical
            therapy technician.
          Verbal orders for the ordering of respiratory therapy procedures may be
            given to a respiratory therapist.




Lake Health Medical Staff Bylaws             61                             October 26, 2009
               Verbal orders for the ordering of occupational therapy may be given to an
                occupational therapist.
               Verbal orders for the ordering of a diet may be given to a dietitian.

            c. All verbal orders shall be co-signed by the ordering physician, or his
               designee. A physician shall sign a verbal order within 48 hours of giving
               the verbal order. The physician shall date and time his/her signature.

    6. CO-SIGNATURE OF CHART ENTRIES
       All orders and progress notes entered by a non-physician Allied Health
       Professional (with the exception of those listed in 5a) must be co-signed by a
       physician at time of chart completion.

        All written orders, progress notes and verbal orders by Health Professionals in
        training must be co-signed by supervising member of the Medical Staff at time of
        chart completion.

    7. LABORATORY AND RADIOLOGY
         a. Specimens may be exempted from the requirement of examination and
            these include, but need not be limited to, the following:
            i. Specimens that, by their nature or condition, do not permit productive
            examinations, such as cataracts, appliances, foreign bodies.
            ii. Specimens known to rarely, if ever, show pathologic change.
         b. It shall be the responsibility of the Hospital to have all reports of clinical
            laboratory studies, pathologic studies, and Roentgen examinations
            promptly incorporated in the chart, preferably on the day of performance.

    8. RECORDS
         a. A provisional diagnosis is recorded before the operative procedure by the
            Licensed Independent Practitioner responsible for the patient.
                A post –operative progress note is written in the patient’s medical record
                immediately following the procedure.
                The completed operative report is authenticated by the surgeon and made
                available in the medical record as soon as possible after the procedure.
                The operative report records the:
                    Findings
                    Procedures performed and description of the procedure
                    Specimen(s) removed
                    Post-operative diagnosis
                    Name of primary surgeon and assistants
                    Estimated blood loss, as indicated
            b. No medical record shall be filed until it is complete, except by authority of
               the Medical Records Committee.
            c. All medical staff members must use the hospital dictation system for their
               medical records.
                       records.
            d. Records not complete within 30 days after discharge shall be declared



Lake Health Medical Staff Bylaws             62                              October 26, 2009
               delinquent Staff members will be notified of the status of delinquent
               medical records by the HIM Department on a weekly basis. Notification
               will only occur when the staff member has records that are delinquent, i.e.,
               incomplete more than 30 days after discharge. Staff members who have
               delinquent medical records will receive the following notice:
                    Notification of impending suspension: Records incomplete more
                       than 30 days following discharge. Notification will also include all
                       records that are incomplete.
            e. For the purpose of enforcing this provision, justified reasons for delay in
               completing medical records shall include, without limitation:
                    i. Illness, vacation, or other unavailability of the practitioner, which
                       “other unavailability” shall be communicated to the President of
                       the Medical Staff for acceptance or denial of the reasons for
                       unavailability. A practitioner shall also notify the HIM
                       Department in the event of illness, vacation or “other
                       unavailability.”

                      In the event that a physician who is planning a vacation or other out-
                      of-town absence has medical records which are incomplete, and
                      notifies the HIM Department prior to leaving, the delinquency
                      control procedure within the Hospital Incomplete Chart Control
                      Policy will not be implemented during the physician’s absence. In
                      the event that a physician with incomplete medical records leaves for
                      vacation or other absence without notifying the HIM Department and
                      those medical records become delinquent during the physician’s
                      absence, the delinquency control procedure will be implemented and
                      a physician will receive a suspension of privileges, as defined within
                      the Incomplete Chart Control Policy.

                    ii. That the practitioner is waiting for the results of a late report and
                        the record is otherwise complete for the discharge summary and
                        final diagnosis.
                   iii. That there is transcription delay.

                f. The Health Information Management Department will share the results
                   of its weekly check of delinquent medical records with the Medical
                   Staff Office, the President of the Medical Staff, all Medical Staff
                   department chairpersons, and with other hospital administrative
                   personnel, in accordance with the hospital’s Incomplete Chart Control
                  Policy. Letters of suspension, when appropriate, pursuant to the
                  Incomplete Chart Control Policy, will be issued from the Medical Staff
                  Office. A list of physicians whose privileges have been suspended for
                  delinquent medical records will also be posted in the Medical Staff
                  lounge. These physicians may not admit or schedule elective surgeries or
                  procedures for patients until the charts are complete and HIM notifies
                  the Medical Staff Office. Hospital based physicians may not work until
                  their charts are completed.




Lake Health Medical Staff Bylaws              63                                October 26, 2009
                  Medical Staff Department Chairpersons will review record completion
                  requirements with all physicians whose privileges have been suspended
                  for incomplete medical records.

                 Similarly, the frequency of delinquent medical records will be noted in
                 each physician’s Medical Staff file, and such information may be utilized
                 and considered during the processing of a physician’s reappointment.

            g. All records are the property of the Hospital, and shall not be removed from
               the Hospital except by subpoena, court action or statutory requirement.

            h. In the case of readmission of a patient, all previous records shall be
               available for the use of the attending Staff member.

            i. Access to all medical records of all patients shall be afforded to Staff
               members in good standing for study, research, or committee duties. The
               confidentiality of personal information concerning the individual patients
               shall be preserved.

    9. TEMPORARY INTERRUPTION OF CLINICAL PRIVILEGES
         The following actions or omissions shall subject the practitioner to a
         temporary interruption of is or her elective admitting privileges, or, in the case
         of contract or hospital-based practitioners, a temporary interruption in
         scheduled work shifts:
         a. Loss or failure to maintain medical malpractice insurance coverage as
             required by Article IV. B.f. or g. of the Bylaws.
         b. Failure to provide annual information regarding PPD status to the Medical
             Staff Office.
         c. Failure to complete medical records as required by Section 8 of these
             Rules and Regulations.
         d. Failure to pay Medical Staff dues within 90 days following initial notice
             and issuance of dues statement.

            Once the action or omission which precipitated the interruption of elective
            admitting privileges or future work shifts has been resolved, then elective
            admitting privileges or scheduled work shifts shall be immediately reinstated.




Lake Health Medical Staff Bylaws             64                              October 26, 2009
    10. RULES REGARDING NEW STAFF MEMBERS
          An applicant for privileges may not be observed exclusively by an associate in
          practice.

    11. CONSULTATION
        a. The President of the Staff, Department Chairman, Hospital Administrator or
           Board of Trustees have the authority to require consultation under special
           circumstances.
        b. Except in an emergency, consultation will be required in the interruption of
           uterine pregnancy.
        c. Except in an emergency, there shall be a written consultation note by the
           surgeon before operation in cases that are admitted by another person.
        d. Consultation is recommended and should be obtained or offered to patients:
              i. who are not a good risk;
             ii. in whom the diagnosis is in doubt, or whenever there is a question as to
                 the best therapy;
            iii. in cases of attempted suicide or drug overdose, or;
            iv. in cases where the patient or patient’s authorized representative so
                 requests.
        e. The physician requesting the consultation shall specify in the request, the date
           and time of the request, as well as the time period within which the
           consultation must be completed. In the event that the consulting physician is
           unable to complete the consultation within the requested time period, the
           consulting physician shall immediately notify the physician who has requested
           the consultation.

    12. MASS CASUALTY PLAN
             The Staff shall cooperate with the Hospital administration in the
             establishment of a mass casualty plan.

    13. CONTRACT PHYSICIAN
            Any physician retained by the Hospital as an employee contractor, vendor,
            etc. for the purpose of providing clinical services to patient, shall be a
            member of the Medical Staff of the Hospital as provided in these Bylaws.
            In the event any physician so retained is relieved of his prescribed duties,
            as defined in his agreement with the Hospital, the status of the physician
            as a member of the Staff of Lake Health, shall not be affected.
            Membership on the Staff of the Hospital shall be affected only by the
            action of the Staff, as set forth in the Staff Bylaws, Rules and Regulations.

    14. EMERGENCY CENTER ON CALL ROSTERS
        Each clinical department shall establish an emergency center on call roster. The
        Active members of each clinical department will decide which members of that
        department will serve on those rosters, which are under the jurisdiction of that
        department.




Lake Health Medical Staff Bylaws            65                              October 26, 2009
        It is the responsibility of the medical staff to support the patient care mission of
        the Hospital by providing treatment for the patients presenting to the facility
        seeking emergency medical care, regardless of the patient’s ability to pay for such
        services. Every member of the medical staff shall be expected to participate in
        the on-call system if requested, and to respond promptly (in accordance with
        applicable medical staff policies) when called to render clinical services within
        their area of specialization.

        It is the duty of the physician on the on call roster to provide medical care and
        appropriate follow-up to that patient for that particular medical event for which
        the Emergency Department physician refers the patient. Physicians whose names
        appear on the on call list are responsible for finding a suitable replacement if they
        cannot be available for duty, and for updating the call list with the replacement
        physician’s name and other appropriate information. The replacement must be a
        member of the medical staff.




Lake Health Medical Staff Bylaws             66                               October 26, 2009
            POSITION ON USE OF SERVICES AT LAKE HEALTH

            In accordance with the Joint Commission on Accreditation of Hospitals,
            Medical Staff members shall be limited to those individuals currently fully
            licensed to practice medicine or dentistry, podiatry or psychology (M.D.,
            D.O., D.D.S., D.M.D., D.P.M., PhD/Psych). Personnel not fully licensed to
            practice medicine, dentistry, podiatry or psychology must secure approval
            from a qualified member of the Medical Staff prior to using hospital services
            or departments.




Lake Health Medical Staff Bylaws            67                              October 26, 2009

				
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