Mercy Hospital Medical Staff Bylaws - Mercy Health

Mercy HospitalMedical StaffBylaws

Table of ContentsPREAMBLE……………………………………………………………………………...11. DEFINITIONS ............................................................................................................... 6-52. PURPOSES AND RESPONSIBILITIES OF THE MEDICAL STAFF .................. 5-72.1. PURPOSES OF THE MEDICAL STAFF.................................................................. 12-62.2. RESPONSIBILITIES OF THE MEDICAL STAFF ..........................................................62.3 HISTORY AND PHYSICAL EXAMS……...…….………………………………….6-73. MEDICAL STAFF MEMBERSHIP............................................................................ 7-93.1. NATURE OF MEDICAL STAFF MEMBERSHIP, GENERALLY ....................................73.2. QUALIFICATIONS FOR MEMBERSHIP......................................................................73.3. RESPONSIBILITIES OF MEDICAL STAFF MEMBERSHIP .................................... 14-83.4. GENERAL CONDITIONS OF MEDICAL STAFF MEMBERSHIP .............................. 8-93.5. VOLUNTARY RESIGNATIONS FROM THE MEDICAL STAFF.....................................94. CATEGORIES OF MEMBERSHIP.......................................................................... 9-194.1. ACTIVE............................................................................................................... 9-204.2. COURTESY ...........................................................................................................1904.3. AFFILIATE..............................................................................................................104.4. HONORARY ............................................................................................................105. APPOINTMENT/REAPPOINTMENT TO THE MEDICAL STAFF................. 10-135.1. NATURE OF APPOINTMENT ............................................................................. 10-115.2. REGIONAL CENTRAL CREDENTIALS OFFICE .......................................................115.3. PROFESSIONAL CRITERIA FOR EVALUATING APPLICATIONS........................ 11-255.5. TIME PERIODS FOR PROCESSING APPLICATIONS .......................................... 12-13

6. CLINICAL PRIVILEGES........................................................................................ 13-176.1. DELINEATION OF CLINICAL PRIVILEGES ....................................................... 13-276.2. MEC INVOLVEMENT IN BOARD DECISIONS TO CONTRACT, DEFINE OR LIMITSERVICES ......................................................................................................... 14-166.3. TEMPORARY PRIVILEGES .....................................................................................166.4. EMERGENCY PRIVILEGES .....................................................................................366.5 DISASTER PRIVILEGES ..........................................................................................177. CLINICAL DEPARTMENTS.................................................................................. 37-187.1. ORGANIZATION OF DEPARTMENTS ................................................................ 37-187.2. DEPARTMENT LEADERSHIP ................................................................................3888. OFFICERS ................................................................................................................. 18-228.1. SELECTION, TENURE AND REMOVAL ...................................................................198.2. DUTIES OF OFFICERS ...................................................................................... 20-229. COMMITTEES.......................................................................................................... 47-259.1. COMMITTEES, GENERALLY ..................................................................................479.2. MEDICAL EXECUTIVE COMMITTEE ............................................................... 48-249.3. JOINT REVIEW COMMITTEE ........................................................................... 52-259.4. BYLAWS COMMITTEE ...........................................................................................259.5. CHARACTERISTICS COMMON TO ALL OTHER COMMITTEES..............................5310. MEETINGS................................................................................................................ 53-2710.1. MEDICAL STAFF MEETINGS ........................................................................... 53-2610.2. COMMITTEE AND DEPARTMENT MEETINGS ......................................................53610.3. REQUIREMENTS FOR CONDUCTING BUSINESSERROR! BOOKMARK NOT DEFINED.-2711. RESOLVING PROFESSIONAL COMPETENCE, CONDUCT ORDISCIPLINE ISSUES ............................................................................................... 57-3311.1. EDUCATION AND IMPROVEMENT ..........................................................................57

11.2. ROUTINE CORRECTIVE ACTIONS ................................................................... 57-2911.3. TEMPORARY SUSPENSIONS ............................................................................. 30-3111.4. SUMMARY SUSPENSIONS…………...………………………………………...31-3211.5. BOARD RATIFICATION .................................................................................... 64-3312. FAIR HEARING PLAN............................................................................................ 33-3912.1. REQUIREMENTS OF A PROFESSIONAL REVIEW ACTIONERROR! BOOKMARK NOT DEFINED.312.2. RIGHT TO A HEARING ........................................ERROR! BOOKMARK NOT DEFINED.12.3. NOTICE OF RIGHT TO HEARING ......................ERROR! BOOKMARK NOT DEFINED.412.4. NOTICE OF HEARING AND LISTS OF WITNESSESERROR! BOOKMARK NOT DEFINED.-3512.5. THE HEARING PANEL OR OFFICER .................ERROR! BOOKMARK NOT DEFINED.512.6. CONDUCT OF THE HEARING............................................................................ 36-3712.7. THE REPORT AND RECOMMENDATION ..............................................................68712.8. APPELLATE REVIEW ........................................ERROR! BOOKMARK NOT DEFINED.712.9. REPORTING REQUIREMENTS ................................................................................7312.10. MISCELLANEOUS.......................................... ERROR! BOOKMARK NOT DEFINED.-3913. ALLIED HEALTH PROFESSIONALS.................................................................. 39-4213.1. GENERAL ............................................................ERROR! BOOKMARK NOT DEFINED.13.2. REQUIREMENTS FOR ALLIED HEALTH PROFESSIONALSERROR! BOOKMARK NOT DEFINED.13.3. SUPERVISION AND FUNCTIONING OF ALLIED HEALTH PROFESSIONALSERROR! BOOKMARK NOT D13.4. LIMITATIONS ON ALLIED HEALTH PROFESSIONALSERROR! BOOKMARK NOT DEFINED.13.5 TEMPORARY SUSPENSIONS ............................................................................. 40-4113.6 AUTOMATIC TERMINATION OF ALLIED HEALTH PROFESSIONALS ……………4113.7 PROFESSIONAL REVIEW ACTIONS AGAINST ALLIED HEALTH...................... 41-4213.8. SUMMARY SUSPENSION OF ALLIED HEALTH PROFESSIONALS............................4214. CONFIDENTIALITY, IMMUNITY AND RELEASE................................................4414.1. INFORMATION COLLECTION AND HANDLING ......................................................43

14.2. CONFIDENTIALITY IN PROFESSIONAL REVIEW ACTIVITIES................................4314.3. IMMUNITY AND RELEASE......................................................................................4415. RULES AND REGULATIONS................................................................................ 44-4516. ADOPTION AND AMENDMENT .......................................................................... 45-4616.1. RESPONSIBILITY....................................................................................................4516.2. PROCEDURE...........................................................................................................4516.3. ADOPTION..............................................................................................................4617. CONFLICT MANAGEMENT .......................................................................................46

1.1.6. CHIROPRACTOR is an individual who has been awarded the degree ofDoctor of Chiropractic (D.C.) holding a license to practice chiropracticissued pursuant to Chapter 4734 of the Ohio Revised Code.1.1.7. Clinical Privileges refers to the permission granted by the Board toprovide a defined scope of clinical services to provide patient careservices to those who admit patients and/or provide patient care byrendering specific professional, diagnostic, therapeutic, medical, dental,podiatric, psychological, chiropractic or surgical services.Comment: Text moved here1.1.8. Clinically Active – Refers to a practitioner who provides 24 patientservices in a two(2) year period, exclusive of Outpatient diagnostictesting or telemedicine, at an individual acute care facility.1.1.9. Co-Admit – Co-admission requires the consent of a fully licensedindependent practitioner in admitting and treating a patient, if requiredby privileges. The Co-admitting Licensed Independent Practitioner willbe the attending physician of record.1.1.10. Consultant – If, in the good faith belief of the Medical ExecutiveCommittee, such action is necessary to assist or enable it to fulfill itsresponsibilities pursuant to these Bylaws, the Medical ExecutiveCommittee may make use of appropriately qualified Consultants who arenot Medical Staff Members or employees or officers of the Hospital. TheMedical Executive Committee may appoint such a Consultant to assistany individual or Committee in carrying out a responsibility imposed bythese Bylaws. To the extent possible, any Consultant so appointed shallfollow the procedures set out in these Bylaws relating to the matter inwhich it/he/she has been appointed and shall be considered part of thepeer review process.1.1.11. Criminal Conviction means conviction of, or a plea of guilty or nocontest to any felony, or a conviction or plea to any misdemeanor relatedto the practice of a health care profession, to Federal Health Programfraud or abuse, to third-party reimbursement, or to controlled substances.1.1.12. When The term counting Days, refers to business days for purposes ofthese documents. the first day of any period is not counted; the last oneis. If a period ends on a Saturday, Sunday or holiday, then the period isdeemed to end on the next business day. If a period is six days or shorter,do not count intervening Saturdays, Sundays or holidays.1.1.13. DENTIST means an individual who has been awarded the degree ofDoctor of Dentistry (D.D.S.) or Doctor of Dental Medicine (D.M.D.)holding a license to practice dentistry issued pursuant to Chapter 4715 ofthe Ohio Revised Code.1.1.14. Designee means an appropriately privileged Practitioner designated by aMember to provide patient care as necessary.- 7 -

1.1.15. Direct Economic Competition means another clinician who seeks todeliver substantially similar clinical services to the same pool of patientstaking into account factors which include but are not limited to specialty,sub-specialty, geographic location and referral sources.1.1.16. EX OFFICIO means service as a member of a body by virtue of an officeor position held. and, unless otherwise expressly provided, means withvoting rights.1.1.17. Fair Hearing Plan means the procedures for hearings and appealsapplicable to Physicians, dentists, podiatrists, chiropractors andpsychologists set forth in these Bylaws, as they may be amended fromtime to time.1.1.18. Federal Health Program means Medicare, Medicaid or any other federalor state program providing health care benefits which is funded directly orindirectly by the United States government.1.1.19. Focused Professional Practice Evaluation (FPPE) is a process wherebythe organization evaluates the privilege-specific competence of thePractitioner who does not have documented evidence of competentlyperforming the requested Clinical Privileges at the organization. Thisprocess may also be used when a question arises regarding a currentlyprivileged Practitioner’s ability to provide safe, high-quality patient care.Focused Professional Practice Evaluation is a time-limited period duringwhich the organization evaluates and determines the Practitioner’sprofessional performance.1.1.20. GOOD STANDING means the staff member, at the time the issue israised, has met the attendance requirements during the previous medicalstaff year, is not in arrears in dues payment, and is not under suspensionof his appointment or clinical privileges (other than for medical recordcompletion delinquency).1.1.21. Hospital means (The Jewish Hospital) each of the Hospitals affiliatedwith Mercy Health and all its inpatient and outpatient ambulatory carefacilities to which these Bylaws apply.1.1.22. Chief Executive Hospital Administrative Officer means the siteadministrator, or other executive designated by Mercy to serve as theadministrative leader of the Hospital.1.1.23. An Investigation means the focused and purposeful gathering ofinformation, records and other data with respect to the competence,professional conduct or practice patterns of a Practitioner for the purposeof determining whether to take or recommend a Professional ReviewAction. Only the MEC may initiate an Investigation. The routinefunctioning of the Medical Staff, of its committees, of the Hospital’squality improvement or resource management departments or committeesand all discussions with a Physician Practitioner relating to these mattersdo not constitute an Investigation.- 8 -

1.1.24. JRC means the Joint Review Committee.1.1.25. MEC (Executive Committee) refers to the Medical Executive Committee.1.1.26. Medical Staff means the single organized body of Physicians, Dentists,Podiatrists, and Psychologists and Chiropractors. Each facility is selfgoverningand has individual Medical Staffs. who have been grantedClinical Privileges to attend to patients in the Hospital. Each of Mercy’sfive Medical Staffs is an integral part of the Hospital(s) it serves and is nota separate entity.1.1.27. MEDICAL STAFF YEAR means the period from the first day of Marchthrough the last day of February.1.1.28. MEDICO ADMINISTRATIVE OFFICER means a practitioner,employed by, or otherwise serving the Hospital, on a full-time orpart-time basis, whose duties include responsibilities, some of which arepurely administrative in nature, some purely clinical in nature, and someboth administrative and clinical in nature. Clinical responsibilities aredefined as those involving professional capability as a practitioner such asto require the exercise of clinical judgment with respect to patient care.1.1.29. Member means a member of the Medical Staff.1.1.30. Membership means that status as set forth in the Medical Staff Bylaws,and determined for an individual Member by the Board which defines aPractitioner’s rights and responsibilities to participate in the Medical Stafforganization.1.1.31. Mercy refers to the Mercy Health Partners of Southwest Ohio, d/b/aMercy Health Partners, its Hospitals and other health care facilities, itsparents, subsidiaries and affiliates.1.1.32. (Special) Notice means written notification that is either (a) delivered inperson via messenger, commercial courier or otherwise or (b) faxed ormailed sent by certified mail (return receipt is not required) return receiptrequested, with and a duplicate sent by ordinary mail, to the recipient’slast known home or office address of record.1.1.33. Ongoing Professional Practice Evaluation (OPPE) is a process whichallows the organization to identify professional practice trends that impacton quality of care and patient safety. Such identification may requireintervention by the organized Medical Staff.1.1.34. A Peer is defined as a appropriate Practitioner in the same professionaldiscipline as the applicant who has personal knowledge of the applicantand the applicant’s ability to practice the requested Clinical Privileges.1.1.35. A Physician is an individual who has received a doctor of osteopathy,dentistry, podiatry, chiropractic or doctor of medicine degree and is- 9 -

currently licensed to practice medicine or surgery in Ohio, pursuant toChapter 4731 of the Ohio Revised Code.1.1.36. Physicians Council is comprised of Medical Staff leaders and placesthem in the center of decision-making and policy-setting on issues thataffect their clinical practice and their engagement with Mercy Health Carefacilities.1.1.37. Podiatrist is an individual who has been awarded the degree of Doctor ofPodiatric Medicine (D.P.M.) holding a license to practice podiatry issuedpursuant to Chapter 4731 of the Ohio Revised Code.1.1.38. A Position Description means a scope of practice for Category 2 AlliedHealth Professionals which who are not credentialed utilizing the medicalstaff process. Refer to the Credentialing Manual for additional details.1.1.39. Practitioner means, unless otherwise expressly limited, any appropriatelylicensed Physician, dentist/oral surgeon, podiatrist, psychologist, orchiropractor or Allied Health Professional who holds or applies formembership and/or Clinical Privileges at the Hospital on the MedicalStaff.1.1.40. Practitioner Effectiveness Committee (PEC) is a committee who’s intentis to provide a mechanism to address disruptive, inappropriate orunprofessional behavior when it is identified in a manner that is separatefrom the core Medical Staff corrective action functions.1.1.41. Prerogative means a participatory right granted, by virtue of staffmembership or affiliate status, and exercisable subject to the conditionsimposed in this Code of Regulations and in policies of the Hospital andthe medical staff.1.1.42. A Professional Review Action --1.1.42.1. Has the following characteristics:1.1.42.1.1. an action or recommendation of a Professional ReviewBody which is taken or made in the conduct of aProfessional Review Activity and which is based on thecompetence or professional conduct of an individualPractitioner that is harmful or potentially harmful topatients where the action or recommendation affects ormight Affect Adversely the Clinical Privileges of thePractitioner and/or, in the case of Physicians, dentists,podiatrists and psychologists, Membership on the MedicalStaff.1.1.42.2. A Professional Review Action includes:- 10 -

1.1.42.2.1. for immunity purposes, all Professional ReviewActivities related to the Professional Review Action aswell as all decisions not to take action; and1.1.42.2.2. actions or recommendations pertaining to applicantswho seek Medical Staff Membership or Clinical Privileges..1.1.42.3. A Professional Review Action does not include actions relating to aPractitioner’s association with a professional society; to aPractitioner’s fees, advertising or other acts to solicit business; to aPractitioner’s participation in prepaid group health plans, tosalaried employment or any other manner of delivering healthservices; to a Practitioner’s association with any particular class ofhealth care practitioner; or to any other matter that does not relateto the competence or professional conduct of the Practitioner1.1.43. A Professional Review Activity means any activity to determine whethera Practitioner may hold Clinical Privileges at the Hospital or, in the caseof Physicians, dentists, podiatrists and psychologists, membership on theMedical Staff, to determine the scope of such Privileges or Membershipor to modify such Privileges or Membership.1.1.44. A Professional Review Body means the Hospital, the Board, or anycommittee of the Hospital or Board that conducts Professional ReviewActivities. It includes each committee of the Medical Staff that assists theHospital or the Board in Professional Review Activities.1.1.45. Psychologist means an individual who has been awarded the degree ofDoctor of Psychology (Psy.D.) or Doctor of Philosophy in Psychology(Ph.D.) or equivalent doctoral degree and holding a license to practicepsychology issued pursuant to Chapter 4732 of the Ohio Revised Code.1.1.46. Research Associate is an allied health professional who will be active inthe Hospital during a defined and specific research project. This associatewill operate under the supervision of the physician in charge and in aresearch protocol approved by the Institutional Review Board (IRB). Thisshall be construed as a special circumstance and no other clinicalprivileges are implied. A research associate’s activities shall terminatewith completion of the research project.1.1.47. Rules and Regulations refers to the Rules and Regulations of theMedical Staff and such other policies and manuals guiding the activitiesand structure of the Medical Staff as may be adopted and as the same maybe amended from time to time pursuant to these Bylaws.1.1.48. SPECIAL NOTICE means written notification sent by certified mail,return receipt requested1.1.49. Supervised/Supervision means that degree of monitoring by anotherindividual which is required either by law or Hospital policy. Unless- 11 -

specifically stated, it does not require the on-premises presence of thesupervisor.1.1.50. Telemedicine – Defined as the use of medical information exchangedfrom one site to another via electronic communications to improvepatients’ health status.2. PURPOSES AND RESPONSIBILITIES OF THE MEDICAL STAFF2.1. Purposes of the Medical StaffThe Hospital has an organized, self-governing Medical Staff that:2.1.1. Ensures that all patients admitted to or treated at the Hospital receivecare without regard to their race, religion, age, sex, national origin orability to pay;2.1.2. Is accountable to the Board for the quality and appropriateness of themedical care, treatment, professional performance and ethical conduct ofits members and affiliates Allied Health Professionals and servicesprovided to patients. Ensure Confirm that appropriate criteria are in placeto evaluate quality of care rendered by Practitioners; the Medical Staff;2.1.3. Provides oversight for the uniform quality of care, treatment, and servicesby recommending Members for appointment to the Medical Staff;2.1.4. Creates a framework of self-governance enforcement, compliance andaccountability to the Board through the implementation of Bylaws, Rulesand Regulations and policies within which Members can act with areasonable degree of freedom and confidence;2.1.5. Provides a mechanism for the delineation of Clinical Privileges and tomonitor and evaluate the clinical performance of Practitioners withdelineated Clinical Privileges through Medical Staff participation inmeasurement, assessment and improvement of other processes; and2.1.6. Provides a means for the Medical Staff to communicate effectively withthe Board, Mercy and Hospital administration and to represent itself andparticipate in all Hospital deliberations affecting the discharge of theMedical Staff’s responsibilities; and2.1.7. To Supports research and educational activities in the interest ofimproving patient care, the skills of persons providing health services, andthe promotion of the general health of the community.2.1.8. The Medical Staff is organized in a manner approved by the Board.2.2. Responsibilities of the Medical Staff- 12 -

To carry out these purposes, the Medical Staff assumes responsibility to: the followingresponsibilities:2.2.1. Utilize all available information from all Mercy resources in order tomonitor and evaluate the quality of care and the clinical performance ofits Members and other Practitioners with delineated Clinical Privileges;2.2.2. Perform the oversight activities of the organized Medical Staff;2.2.3. Make recommendations to the Board with respect to Medical StaffMembership and the exercise of Clinical Privileges; Communicatefindings, conclusions, recommendations, and actions to improveperformance; to appropriate staff members and the Governing Body.2.2.4. Assessment and treatment of patients. including coordination of care,treatment and services with other Practitioners and Hospital personnel asrelevant to the care, treatment and services of individual patients;Coordinate care, treatment, and services with other Practitioners, hospitalpersonnel, and the Board, as relevant to the care, treatment and services ofan individual patient;2.2.5. Participate in Mercy performance improvement programs; and determinethe use of this information in the ongoing evaluation of Practitioners’competence Review findings of the assessment process that are relevantto an individual’s performance. The organized Medical Staff isresponsible for determining the use of this information in the ongoingevaluations of a practitioner’s competence;2.2.6. Assess inpatient and hospital outpatient medical and health servicesusing a utilization review program based upon specific determination ofindividual medical needs;2.2.7. Participate with Mercy in identifying and meeting community health careneeds and in recommending appropriate institutional goals andimplementing programs to meet those needs;2.2.8. Provide oversight in the process of analyzing and improving patient safetyand satisfaction; and2.2.9. Provide education to patients and families; and2.2.10. Cooperate with and assist the Hospital in maintaining accreditation.3. MEDICAL STAFF MEMBERSHIP3.1. Nature of Medical Staff Membership, GenerallyMedical Staff Membership is not a right but a privilege extended by the Board to thoseprofessionally competent physicians, dentists, podiatrists, psychologists, and chiropractorsand other health professional affiliates Practitioners who continuously meet the- 13 -

qualifications, standards and requirements set forth in these Bylaws. Unless acting undertemporary or emergency Privileges as described in these Bylaws, no person (includingthose in administrative positions) may render health care services independently at theHospital without holding both (a) Medical Staff Membership or authority as an AlliedHealth Professional and (b) delineated Clinical Privileges. No person may admit patientsto the Hospital unless he or she is a Member of the Medical Staff, and then only within thescope of his or her licensure and the Clinical Privileges held he or she holds. A Member isnot an employee or an independent contractor of the Hospital, unless such a relationship isestablished in writing between the Member and the Hospital.3.2. Qualifications for MembershipWith the exception of Emeritus Staff, only Physicians, dentists/oral surgeons, podiatrists,chiropractors, health professional affiliates and psychologists individuals licensed orcertified to practice in the State of Ohio who continuously meet the qualifications andrequirements of Articles 3, 4 and 5 are eligible for Medical Staff Membership. EachMember must:3.2.1. have graduated from a professional school approved by the appropriateaccrediting body; document their experience, background, training,demonstrated ability, and upon request of the Executive Committee of theMedical Staff or of the Board, physical and mental health status, withsufficient adequacy to demonstrate to the Medical Staff and the Board thatthey will provide care to patients at the generally recognized professionallevel of quality, in an economically efficient manner, taking into accountpatients' needs, the available hospital facilities and resources, andutilization standards in effect at the Hospital;3.2.2. hold an current active license to practice medicine, dentistry, podiatry,chiropractic medicine or psychology in Ohio;3.2.3. not be under suspension under a Federal or State Health Program;3.2.4. possess good moral character and the ability to work cooperatively withothers, . are as determined, on the basis of documented references, toadhere strictly to the ethics of their respective professions, and to bewilling to participate in the discharge of Medical Staff responsibilities;3.4.5 in the case of physicians other than members of the Contributing Staff, meetthe standards of the American Board of Medical Specialties or theAdvisory Board for Osteopathic Specialists in their respectivespecialties at the time of initial application or met the standards of suchBoard with respect to formal education and training at the time of thecompletion of their formal education and training, and in the case ofdentists, podiatrists, psychologists, and chiropractors meet standards ofsimilar advanced professional training at comparable times; and3.2.5. Members with clinical privileges must provide evidence of individualprofessional liability insurance coverage in an amount approved by theBoard and with a carrier acceptable to the Board if clinical privileges areheld determined annually by the Staff Executive Committee and appendedto this Code.- 14 -

3.4.6 Administrative and Medico-Administrative Officers A physician, dentist,podiatrist, psychologist, or chiropractor employed by the Hospital in apurely administrative capacity, with no clinical duties or privileges, issubject to the terms of his contract or other conditions of employment,and need not be a member of the Medical Staff. Amedico-administrative officer, i.e., one with clinical responsibilities,must be a member of the Medical Staff, achieving this status by theprocedure provided in Article VI. His clinical privileges must bedelineated in accordance with Article VII. The Medical Staffmembership and clinical privileges of any medico-administrative officershall not be contingent on his continued occupation of that position,unless otherwise provided in his employment agreement3.3. Responsibilities of Medical Staff MembershipBy applying for and holding Medical Staff Membership, each Member agrees to:3.3.1 provide continuous care to his or her patients at a generally recognizedprofessional level of quality and efficiency, if clinical privileges are held;3.3.2 enforce and comply with these Bylaws, the Rules and Regulations and allother rules, policies and regulations of the Medical Staff and of theHospital and Mercy;3.3.3. abide by commonly accepted standards of professional ethics and whilepracticing at the hospital abide by the Ethical Directives for CatholicHealth Care services; the Ethical and Religious Directives for Catholichealth care services while practicing at the Hospital and by othercommonly accepted standards of professional ethics3.3.4. provide where appropriate, emergency care and other professionalservices to patients without regard for their ability to pay;3.3.5. participate in performance improvement and peer review activities;3.3.6. discharge in a responsible and cooperative manner such reasonableresponsibilities and assignments as a Member may assume or receive byvirtue of Medical Staff membership in the applicable Medical Staffcategory, including committee, Department leadership and officerassignments;3.3.7. work cooperatively with Members, non-Member healthcare providers,Hospital administration, Mercy and others so as to ensure the efficientoperation of the Hospital and the provision of quality healthcare to thepatient population;3.3.8. provide accurate information relating to his or her qualifications forMedical Staff Membership and Clinical Privileges (including but notlimited to information that might result in automatic termination) andpromptly provide updated information as changes occur with regard torevocation or suspension of professional license/imposition of terms of- 15 -

probation or limitation of practice by any state licensing agency; loss ofstaff membership or loss or restriction of privileges at any hospital orother health care institution; cancellation or restriction of professionalliability insurance coverage; revocation, suspension or voluntaryrelinquishment of Drug Enforcement Agency (DEA) registration number;the commencement of a formal investigation; the filing of charges by theInspector General, Department of Health and Human Services;3.3.9. make timely payment of dues and assessments as may be levied from timeto time;3.3.10. discharge such other Medical Staff obligations as may be lawfullyestablished from time to time by the Medical Staff or MEC;3.3.11. provide accurate, timely information on changes of address, contactnumbers and coverage arrangements;3.3.12. comply with rules, regulations and policies related to medical records; theMedical Record policy regarding completion of medical records: MedicalRecords policy requires the timely completion of medical records. Thisincludes completion of dictation and signing of appropriate records.When records are not completed in the designated time frame, they areconsidered delinquent. Physicians are notified of their delinquent statusaccording to the Medical Record policy. Failure to complete recordsaccording to the policy shall be monitored by the Medical RecordCommittee and reported to the Medical Executive Committee. Physicianswho are repeatedly delinquent may be required to appear before theMedical Executive Committee to explain their non-compliance. TheMedical Executive Committee shall have the power to recommendcorrective action which may include counseling, letters of reprimand forthe staff members credentials file, temporary suspension of privileges, ortermination of staff privileges, for repetitive non-compliance or failure tocomplete delinquent records while under temporary suspensionStaff members shall have the right to discuss their situation with theMedical Executive Committee prior to the committee makingrecommendations for sanctions. Staff members who are recommended fortermination of medical staff privileges under this section of the bylawsshall have been considered to have voluntarily resigned from the medicalstaff, and, as such, shall not be eligible for a Fair Hearing, as definedelsewhere in the bylaws3.3.13. will maintain professional liability insurance as required by Article 15.4of this Code consistent with your specialty and clinical privileges andscope of practice3.4. General Conditions of Medical Staff Membership3.4.1 Term of Appointment: No appointment or reappointment to the MedicalStaff may exceed two years. Modification of membership or privilegesshall not extend beyond the term of appointment. Modification of- 16 -

appointment, pursuant to Section 6.6, shall be for a period extending tothe end of the then current appointment period.3.4.2 Effect of Other Affiliations: No (physician, dentist, podiatrist, psychologistor chiropractor) person shall be (automatically) entitled to Membershipon the Medical Staff or to exercise particular clinical privileges, merelybecause (he is licensed to practice in this, or in any other state, or becausehe is a member of any professional organization, or because he is certifiedby any clinical board, or because he had or presently has) of his or herMembership, status or Clinical Privileges at any other organization orfacility.3.4.3 Privileges Required: Membership by itself confers no Clinical Privileges.Members must separately apply for and hold Clinical Privileges in orderto perform patient care services.3.4.4 Fees: The MEC, by Membership vote, may impose regular dues, specialassessments, late fees and other fines upon Members.4.2.1 PROVISIONAL STATUS3.4.1.1.Initial AppointmentExcept as otherwise determined by the Board, all initialappointments to any category of the Staff, except consulting,honorary and emeritus, shall be provisional. Eachprovisional appointee shall be assigned to a Department orsuch director’s designee. An initial appointment (andrenewals thereof) shall remain provisional until theDepartment Director or his designee:a) completes a “satisfactory” evaluation of thepractitioner’s professional practice and competence.The extent of this evaluation is determined by theDepartment Director or his designee, or(b) if there is insufficient practice volume at the Hospitalto evaluate the practitioners professional practice andcompetence, “satisfactory” quality data must beobtained from the hospital where the practitioner ismost active in order for the practitioner to be(c)reappointed.upon the Department Director’s completion of a“satisfactory” evaluation, such report shall be madeto the Credentials Committee which will recommendto the MEC and the Board removal of the practitionerfrom Provisional Status.3.4.1.2.Modification in Staff Category and Clinical PrivilegesThe Executive Committee of the Medical Staff mayrecommend to the Board that a change in staff category of a- 17 -

current staff member, or the granting of additional privilegesto a current staff member pursuant to Section 6.6, be madeprovisional in accordance with procedures similar to thoseoutlined in Section 3.5-1 for initial appointments3.4.1.3.Waiver of Provisional Appointment RequirementThe requirement that a practitioner's initial appointment beprovisional may be waived or reduced by a three-fourths(3/4) vote of the Staff Executive Committee, concurred in byeach of the Board. A waiver may be considered in the caseof an extensively experienced practitioner or in such othercircumstances as may be appropriate3.4.5 Leave of Absence: Subject to the duty under these Bylaws to providecontinuous care, a Member may obtain request a voluntary leave ofabsence for a an initial period to not exceed a Member’s unexpired periodof appointment by submitting written Notice stating reason, and andexpected dates of leave return to the CEO Hospital AdministrativeOfficer, and and to the Chief of Staff or MEC. not to exceed one year(stating exact period of time for the leave, which may not exceed twoyears.) (extendable for an additional year by the MEC for good causeshown) by submitting written Notice to the Chief Executive Officer and tothe Chief of Staff or MEC. Leave may not exceed a Member’s unexpiredperiod of appointment. During such leave, the Member's ClinicalPrivileges and prerogatives are suspended.At least 30 days prior to termination of the leave, the Member may requestreinstatement by written request to the Hospital Administrative Officer,Chief of Staff or MEC, which shall include a summary of his or heractivities, maintenance of skills and continuing education during the leave(if the Executive Committee or the Board so requests). The MEC mustthen make a recommendation to the Board as to reinstatement (ofmember’s privileges and prerogatives). Failure to request reinstatementwithin the time allowed may be deemed a voluntary resignation if theperiod of requested leave was less than the unexpired period ofappointment. Where the period of requested leave was less than theunexpired period of appointment, failure to request reinstatement withinthe time allowed will be deemed a voluntary resignation (automatictermination of staff membership, privileges and prerogatives without rightof hearing or appellate review) of Medical Staff Membership. A requestfor staff membership subsequently received from a staff member soterminated shall be submitted and processed in the manner specified forapplications for initial appointments3.5. Voluntary Resignation from the Medical StaffA Medical Staff Member may voluntarily resign Membership and/or Clinical Privileges bysubmitting a written Notice. Such resignation will be effective upon delivery of writtenNotice, which may be submitted electronically, to the medical staff office. Suchresignation shall be effective immediately unless otherwise stated in the written Notice. AMedical Staff Member who resigns to avoid or while under investigation shall be reportedto the National Practitioner Data Bank as required by law.- 18 -

4. CATEGORIES OF MEMBERSHIPThere are four categories of Medical Staff Membership. They are Associate, Active,Associate, Courtesy, Consulting, Contributing, Affiliate and Honorary and Emeritus. Allinitial appointments shall be to the Associate or Affiliate Staff. The qualifications andresponsibilities listed below are in addition to the general qualifications and responsibilitieslisted in the preceding Article.4.1. ASSOCIATE STAFF4.1.1 Qualifications All initial appointments shall be madeto the Associate Staff. which The associate staff shallconsist of physicians, dentists, podiatrists, psychologists, and chiropractors.In order to advance to the Active Staff after completion of two years in thiscategory, Members must be clinically active with a minimum of 24 patientencounters in the Mercy facility in which advancement is sought, within thefirst two-years or be active in Medical Staff affairs.(a) will advance to active staff membership and will, in the ordinarycourse of events, and unless he requests otherwise, be advanced to activestaff status, if he meets the qualifications and after serving two years on theassociate staff;(b) Meets the qualifications specified in Section 4.2-1 for members ofthe active staff;Provided, that chiropractors need not possess clinical privileges in theHospital in order to be members of the associate staff4.1.1 Prerogatives Rights: An Associate Staff member is not required to holdclinical privileges. Associate members who have clinical privileges mayregularly admit patients without limitation within the scope of grantedclinical privileges. Associate Members may attend Medical Staffmeetings but may not vote, hold office or be a Department/CommitteeChair. may hold Level 0 privileges with no admitting privileges. Theprerogatives rights of an Associate staff member shall be to:(a) Admit patients to the Hospital under the same conditions asspecified in Section 4.2-2(a) for active staff members;(b) Exercise such clinical privileges as are granted to him pursuant toArticle VII;(c) Vote on all matters presented at meetings of the department andcommittees of which he is a member.Associate staff members shall not be eligible to hold office in this MedicalStaff organization, or vote at general and special meetings of the Staff4.1.2 Responsibilities- 19 -

4.2. ActiveMembers of the Associate Staff who hold clinical privileges must takeinpatient call and regardless of clinical privileges must accept referrals foroutpatient follow-up, unless excused by the Department Chair as stipulatedin the Rules and Regulations. Each member of the associate staff shall berequired to discharge the same responsibilities as those specified in Section4.2-3 for members of the active staff. Failure to fulfill those responsibilitiesshall be grounds for denial of advancement to active staff status AssociateMembers with clinical privileges will be required to take call unlessexcused for good cause by the Department Chair pursuant to the Rules andRegulations.4.2.1 Qualifications: Active Members must complete a minimum of two years asan Associate member of the Medical Staff. Members of this categoryshall regularly provide evaluation and management services or proceduresto inpatients or outpatients at the Hospital or actively participate inMedical Staff Affairs. In order to advance to or remain a Member of thiscategory, Active Members must be clinically active at the site at whichmember seeks Active membership, or must actively participate in MedicalStaff affairs at the site at which member seeks Active membership.Members of the Active category who do not meet thisclinical/participation requirement will be moved to the Associate Staff atreappointment. Members who exclusively practice telemedicine may notbe Members of the Active Staff. maintain a level of clinical activity of atleast 24 patients at a Mercy facility in a two-year period or must activelyparticipate in Medical Staff Affairs.4.2.2 Rights(Prerogatives): Active Members may admit patients withoutlimitation within the scope of granted Clinical Privileges (except as maybe otherwise provided in the Medical Staff Rules and Regulations orprohibited by law); attend and vote at all Department, Section andcommittee meetings of which he or she is a Member and at all MedicalStaff meetings; hold office; and chair committees. Active Members whoare at least 60 (63 need not accept assigned administrative duties orresponsibilities, but shall have the privilege of participating in all staffactivities) years old and have been on Active status for at least ten yearswho desire designation as a Senior Active status member must submit arequest in writing. Senior Active is an honorary designation and doesnot carry any special privileges. Subject to Section 7.3 below, a dentist,podiatrist, or psychologist member may admit in accord with hisprivileges provided it is demonstrated, at the time of admission, that aphysician member of the Medical Staff has assumed responsibility forthe basic medical appraisal of the patient and for the care of any medicalproblem that may be present or may arise during hospitalization. Achiropractor member shall not be eligible to admit patients in theHospital.4.2.3 Responsibilities: Members of the Active Staff who hold clinicalprivileges must take inpatient call, and regardless of clinical privileges,must accept referrals for outpatient follow-up, emergency call unless- 20 -

excused for good cause by the Department Chair pursuant to as stipulatedin the Rules and Regulations. contribute to the organization andadministration of the Medical Staff. They must will be required to4.2.3.3 Retain responsibility within the area of professional competencefor the daily care and supervision of each patient in the Hospital forwhom they are providing services, or when unavailable arrange asuitable alternate practitioner for such care and supervision.4.2.3.4. Actively participate in the patient care review process andother quality review and improvement activities required of the staff, insupervising provisional appointees of his same profession, and indischarging such other staff function as may from time to time berequired.4.2.3.5. When the physician of record, have the ultimateresponsibility for the patient unless there is a formal written transfer ofcare.4.2.3.6. Report to the director of the department to which he isassigned any quality denial from the PRO, wherever the underlyingevents may have occurred, within one week of receipt.4.3 Courtesy4.3.1. Qualifications: Courtesy Members do not regularly admit patients (mayadmit to the hospital within the limitations and under the same conditionsas specified in section 4.2-2 for active members) and do not regularlycare for Hospital patients. There are no limitations to the number ofpatients that a courtesy staff member may admit, but any member whoadmits more than 12 patients a year in consecutive years will beencouraged to become an active staff member.4.3.2. Rights(Prerogatives): Courtesy Members may attend Medical Staffmeetings (or Hospital Education programs) but may not vote except inassigned committees, hold office or chair any meetings. He may attenddepartment meetings of which he is a member, by invitation.4.3.3. Responsibilities: Courtesy Members may (actively participate in) requestor be required to take emergency call in accordance with the provisionsof the Rules and Regulations. Retain responsibility within his area ofprofessional competence for the care and supervision of each patient inthe Hospital for whom he is providing services, or when unavailablearrange a suitable alternate practitioner for such care and supervision.When the physician of record, have the ultimate responsibility for thepatient unless there is a formal written transfer of care. Report to thedirector of the department to which he is assigned any quality denialfrom the PRO, wherever the underlying events may have occurred,within one week of receipt.4.4 Consulting Staff- 21 -

4.4-1 Qualifications: The consulting staff shall consist of those specialists whoare willing to serve in an advisory capacity when called upon by thedirector of the department involved, and each of whom meets the basicqualifications set forth in Section 3.2-1 (a), (b), and (d).4.4-2 Prerogatives(a) Generally, consulting staff members may write orders; however,they are not eligible to admit patients to the Hospital, or to exerciseclinical privileges such as procedures or surgeries in the Hospital.However, the Executive Committee of the Medical Staff and the SeniorVice President upon recommendation of the director of the departmentinvolved may grant an exception to this rule. When such an exception isgranted, the consulting staff member may admit patients to the Hospitalwithin the limitations provided in Section 4.2-2 for active staff members,and may exercise such clinical privileges as are granted to him pursuant toArticle VII.(b) Consulting staff members shall have the prerogative to attend staffand department meetings and any staff or hospital education meetings.(c) Consulting staff members shall not be eligible to vote or to holdoffice in this organization.4.4-3 ResponsibilitiesEach member of the consulting staff shall be required to discharge thebasic responsibilities specified in paragraphs (b) and (e) of Section 3.3,provided, however, that a consulting staff member granted clinicalprivileges shall be required:5. To discharge all of the basic responsibilities specified in Section3.3; and(b) To retain responsibility within his area of professional competencefor the care and supervision of each patient in the Hospital for whomhe is providing services, or when unavailable arrange a suitablealternate practitioner for such care and supervision.4.3 Affiliate4.3.1. Qualifications: The Affiliate Medical Staff shall consist of Practitionersaffiliated with the Hospital who do not hold Clinical Privileges. Toqualify for the Affiliate Staff, a Practitioner must meet the applicablegeneral qualifications as set forth in these Bylaws. An Affiliate Staffmember must hold Active or Associate membership at one or more MercyHealth Hospital(s), which will be considered their primary hospitalaffiliation.4.3.2 Rights: Each appointee to the Affiliate Medical Staff may:4.3.2.1 Visit their patients who are in the Hospital and review theirpatients’ Hospital medical records, but may not make entries;4.3.2.2 order outpatient diagnostic tests;4.3.2.3 not order therapeutic procedures;- 22 -

Honorary 4.4 EmeritusEmeritus Staff4.3.2.4 not attend Medical Staff meetings or functions. but may not vote,hold office or chair any meeting.4.4.1 Qualifications: Honorary Emeritus Members are nominated by theMEC and approved by the Board for distinguished service. They musthave been active in the Hospital community. served as an ActiveMember. The honorary Emeritus staff shall consist of physicians,dentists, podiatrists, psychologists, and chiropractors recognized for theiroutstanding reputations, their noteworthy contributions to the health andmedical sciences, or their previous long standing service to the Hospital orthe community.4.4.2 Rights: Honorary Emeritus Members may be appointed to Medical StaffCommittees with vote. Members may at their discretion attend generalMedical staff and educational meetings and may , at their discretion,attend Medical Staff, committee and may vote educational meetings butmay not hold office or vote. They may not admit patients or exerciseClinical Privileges. unless they also hold status in another Medical Staffcategory.Qualifications: The emeritus staff shall consist of those who have retired frompractice. Emeritus staff are not required to possess a license or certificateto practice in the State of Ohio.Prerogatives: The prerogatives of an emeritus staff member shall be to attendStaff and department meetings, and any Staff or hospital educationmeeting. Emeritus staff members shall not be eligible to vote or to holdoffice in this organization, or to admit and/or care for patients in theHospital.Responsibilities: Each member of the emeritus staff shall be required to dischargethe basic responsibilities specified in paragraphs (b) and (e) ofSection 3.3. Each member, having met these responsibilities, shall not berequired to be reappointed.Contributing StaffQualifications: The contributing staff shall consist of physicians, dentists,podiatrists, psychologists, and chiropractors.Prerogatives: The prerogatives of a contributing staff member shall be to attendStaff and Department meetings, and any Staff or hospital educationmeeting. Contributing staff members shall not be eligible to vote or tohold office in this organization, or to admit and/or care for patients or toexercise clinical privileges in the Hospital.- 23 -

Responsibilities: Each member of the contributing staff shall be required todischarge the basic responsibilities specified in Paragraphs (b) and (e) ofSection 3.3.Limitation of PrerogativesThe prerogatives set forth under each staff category are general in nature and maybe subject to limitation by special conditions attached to a physician's, dentist's,podiatrist's, psychologist's, or chiropractor's staff membership, by other Sections ofthis Code, or by other policies of the Hospital.4.5 Waiver of QualificationsAny qualification for Medical Staff membership may be waived in uponrecommendation of the MEC and at the discretion of the Board upon determinationthat such waiver will serve the best interests of the patients and of the Hospital.5. APPOINTMENT/REAPPOINTMENT TO THE MEDICAL STAFF5.1. Nature of AppointmentThe Board or delegated Board has final authority for appointments andreappointments to the Medical Staff and the granting, renewal or denial of ClinicalPrivileges based upon the recommendations of the Medical Staff. Applications areprocessed in accordance with the Mercy Health Partners Credentialing Manual,based upon the professional criteria set forth in this Article.5.2. Regional Central Credentials Office (CCO)Mercy Health Partners Southwest Ohio has established a division region-wideCCO. The A purpose of the CCO is to serve as a central credentials informationcollection and verification resource with respect to Practitioners who apply forMedical Staff Membership or Clinical Privileges at one or more of Mercy’sHospitals.5.2.1 Credentialing information will be verified and may be shared within theMercy Health Partners of Southwest Ohio system and is protected fromdisclosure. in accordance with the Mercy Health Partners Medical StaffCredentialing Manual Bylaws.5.2.2 No Discrimination: Neither Medical Staff Membership nor the granting,modification or renewal of Clinical Privileges may not be denied to anyperson solely on the basis of age, sex, race, religion, creed, national originor disability. or any other consideration not impacting on the applicant’sability to properly exercise the Clinical Privileges for which he or she hasapplied. Standards for credentialing and privileging will be uniformlyapplied to all applicants and based on documented training and/orexperience.5.2.3 Incomplete or Misrepresented Information: Material misstatements,omissions or misleading statements are grounds for denial of an- 24 -

application or reapplication, without a hearing under the Fair HearingPlan. Any misrepresentation or misstatement in, or omissions from anapplication, whether intentional or unintentional, shall may be cause forthe application to immediately become null and void, thus, resulting indenial ineligibility for of membership. In the event this application isdeemed null & void or a misrepresentation or misstatement is discoveredon a current Member, such discovery may result in immediate terminationof membership and/or clinical privileges upon the recommendation of theMedical Executive Committee to the Board of Trustees without the rightto a fair hearing and an appeal. If this clause is invoked, the practitionermay not reapply for one year. In the event that membership has beengranted prior to the discovery of such misrepresentation, misstatement, oromission, such a discovery mayA statement that information given in or attached to the application isaccurate and fairly represents the current level of the applicant's training,experience, capability and competence to practice with the clinicalprivileges requested; that any misrepresentation or misstatement in, oromission from the application may constitute cause for automatic andimmediate rejection of the application resulting in denial of appointmentand clinical privileges; and that in the event that appointment or privilegeshave been granted prior to the discovery of such misrepresentation,misstatement or omission, such discovery may result in immediatetermination of the applicant's appointment or privileges.5.3. Professional Criteria for Evaluating Applications5.3.1 Initial Applicants5.3.1.1 An initial applicant will be evaluated to determine whether he or shemeets the prescribed qualifications for Medical Staff Membership.including current licensure, relevant training or experience, currentcompetence and the ability to perform the Clinical Privileges he or she hasrequested. Decisions regarding credentialing and privileging shall relate tothe applicant’s competence, as evidenced by the prescribed qualifications,and by criteria that relate to the quality of the care provided anddocumented by the applicant. If privileging criteria are used that areunrelated to quality of care or professional competence, evidence exists thatthe impact of resulting decisions on the quality of care is evaluated.5.3.1.2 Peer References: Recommendations from peers are obtained andevaluated for all new applicants for Medical Staff Membership. Specificguidelines related to obtaining peer references for both initial andreapplicants are reflected in the Mercy Health Partners Credentials Manual,2.25. privileges. A recommendation from peers is defined as anappropriate Practitioner in the same professional discipline as the applicantwho has personal knowledge of the applicant and the applicant’s ability topractice the requested Clinical Privileges.5.3.1.3 A period of Focused Professional Practice Evaluation isimplemented for all initially requested privileges. The criteria for- 25 -

conducting performance monitoring and for a Focused Professional PracticeEvaluation are reflected in the Mercy Health Partners Credentials Manual.5.3.2 Reappointment Applicants5.3.2.1 Data from the applicant’s practice is used to evaluate currentprofessional competence, judgment and clinical and technical skills. Thetype of data collected and reviewed is determined by the individualdepartments and approved by the organized Medical Staff. Hospitalcollects data which may be used to evaluate Patient Care; Medical/ClinicalKnowledge; Practice Based Learning & Improvement; Interpersonal &Communication Skills; Professionalism; and Systems-Based Practice.5.3.2.2 Peer References: In circumstances where there is insufficientHospital data or information when evaluating an applicant or reapplicant,the organized Medical Staff uses peer recommendations. Specificguidelines related to obtaining peer references for reapplicants are reflectedin the Mercy Health Partners Credentials Manual, 2.25.A recommendationfrom peers is defined as an appropriate Practitioner in the same professionaldiscipline as the applicant who has personal knowledge of the applicant andthe applicant’s ability to practice the requested Clinical Privileges.5.3.2.3 In addition, she/he must satisfy the following additional criteria thefollowing criteria may be considered:5.3.2.3.1 Appropriate use of the Hospital facilities activitiescommensurate with his or her category of membership; membershipand Clinical Privileges;5.3.2.3.2 Cooperation with others and the ability to work with otherhealth care providers and Hospital and Mercy administrativepersonnel; and5.3.2.3.3 Compliance with performance improvement programs andbehavior standards. including reported concerns regarding aprivileged Practitioner’s professional practice are uniformlyinvestigated and addressed through the peer review process asdefined in the Rules and Regulations.5.4. Time Periods for Processing Applications5.4.1 Initial Applications:5.4.1.1 The application process shall be completed within a reasonable time.5.4.1.2 The CCO shall collect and verify information as specified in theMercy Health Partners Credentials Manual, 2.2.13.1.5.4.2 Reappointment applications:- 26 -

6. CLINICAL PRIVILEGES5.4.2.1 Will be mailed out to the reapplicants six months (150 days) prior tothe Hospital reappointment expiration date or earliest Hospitalreappointment expiration date (if Practitioner is on staff at more than oneMHP Hospital);5.4.2.2 will be processed by the CCO as specified in the Mercy HealthPartners Credentials Manual;5.4.2.3 will be submitted to the Hospitals where they will be processedbased upon the earliest Hospital reappointment expiration date.These time limits are guidelines only and do not create any right to have anapplication processed within a particular time.6.1. Delineation of Clinical Privileges6.1.1 Generally: Medical Staff Membership by itself confers no ClinicalPrivileges. Each Practitioner must request Clinical Privileges and mayonly practice within the scope of the Privileges as determined throughmechanisms defined by the organized medical staff. The Board ordelegated Board has final authority for the granting, renewal or denial ofClinical Privileges based upon the recommendations of the Medical Staff.Applications are processed in accordance with the Mercy Health PartnersCredentialing Manual, based upon the professional criteria set forth in thisArticle.6.1.2 Department Responsibility for Delineations: Each Department mustdevelop or revise Clinical Privileges pertinent to its Department inaccordance with the Mercy Health Partners Credentials Manual. Theorganized Medical Staffs, working cooperatively, establishes recommendsuniform criteria for Clinical Privileges, which are then approved by theBoard.6.1.3 Requests For Clinical Privileges: Each Practitioners who desires specificClinical Privileges, or a modification of existing Clinical Privileges mustmake a request by through for them, including completing of theappropriate Clinical Privileges form, if applicable. The burden is on theapplicant to supply all the necessary required information for evaluation.in support of the privilege request.6.1.4 .Basis for the Granting of Clinical Privileges: Clinical Privileges arespecific to the each Hospital. Initial, reapplication and requests formodification of privileges and are and awarded on the basis of theapplicant’s current licensure, education, training, experience, competence,ability and judgment and, if available, OPPE data. Requests forreappointment or status change requests may Also included is informationfrom take into account in Ongoing professional practice evaluation arereview of operative and other clinical procedures performed and theiroutcomes; pattern of blood and pharmaceutical usage; requests for tests- 27 -

and procedures; length of stay patterns; morbidity and mortality data;practitioner’s use of consultants; other relevant criteria as determined bythe organized medical staff are also considered. Review methods and theprocesses for OPPE are defined in the FPPE/OPPE Policy. Informationresulting from the ongoing professional practice evaluation is used todetermine whether to continue, limit or revoke any existing privilege.monitoring concerning the individual’s professional performance,judgment, documented experience in categories of treatment areas orprocedures, results of treatment, the conclusions drawn from organizationperformance-improvement activities when available, and any informationabout adverse privileging decisions, clinical and technical skills. AllClinical Privileges granted must relate to:6.1.4.1. an individual’s documented experience in categories of treatmentareas or procedures;6.1.4.2. the results of treatment; and6.1.4.3. the conclusions drawn from organization performanceimprovementactivities when available.Subject to Section 7.3 below, a dentist, podiatrist, or psychologistmember may admit in accord with his privileges provided it isdemonstrated, at the time of admission, that a physician member ofthe Medical Staff has assumed responsibility for the basic medicalappraisal of the patient and for the care of any medical problem thatmay be present or may arise during hospitalization. A chiropractormember shall not be eligible to admit patients in the Hospital.A chiropractor who does not currently possess clinical privileges shallnot be granted clinical privileges unless the director of thedivision of chiropractic has personally supervised manipulationsby the member of three inpatients or outpatients within theHospital as part of the Hospital's normal clinical services,requested by physician members of the medical staff. Thisinformation shall be added to and maintained in the medicalstaff files established for a staff member.6.1.4.4 Each department director shall recommend the criteria forclinical privileges in his department after consultation withother active members of the department. Upon approval suchcriteria shall be appended to the department's rules andregulations and applicants for privileges in the department shallbe entitled to access to such criteria. The department directorshall review such criteria and the departmental privilege listannually and revise and update them as appropriate.6.2. Regional Central Credentials Office (CCO)- 28 -

6.2.1 Mercy Health Partners Southwest Ohio has established a division regionwideCCO. The purpose of the CCO is to serve as a central credentialsinformation collection and verification resource with respect toPractitioners who apply for Medical Staff Membership or ClinicalPrivileges at one or more of Mercy’s Hospitals.6.2.1.1.Credentialing information will be verified and may beshared within the Mercy Health Partners of Southwest Ohiosystem and is protected from disclosure in accordance withthe Mercy Health Partners Medical Staff CredentialingManual.6.2.1.2.No Discrimination: The granting, modification or renewalof Clinical Privileges may not be denied to any person onthe basis of age, sex, race, religion, creed, national origin,disability or any other consideration not impacting on theapplicant’s ability to properly exercise the ClinicalPrivileges for which he or she has applied. Standards forcredentialing and privileging will be uniformly applied toall applicants and based on documented training and/orexperience.6.2.1.3.Incomplete or Misrepresented Information: Materialmisstatements, omissions or misleading statements aregrounds for denial of an application or reapplication,without a hearing under the Fair Hearing Plan. Anymisrepresentation or misstatement in, or omissions from anapplication, whether intentional or unintentional, shall because for the application to immediately become null andvoid; thus, resulting in denial of membership and/or clinicalprivileges. In the event that membership has been grantedprior to the discovery of such misrepresentation,misstatement, or omission, such a discovery may result inimmediate termination of membership and/or clinicalprivileges without the right to a fair hearing and an appeal.Incomplete or Misrepresented Information: Materialmisstatements, omissions or misleading statements aregrounds for denial of a request for privileges, without ahearing under the Fair Hearing Plan. Any misrepresentationor misstatement in, or omissions from an application,whether intentional or unintentional, shall may be cause forthe application to immediately become null and void, thus,resulting in denial ineligibility for of membership and/orclinical privileges. In the event this privilege request isdeemed null & void or a misrepresentation or misstatementis discovered on a current Member, such discovery may Inthe event that membership has been granted prior to thediscovery of such misrepresentation, misstatement, oromission, such a discovery may result in immediatetermination of membership and/or clinical privileges uponthe recommendation of the Medical Executive Committeewithout the right to a fair hearing and an appeal. If this- 29 -

clause is invoked, the applicant practitioner may not reapplyfor one year.A statement that information given in or attached to the application isaccurate and fairly represents the current level of the applicant's training,experience, capability and competence to practice with the clinicalprivileges requested; that any misrepresentation or misstatement in, oromission from the application may constitute cause for automatic andimmediate rejection of the application resulting in denial of appointmentand clinical privileges; and that in the event that appointment or privilegeshave been granted prior to the discovery of such misrepresentation,misstatement or omission, such discovery may result in immediatetermination of the applicant's appointment or privileges.6.3. Qualifications for Clinical Privileges6.3.1 Board Certification6.3.1.1 If required by applicable delineation of privileges, allosteopathic & allopathic physicians, podiatrists, dentistsand oral surgeons applying for clinical privileges atAnderson, Clermont, Fairfield, and Mercy West, afterJanuary 1 2005, must be board certified, or activelypursuing board certification by an organizationacceptable to the Board, at the time of granting ofprivileges and in all cases must be board certified withinsix (6) years of granting of privileges. Those physicianswho have continuously maintained an appointment sinceDecember 31, 2004, are excluded from this requirement.6.3.1.2 If required by applicable delineation of privileges, allosteopathic & allopathic physicians, podiatrists, dentistsand oral surgeons applying for clinical privileges atJewish after the effective date of these Bylaws, must beboard certified, or actively pursuing board certificationby an organization acceptable to the Board, at the time ofgranting of privileges and in all cases must be boardcertified within six (6) years of granting of privileges.Those physicians who have continuously maintained anappointment since March 1, 2010, are excluded from thisrequirement6.3.2 Waiver of QualificationsAny qualification for Medical Staff membership may be waived inupon recommendation of the MEC and at the discretion of the Boardupon determination that such waiver will serve the best interests ofthe patients and of the Hospital.6.3.3 Initial Applicants- 30 -

6.3.3.1 An initial applicant will be evaluated to determinewhether he or she meets the prescribed qualifications forClinical Privileges, including current licensure, relevanttraining or experience, current competence and theability to perform the Clinical Privileges he or she hasrequested. Decisions regarding privileging shall relate tothe applicant’s competence, as evidenced by theprescribed qualifications, and by criteria that relate to thequality of the care provided and documented by theapplicant. If privileging criteria are used that areunrelated to quality of care or professional competence,evidence exists that the impact of resulting decisions onthe quality of care is evaluated.6.3.3.2 Peer References: Recommendations from peers areobtained and evaluated for all new applicants forprivileges. Specific guidelines related to obtaining peerreferences for both applicants are reflected in theCredentials Manual.6.3.3.3 Hold professional liability insurance coverage in anamount approved by the Board and with a financiallysecure and viable professional liability insurance carrieras determined by the Board, applicable to privilegesrequested;6.3.3.4 A period of Focused Professional Practice Evaluation isimplemented for all initially granted privileges. Thecriteria for conducting performance monitoring and for aFocused Professional Practice Evaluation are reflected inthe Credentials Manual FPPE/OPPE Policy.6.3.4 Reappointment Applicants6.3.4.1 Hospital collects data which may be used to evaluatepatient care, medical knowledge, professionalism,systems-based practice, practice-based learning andimprovement, and interpersonal and communicationskills.6.3.4.2 Peer References: In circumstances where there isinsufficient Hospital data or information when evaluatinga applicant or reapplicant, the organized Medical Staffuses peer recommendations. Specific guidelines relatedto obtaining peer references for reapplicants are reflectedin the Credentials Manual.6.3.5 In addition, the following criteria may be considered:6.3.5.1 appropriate activities commensurate with his or hercategory of membership and Clinical Privileges;- 31 -

6.3.5.2 compliance with performance improvement programsand behavior standards; including reported concernsregarding a privileged Practitioner’s professional practiceare uniformly investigated and addressed through thepeer review process as defined in the Rules andRegulations.Hold professional liability insurance coverage in an amount approved bythe Board and with a financially secure and viable professionalliability insurance carrier as determined by the Board;6.3.5.3 demonstrate current clinical competence, as specificallyestablished by professional education, training andexperience;6.3.5.4 possess the physical, mental and emotional capacity toexercise the Clinical Privileges he or she holds orrequests;6.3.5.5 Have the ability to provide provide continuous care to hisor her patients.6.3.6 Procedures: Clinical Privilege requests will be processed in thesame manner as requests for Medical Staff membership inaccordance with the Mercy Health Partners Credentials Manual.6.3.7 Duration of Clinical Privileges: Clinical Privileges are awarded fora period not exceeding two years, or for such shorter period as maybe specified.6.1.8. Special Conditions for Chiropractic, Dental, Podiatric & PsychologicPrivileges : Requests for clinical privileges from podiatrists, dentists,psychologists and chiropractors shall be processed in the manner specifiedin Section 7.2. Surgical procedures performed by podiatrists shall be underthe overall supervision of the Director of Orthopedic Surgery. Surgicalprocedures performed by dentists shall be under the overall supervision ofthe director of the Department of Surgery. Service performed bypsychologists shall be under the overall supervision of the director of theDepartment of Internal Medicine. All chiropractors shall be members of theDepartment of Orthopaedics and all chiropractic services performed bychiropractors shall be under the overall supervision of the director of theDepartment of Orthopaedics. A physician member of the Medical Staffshall be responsible for the care of any medical problem that may be presentat the time of admission, or that may arise during hospitalization, and shalldetermine the risk and effect of the proposed procedure or service on thetotal health status of the patient. All dental, podiatric and psychologicpatients shall receive the same medical appraisal as patients admitted toother surgical services.6.1.9. Special Conditions for Health Professional Affiliate Services: Requests toperform specified patient care services from health professional affiliates(Adjunct-Affiliate Members) shall be processed in the manner specified in- 32 -

7 Exclusive ContractsSection 7.2. A health professional affiliate may, subject to any licensurerequirement or other legal limitations, participate directly in the medicalmanagement of patients under the supervision of a physician who has beenaccorded privileges to provide such care, and who has ultimateresponsibility for the patient's care.MEC Involvement in Board Decisions to Contract, Define or Limit ServicesExclusive contracts7.1 The Board, after consultation with the MEC, may7.1.1 establish exclusive contractual relationships with any individual or group ofindividuals for the provision of clinical services, or the management ofspecific clinical Departments;7.1.2 close a Department or specialty or limit the number of Practitioners; or7.1.3 define or limit the patient care services to be provided at the Hospital.7.2 Such Board action should take into consideration the efficient management of theHospital; the availability, adequacy and extent of Hospital facilities, adequatelytrained support and monitoring personnel; standards of quality patient care; patientneeds; community needs; and such other criteria as the Board, in consultation withthe MEC, may develop.7.3 Nothing in this section limits the Board’s power to deny Medical Staffappointments or Clinical Privileges in specific cases if the Hospital would beunable to provide adequate facilities, properly trained support personnel ormonitoring of the applicant’s Clinical Privileges or patients.7.4 Exclusive contracts: Exclusive contracts shall only be authorized by specific actionof the Board. The duration, terms and extent of these contracts shall be governedby Board policy.7.4.1 A Member under an exclusive contract (or who is affiliated with agroup under an exclusive contract) with the Hospital must meetand hold continuously all the necessary qualifications of MedicalStaff Membership and Clinical Privileges applicable to thefacilities he or she uses or the services he or she provides.7.4.2 When the Hospital enters into an exclusive contract, Membersmust honor the exclusivity policy and, except in emergencies,arrange for the care of their patients in accordance with theHospital policy and the terms of the applicable agreements.- 33 -

8 TEMPORARY PRIVILEGES8.1 Temporary Privileges7.4.3 Applications for Clinical Privileges covered by a Hospitalexclusivity policy will not be accepted or processed, except inaccordance with the Board policy and/or any existing writtenagreements.7.4.4 Termination of an exclusive contract between the Hospital and:7.4.4.1 a Member (for reasons other than competence orprofessional conduct) is deemed a voluntary resignation of theMember’s Medical Staff Membership and Clinical Privileges;7.4.4.2 a group is deemed a voluntary resignation of theMembership and Clinical Privileges of each Member in the groupunless an individual member continues to provide services withanother group contracted with Mercy Health7.4.5 Termination of any relationship between a group holding anexclusive contract and one or more of its members is deemed avoluntary resignation of the Membership and Clinical Privileges ofthe departing Member(s).7.4.6 Termination of a relationship does not result in theresignation of Membership or Clinical Privileges of a Practitioner tothe extent he or she holds other Clinical Privileges that are not thesubject of an exclusive contract at the Hospital. If Active orAssociate membership is held elsewhere at another Mercy HealthHospital, that membership shall be maintained. will betransferred to Affiliate. Otherwise, membership will bevoluntarily resigned. If practitioner is employed by anothergroup thereafter, a 90-day window after termination withinwhich Affiliate membership may be maintained whileapplication is processed at other site.8.1.1 Circumstances: There are two circumstances in which temporary privilegesmay be granted. Each circumstance has different criteria for grantingprivileges; specific criteria are outlined in the Mercy Health CredentialsManual. The circumstances for which the granting of temporary privilegesis are acceptable include: Temporary privileges are available toPractitioners or AHP’s who have filed appropriate completed applicationsunder two circumstances:8.1.1.1 An applicant for new privileges with a complete applicationthat raises no concerns and is awaiting review and approval by theMedical Executive Committee and the governing body for no more than- 34 -

120 days;Temporary privileges for a new applicant may be granted for nomore than 120 days upon verification of criteria defined in the MercyHealth Partners Credentialing Manual and8.1.1.2 To fulfill an important patient care, treatment and serviceneed. Temporary privileges to fill an important patient care needas set forth in the Mercy Health Partners Credentialing Manual.6.1.5.1 Locum Tenens: Upon receipt of a written request, anappropriately licensed practitioner who possesses the basicqualifications set forth in Section 3.2-1, and who is serving as alocum tenens for a member of the Medical Staff may, withoutapplying for membership on the staff, be granted temporaryprivileges for an initial period of thirty (30) days, but not toexceed his services as locum tenens. Such temporary privilegesmay be granted only after receipt of verification of licensure fromthe appropriate Ohio State licensing board, and verification inwriting of clinical competency to serve as a locum tenens for amember of the staff (if the practitioner is a member of the staff ofanother hospital, by the practitioner's department director on thatstaff).8.1.2 Standards for Approval of temporary privileges: The Hospital ChiefExecutive Administrative Officer (or his/her designee), upon therecommendation of the Chief of Staff (or his/her designee), (Upon writtenconcurrence of the director of the department where the privileges will beexercised, the Sr. VP, or his designee) may grant a request for temporaryprivileges if the applicant meets the qualifications set forth in theseBylaws and in the Mercy Health Partners Credentialing Manual.8.1.3 Condition: Temporary privileges may be granted only when theinformation available reasonably supports a favorable determinationregarding the requesting practitioner’s qualifications, ability and judgmentto exercise the privileges requested, and only after the practitioner hassatisfied the requirement of Section 15.4 regarding professional liabilityinsurance. Special requirements of dual admission, consultation, and/orreporting may be imposed by the director of the department responsiblefor supervision of a practitioner granted temporary privileges. Beforetemporary privileges are granted, the practitioner must acknowledge inwriting that he will abide by the Medical Staff Code of Regulations in allmatters relating to his temporary privileges.8.1.4 Denial or Termination of temporary privileges: The Chief ExecutiveHospital Administrative Officer may, upon consultation with one of thefollowing, Chief of Staff; Chief Elect; Immediate Past Chief; or aDepartment Chairperson (COS not required in TJH—states Chair ofExecutive Cte, which is COS) and the appropriate DepartmentChairperson (or their designees), deny, modify or terminate temporaryprivileges. The termination may also be effected by any person entitled toimpose summary suspension under Article VIII. In the event of any suchtermination, the practitioner's patients then in the Hospital shall beassigned to another practitioner by the department director responsible for- 35 -

supervision. The wishes of the patient shall be considered, wherefeasible, in choosing a substitute practitioner. Such actions, unlessotherwise described, are deemed not to relate to the applicant’s or holder’sprofessional competence or conduct and do not entitle him to a hearingunder the Fair Hearing Plan. Grounds not entitling a practitioner to ahearing may include:8.1.4.1 the applicant’s failure to bear the burden of providing sufficientinformation regarding his licensure, insurance or competence;8.1.4.2 the information reasonably available is insufficient under thecircumstances to allow or continue to allow the practitioner to exercisethe requested Clinical Privileges.8.1.5 Hearing Right: If the applicant’s temporary privileges are terminated MECdenies or terminates temporary privileges on the basis of an appropriateconcern of or professional conduct or competency, the applicant isentitled to hearing rights under Article 1214. A practitioner shall not beentitled to the procedural rights afforded by Article IX because of hisinability to obtain temporary privileges, or because of any termination orsuspension of temporary privileges.8.2 Emergency PrivilegesIn an emergency, any medical staff member with clinical privileges is permitted toprovide any type of patient care, treatment, or services necessary as a life-savingmeasure or to prevent serious harm—regardless of his or her medical staff status orclinical privileges—provided that the care, treatment and services provided arewithin the scope of the individual’s license. Where an emergency exists (meaningthat immediate treatment is necessary to prevent serious or permanent harm, topreserve life or to prevent the serious deterioration or aggravation of a condition),any Member is authorized to do everything possible, within the authority of his orher license, to address the emergency. He or she may do so irrespective of his orher Medical Staff status, Department assignment or Clinical Privileges. He or shemust summon help as soon as possible to arrange for follow-up care by anappropriately privileged Member. A practitioner utilizing emergency privilegesshall promptly provide to the Executive Committee of the Medical Staff, upon itsrequest, in writing a statement explaining the circumstances giving rise to theemergency.8.3 Disaster PrivilegesThe hospital grants disaster privileges to volunteer licensed independentpractitioners only when the Emergency Operations Plan has been activated inresponse to a disaster and the hospital is unable to meet immediate patient needsand the Chief Hospital Administrative Officer has determined that additionalmedical personnel are needed in order to address the emergency. Refer toCredentialing Manual for further information. The (Staff Executive Committeeand the Board of Trustees) organization may grant disaster privileges to volunteerseligible to be licensed independent practitioners when the Chief Executive Officeror his designee has implemented the Hospital’s Emergency Management Plan, and- 36 -

has determined that additional medical personnel are needed in order to address theemergency. Refer to Credentialing Manual (Section 2.3).9 CLINICAL DEPARTMENTS9.1 Organization of DepartmentsEach department shall be organized as a separate part of the MedicalStaff, and shall have a director who is selected, and has the authority,duties, and responsibilities as specified in Article XI. Departments mayalso be subdivided into Divisions and Sections. Such organization of adepartment shall be defined in the Department Rules and Regulations andshall be approved by the Executive Committee of the Medical Staff.9.1.1 The Medical Staff is organized into clinical Departments, each with aChair person. The Departments of the Medical Staff are Medicine andSurgery. 1Current Departments: The current departments are: Clinical Laboratory,Emergency Medicine, Family Practice, Internal Medicine, RadiationMedicine, Radiology, and Surgery.Future Departments: When deemed appropriate, the ExecutiveCommittee of the Medical Staff and the Board, by their joint action, maycreate a new, eliminate, subdivide, further subdivide, or combinedepartments.9.1.2 During the appointment or reappointment process, each Member orPractitioner is may be assigned to one Department. Practitioners mayhold Clinical Privileges in more than one Department but may only votein their assigned Department and are subject to the any rules andregulations of the Department to which they are assigned and of thoseDepartments in which they hold Clinical Privileges.9.1.3 Each Department may organize or operate specialty sections to assist incarrying out the purposes of the Department, advancing education orimproving patient care.9.1.4.1 Each Department Chairperson may, with MEC approval,establish or eliminate such divisions and sections within his or herdepartment and designate the membership of each as he or shedeems appropriate, based on Clinical Privileges 2 . Each Department1Anderson: add Obstetrics/Gynecology; Clermont: add Emergency Medicine and Psychiatry; Fairflield: addEmergency Medicine and Obstetrics/Gynecology; Jewish: add Emergency Medicine, Family Practice, InternalMedicine, Laboratory Services, Radiology, Radiation Medicine and Surgery.2Anderson: Divisions and Sections are established, and members of the division/section chosen, by theChief of Staff, subject to MEC approval.- 37 -

10 OFFICERS9.2 Department LeadershipChairperson, may, with MEC approval, eliminate such Divisionsand sections within his or her Department as deemed appropriate.9.1.4.2 Division or Section leaders are appointed by theDepartment Chair with MEC approval for a elected bysection members to serve a two-year term unless the sectionleader is removed or resigns, or the term is unless otherwiseestablished by contract. Division or Section leaders mayserve multiple terms. Mail balloting is permitted. Divisionor Section Leaders may be removed by a majority vote ofthe Active staff members of that section, by mail ballot or ameeting called for that purpose. The DepartmentChairperson may remove the Division or Section Chair. 39.1.4.3 Divisions and Sections meet as often as is necessary tocarry out their purposes.9.1.4.4 The Department Chairperson is an ex officio member ofeach Division or section, without vote.9.2.1.Positions: Each Department has a Chairperson. and such OtherDepartment leaders may be appointed as the Department may require toperform such functions as required by the Department Chair from time totime.10.1 Selection, Tenure and Removal10.1.1 Identity: The officers of the Medical Staff are the Chief of Staff(President), Chief-Elect (President-Elect), Treasurer, the Immediate PastChief, Clinical Department Chairs and At-Large Members of the MedicalExecutive Committee. 410.1.2 Qualifications: Medical Staff officers must be Members of the ActiveStaff at the time of nomination and election, and must remain sothroughout their tenure. They must hold board certification by anappropriate specialty board. The President-Elect shall not be eligible3Anderson: Division and Section leaders are selected by the Chief of Staff, unless otherwise designated bycontract. They serve two year terms unless they resign or are removed. They may be removed for Reasonable Causeby a vote of the MEC or without cause by the Chief of Staff. Jewish: Division and Section leaders are appointed andremoved by the Chief Hospital Administrative Officer.4 Jewish: The officers of the Medical Staff are Chief of Staff, Chief-Elect, Immediate Past Chief andTreasurer- 38 -

again for election to that post until he has ceased to hold any office listedin Section 11.1-1 for a period of one year.10.1.3 Tenure: The Chief of Staff, Chief-Elect and Immediate Past Chief eachserve two-year terms. Officers commence their terms on January 1 5 (firstday of March following election) following their election and serve untilremoval, resignation or natural expiration of their term. The Secretarymay be removed by the President. Unless otherwise specified by contract,Department Chairpersons serve for a period of two years and may servemultiple terms. He shall serve until the end of the succeeding oddnumbered medical staff year, and until his successor is chosen. A dept.director shall be eligible to succeed himself.10.1.4 Selection: Officers are selected as follows:10.1.4.1 By majority vote of the Active Staff Members, (by and uponthe approval of the Board of Trustees) with the exception ofClinical Department Chairs, who are selected by majority vote ofthe Department’s Active Members, unless otherwise specified bycontract. 6 Associate directors, division directors and sectionchiefs shall be appointed by the Department Director with theapproval of the Executive Committee of the Medical Staff.10.1.4.2 The Chief-Elect succeeds to Chief of Staff at the end of hisor her term; the Chief of Staff, in turn, succeeds to ImmediatePast Chief.10.1.4.3 A Chief-Elect is selected every two years.10.1.4.4 A nominating committee of at least two Active Membersselected by the MEC must propose one or more qualifiedcandidates for each year’s opening offices. Members may alsopropose additional candidates for addition to the ballot. 7Nominations shall be made by a nominating committee consistingof five members appointed by the President of the MedicalStaff two weeks prior to the final yearly general staff meeting.(a) Of the five members:(1) One (1) member shall be a medical staff member withless than three years’ experience.5 Jewish: First day of March following election6 Jewish: Department Directors are appointed by the Chief Hospital Administrative Officer7 Jewish: Nominations shall be made by a nominating committee consisting of 5 members appointed by theChief of Staff two weeks prior to the final yearly general staff meeting. Of the five members, one shall be a medicalstaff member with less than three years’ experience; four members shall be representatives of different specialties anddepartments. The names of the 5 persons selected for the nominating committee will be announced by the Chief ofStaff at the final yearly meeting of the Medical Staff. The nominees for vac ancies will be reported by the nominatingcommittee at the annual meeting of the Medical Staff. Nominations will be accepted from the floor at the annualmeeting.- 39 -

(2) Four members shall be representatives of differentspecialties and departments.(b) The names of the five (5) persons selected for theNominating Committee will be announced by the Presidentof the Medical Staff at the final yearly meeting of theMedical Staff.(c) The nominees for vacancies will be reported by theNominating Committee at the annual meeting of the MedicalStaff.(d) Nominations will be accepted from the floor at theannual meeting.10.1.4.5 Elections are conducted by written ballot (voice vote, unlessnominee requests written) over a 30-day voting period (at theannual meeting of the Staff in each even numbered year). Afterthe expiration of the 30-day voting period, the candidate with themost votes wins. Winners will be announced to the generalMedical Staff. In the event of a tie, the candidates involved in thetie will participate in a 15-day election. The candidate receivingthe most votes will win.Only staff members accorded the prerogative to vote for generalstaff officers under Article IV shall be eligible to vote. Theslate, excluding floor nominations (See 11.1-3(e)), shall beprecirculated to eligible voting members of the Staff at leastthirty (30) days prior to the Annual Meeting. A nominee shallbe elected upon receiving a majority of the votes cast. TheBoard shall be notified of the results of the balloting in writing.Exception:(a) Sections 11.1-3 and 11.1-4 (Nomination & Election)shallnot apply to the Office of President. The President-Elect shall,upon completion of his term of office in that position, immediatelysucceed to the office of President.(b) Sections 11.1-3 and 11.1-4 shall not apply to the Office ofSecretary. The Secretary shall be selected from among themembership of the Executive Committee by the President and willserve in the office concurrently with the President.10.1.4.6 Removal from Office:10.1.4.6.1 An officer who no longer meets the requirements for theoffice held shall be removed;10.1.4.6.2 Officers may be removed by the a 2/3 vote of the MECor by a majority vote of Medical Staff Members eligibleto vote;- 40 -

10.1.4.6.3 Chief of Staff, Chief Elect, Past Chief and MEC At-Large Members may be removed by a (2/3) majority(ballot vote) of Members eligible to vote. Voting maywill be accomplished by written ballot or at a meetingcalled for that purpose;Medical Staff officers may be removed from office by a 2/3 voteof the Executive Committee for any of the following:(1) Failure to perform the duties of the office in a timely andappropriate manner(2) Failure to continuously satisfy the qualifications for and theresponsibilities of the office(3) Physical or mental infirmity that renders the officerincapable of fulfilling the duties of his/her office(4) Conviction of a felonyOr actions as deemed detrimental by a 2/3 vote of the ExecutiveCommittee10.1.4.6.4 Unless otherwise specified by contract, DepartmentChairs may be removed by a majority (may be initiatedby the Board acting upon its own recommendation, orupon the recommendation of the Medical ExecutiveCommittee, or by a two-thirds majority vote of thedepartment members eligible to vote. Removal fromoffice shall be accomplished pursuant to Section 9.3) ofmembers of the Department eligible to vote. Voting maybe accomplished by written ballot or at a meeting calledfor that purpose.General Manner of Removal from office of Medico-AdminOfficerRemoval from office of a medico-administrative officer forgrounds unrelated to his professional clinical capability, and/orhis exercise of clinical privileges may be accomplished inaccordance with the policies of the Hospital or the terms of suchofficer's agreement with the Hospital, if any. To the extent thatthe grounds for removal include matters relating to competence inperforming professional clinical tasks and/or in exercisingclinical privileges, resolution of the matter shall be in accordancewith Articles VIII and IX.Statement of GroundsPrior to removal of a medico-administrative officer, the Boardthrough the Senior Vice President shall transmit to suchmedico-administrative officer, and to the President of the MedicalStaff, a written notice of the proposed removal from officetogether with a statement specifying the grounds for suchremoval. To the extent that such grounds explicitly relate toprofessional clinical capability, or to the exercise of clinicalprivileges, notice to the officer whose removal is sought shall- 41 -

take the form of a special notice, and for hearing purposes, theproposed removal shall be deemed equivalent to an adverserecommendation by the Staff Executive Committee10.1.4.7 Vacancies/Resignations:10.2 Duties of Officers10.1.4.7.1 If the office of the Chief of Staff becomes vacant, theChief-Elect serves the balance of that term, as well as theterm to which they were elected. An election, conductedwithin 90 days as described above, must be held to fillvacancy in the office of Chief-Elect.10.1.4.7.2 If the office of Chief-Elect becomes vacant and:10.1.4.7.2.1 an incoming Chief-Elect has beenelected, that person shall take office;10.1.4.7.2.2 a successor has not been identified, anelection will occur within 90 days in themanner described above.A vacancy in the office of President-Elect shall befilled by a special election conducted as reasonablysoon after the vacancy occurs as possible followingthe general mechanism outlined in Sections 11.1-3and 11.1-4(Nominations and Elections)10.1.4.7.3 The MEC may appoint interim officers to fill vacancyuntil an election can be held.Medical Staff officers are responsible for discharging the duties listed below.Mercy administration will provide assistance and support.10.2.1 Chief of Staff10.2.1.1 Coordinate the activities of the Medical Staff with theactivities of the nursing and other patient care services and theactivities of Mercy and the Hospital;10.2.1.2 Communicate with the Board, Chief Executive HospitalAdministrative Officer, Hospital and Mercy administration andrepresent the opinions, policies, concerns, needs and grievancesof the Medical Staff;10.2.1.3 Speak for the Medical staff on external professional andpublic relations matters;- 42 -

10.2.1.4 Communicate the policies of Mercy and the Board to theMedical Staff;10.2.1.5 Assure Medical Staff compliance, cooperation andparticipation in Mercy quality improvement and utilizationmanagement programs;10.2.1.6 Enforce the Medical Staff Bylaws, Rules and Regulations,policies and procedures and ensure compliance with andadherence to procedural safeguards under the Fair Hearing Plan;10.2.1.7 Call, set the agenda for and preside at meetings of theMedical Staff;10.2.1.8 Appoint members to all standing, special andmultidisciplinary Medical Staff committees except the MEC;10.2.1.9 Serve as chairperson of the MEC and as an ex officiomember without vote (except in cases of a tie) on all otherMedical Staff committees, Departments/Sections. and10.2.1.10 Serve as a member of Physician Council. He or she mayvote without restriction in committees of which he or she is amember; and10.2.1.11 Perform such other tasks as the MEC, Mercy or the Boardmay reasonably request.10.2.2 Chief Elect10.2.2.1 Serve as a member of the MEC, Physicians Council, andQuality Committee of the Board;10.2.2.2 Serve as Chairperson of the Quality and Patient SafetyCouncil;10.2.2.3 Serve as Chairman of the Regulations Committee.10.2.2.4 Assume the duties of the Chief of Staff in his or hertemporary or permanent absence or disability;10.2.2.5 Assume such other duties pertaining to his or her office asthe Chief of Staff may reasonably request.10.2.3 Secretary: Treasurer: The Secretary Treasurer shall may be appointed bythe President Chief of Staff from among the twelve (12) members-at-largeof the Executive Committee MEC of the Medical Staff. His The dutiesduty shall be to supervise the collection and accounting for any funds thatmay be collected in the form of staff dues or assessments or applicationfees. Other duties may be assigned as ordinarily pertain to the office.- 43 -

Give proper notice of all staff meetings on order of the appropriateauthorityPrepare accurate and complete minutes for all meetingsSupervise the collection and accounting for any funds that may becollected in the form of staff dues, assessments, orapplication feesPerform such other duties as ordinarily pertain to the office.10.2.4 Immediate Past Chief:10.2.4.1 Serve as member of the MEC and Physicians Council.10.2.4.2 Assume such other duties pertaining to his or her office asthe Chief of Staff may reasonably request. Perform such otherduties as ordinarily pertain to the office.10.2.5 Department Chairpersons: Department Chairpersons have primaryresponsibility for the duties listed below:10.2.5.1 All clinically-related activities of the Department, includingbut not limited to on-call obligations, medical records complianceand disruptive conduct;10.2.5.2 All administratively related activities of the Department,unless otherwise provided for by the Hospital;10.2.5.3 Continuing surveillance of the professional performance ofall individuals in the Department who have delineated ClinicalPrivileges;10.2.5.4 Recommending to the Medical Staff the criteria for ClinicalPrivileges that are relevant to the care provided in the DepartmentUpon approval such criteria shall be appended to the department'srules and regulations and applicants for privileges in thedepartment shall be entitled to access to such criteria. Thedepartment director shall review such criteria and thedepartmental privilege list annually and revise and update them asappropriate;10.2.5.5 Recommending Clinical Privileges for each Practitionerassigned to the Department;10.2.5.6 Recommending membership for each Practitioner assignedto the Department;10.2.5.7 Assessing and recommending to the relevant Hospitalauthority off-site sources for needed patient care, treatment andservices not provided by the Department or the organization;10.2.5.8 Integrating Department or Service into the other primaryfunctions of Mercy or the Hospital;- 44 -

10.2.5.9 Coordinating and integrating interdepartmental andintradepartmental services within Mercy or the Hospital;10.2.5.10 Developing and implementing policies and procedures thatguide and support the provision of care, treatment and serviceswithin the Department;10.2.5.11 Recommending a sufficient number of qualified andcompetent persons to provide care, treatment and services;10.2.5.12 Determining the qualifications and competence ofDepartment or service personnel who are not licensedindependent practitioners and who provide patient care, treatmentand services;10.2.5.13 Performing continuous assessment and improvement of thequality of patient care, treatment and services provided by theDepartment;10.2.5.14 Maintaining quality control programs, as appropriate;10.2.5.15 Orienting and providing continuing education of all personsin the Department;10.2.5.16 Recommending space and other resources needed by theDepartment;10.2.5.17 Enforcing the applicable Medical Staff Bylaws, Rules andRegulations and Board Bylaws, rules and policies within theDepartment;10.2.5.18 Implementing actions of the MEC, the Board or Mercy thataffect the Department; and10.2.5.19 Performing such other responsibilities as the MEC or Boardmay reasonably require.10.2.5.20 Mercy administration will provide assistance and support.Conduct regular periodic meetings for the purposes of receiving,reviewing and considering findings of the quality reviewand improvement program, and the results of thedepartment's review, evaluation and education activities andof performing, or receiving reports on, other department andstaff functions;Establish such committees or other mechanisms as are necessaryand desirable to perform properly the functions assigned toit.- 45 -

Develop and implement departmental programs, in cooperationwith the President of the Staff, and consistent with theprovisions of Section 10.4 and Article XII, for credentialsreview and privileges delineation, quality review andimprovement, continuing medical education, utilizationreview, concurrent monitoring of practices, andretrospective patient care audit.Appoint such committees as are necessary to conduct the functionsof the department specified in Section 10.4, and designate achairman and secretary for each. Appoint the DivisionDirector who shall serve at the discretion and direction ofthe department director.Develop and monitor criteria for proctoring of professionals withinhis or her department. Maintain written records ofproctoring protocol and services providedDevelop and implement consistent methods, forms or procedureswhich reinforce reliable and effective communication for allpractitioners within the department.Assist in the preparation of such annual reports, includingbudgetary planning, pertaining to his or her department asmay be required by the Staff Executive Committee, theSenior Vice President, or the Board.Department Associate Director(a)Each associate director or shall have the qualifications setforth in Section 11.2-1 (a) for department directors and shallbe appointed by the director with the approval of theExecutive Committee.(b)Term of office: An associate director shall serve a termcommencing on his appointment and continuing until hissuccessor is appointed. Removal of an associate directorfrom office may be made by the department director.(c)Vacancy: Upon a vacancy in the office of associate director,the department director shall appoint a member of thedepartment to fill the vacancy.(d)Duties: The associate director, division director and sectionchiefs shall:- 46 -

11 COMMITTEESAdditional OfficersComplaint Procedure11.1 Committees, Generally6.3.1.1.1.(1) Perform such department functions as assigned by thedepartment director consistent with the department rulesand this CodeThe Board of Trustees may, after considering the advice andrecommendations of the Staff Executive Committee,establish other medico-administrative positions to performsuch duties as prescribed by the Board, or as defined byamendment to this Code. To the extent that any such officerperforms any clinical function, he must become and remaina member of the staff. In all events he must be subject tothis Code and to the other policies of the Hospital.If any member of the staff has a complaint with respect to anyofficer or other official of the staff, he may submit thecomplaint to the Senior Vice President, who may refer thematter to the President of the Medical Staff, the StaffExecutive Committee, or the appropriate hospitaladministrative officer for resolution.The standing committees of the Medical Staff are is the MEC which may and theCredentials Committee, and the Cancer Committee (Ethics Committee, InfectionControl Committee, Medical Record Committee, Regulations Committee). TheMEC (President of the Medical Staff) may establish additional committees (eitherstanding committees or ad hoc committees) as necessary to carry out Medical Staffresponsibilities. (There shall be a Medical Staff Executive Committee and suchother standing and special committees of the staff responsible to the ExecutiveCommittee as may from time to time be necessary and desirable to perform thestaff functions listed in Section 12.3, and elsewhere in this Code. The StaffExecutive Committee may, by resolution, and upon approval by the Board ofTrustees, establish a staff committee to perform one or more of the required stafffunctions. Those functions requiring participation of, rather than direct oversightby the staff may be discharged by medical staff representation on such managementcommittees of the Hospital as are established to perform such functions.). MedicalStaff Members from all MHP Medical Staffs comprise standing RegionalCommittees, which include Physicians Council, Bylaws, JRC and the SystemwideCredentials Oversight Committee. The composition, responsibilities and functionsof all committees other than the MEC, the JRC and the Bylaws Committee are setforth in the Medical Staff Committee Manual. To the extent that any Medical Staffcommittee performs as a Professional Review Body, the proceedings and records ofthat committee shall be confidential and shall be regarded as Peer Review Matterwithin the meaning of these Bylaws. All tangible Peer Review Matter must besecurely stored in the Medical Staff Office.- 47 -

11.2 Medical Executive Committee11.2.1 Membership: All Members of the Medical Staff of any discipline orspecialty are eligible for Membership on the MEC. A majority of thevoting MEC are fully licensed physicians (M.D. or D.O.) activelypracticing in the Hospital. The members of the MEC are the Chief ofStaff, the Chief-Elect, the Immediate Past Chief, the DepartmentChairpersons, At-Large Members, and other Members specified below.All these shall be voting members. The Chief Executive HospitalAdministrative Officer or his or her designee and the Vice PresidentMedical Affairs/Associate Medical Director are ex officio memberswithout vote. If a Department Chair/Medical Director is elected to Chief-Elect, they may appoint a subsequent representative to the MEC with avote. The Chief of Staff is chairperson of the committee. TheChairperson votes only in case of a tie vote by other committee members.11.2.2 Voting/At Large Members: In addition to the above MEC members, MECstructure, by Hospital, includes:11.2.2.1 Anderson: Four At-Large members, who are voted on by theActive Staff and serve a two-year term. Service Representativesand System Credentials representative are appointed by the Chiefof Staff for a two-year term and may be invited to attend, buthold no vote.11.2.2.2 Clermont: Two At-Large members both of whom are votedon by the Active Staff and serve a two-year term. ServiceRepresentatives and System Credentials representative areappointed by the Chief of Staff for a two-year term and may beinvited to attend, but hold no vote.11.2.2.3 Fairfield: Four At-Large members, two from the Departmentof Medicine and two from the Department of Surgery, who arevoted on by the Active Staff members of their respectiveDepartments and serve a two-year term. In addition to the MECMembership noted above, the Medical Directors from theservices of Anesthesiology, Radiology, Hospitalists, CardiacServices, and Pathology and the System Credentialsrepresentative the Credentials Committee Chair are members ofthe MEC and hold a vote. In addition, the Credentials CommitteeChair holds a vote.11.2.2.4 The Jewish Hospital: Twelve (12) members-at-large, votedfor a 3-year term. The Treasurer will be selected from among thetwelve (12) members-at-large by the Chief of Staff. TheDirectors of Internal Medicine and Surgery are ex-officiomembers of the MEC and hold a vote.11.2.2.5 Mt. Airy: Four At-Large members, who are voted on by theActive Staff and serve a two-year term. Service Representatives- 48 -

are appointed by the Chief of Staff for a two-year term and maybe invited to attend, but hold no vote.11.2.2.6 Western Hills: Four At-Large members, who are voted on bythe Active Staff and serve a two-year term. The MedicalDirectors from the Sections of Anesthesiology, EmergencyMedicine, Hospitalist Representative, Physical Medicine &Rehabilitation, Radiology, Behavioral Medicine, Pathology andthe Chair of the Quality & Patient Safety Council are members ofthe MEC and hold a vote.11.2.2.7 Mercy West: Six At-Large members, three from theDepartment of Medicine and three from the Department ofSurgery, who are voted on by the Active Staff members of theirrespective Departments and serve a two-year term. In addition tothe MEC Membership noted above, the representatives from theservices of Pathology, Radiology, Anesthesia, EmergencyMedicine and Hospitalists and the System Credentialsrepresentative Credentials Committee Chair are members of theMEC and hold a vote.11.2.3 An MEC member who is not an officer may be removed by a 2/3 vote ofby the MEC.11.2.4 Meetings: The MEC generally meets monthly but must meet not less thansix (6) times a year. must meet at least ten (nine) times a year and keepdetailed minutes of each meeting.11.2.5 Responsibilities: MEC responsibilities include:11.2.5.1 Acting on behalf of the organized Medical Staff betweenMedical Staff meetings;11.2.5.2 Reviewing, acting and reporting Medical Staffrecommendations directly to the Board on matters pertaining to:11.2.5.2.1 Membership termination;11.2.5.2.2 Medical Staff Membership;11.2.5.2.3 The organized Medical Staff structure;11.2.5.2.4 The process used to review credentials and delineateClinical Privileges;11.2.5.2.5 The delineation of privileges for each practitionerprivileged through the Medical Staff process;- 49 -

11.2.5.3 Evaluating Practitioners in instances where there is doubtabout an applicant’s ability to perform the Clinical Privilegesrequested;11.2.5.4 Participating in the Medical Staff performance improvementactivities;11.2.5.5 Measuring, assessing and improving other processes;11.2.5.6 Conducting Fair Hearing Procedures;11.2.5.7 Receiving and acting upon reports and recommendationsfrom Medical Staff committees, clinical departments andassigned activity groups other relevant sources.11.2.5.8 Participating in identification of community health needs,and in setting the Hospital's goals and implementing programs tomeet those needs.11.2.6 Medical Executive Committee Conflict of Interest11.2.6.1 Effective January 1, 2014 a member of the medical staffwho has a Disqualifying Conflict of Interest will not be eligibleto serve as a member, voting or nonvoting, of the MEC. ADisqualifying Conflict of Interest will exist if a member has afinancial relationship (i.e. an ownership or investment interest inor employment arrangement) with an entity that competes withMercy or any affiliate as determined by Mercy Health’s President& CEO or his designee, unless:11.2.6.1.1 The member is a part of a group that has an exclusivecontract with Mercy and Mercy has waived theDisqualifying Conflict of Interest; or11.2.6.1.2 The Disqualifying Conflict of Interest is not anemployment arrangement and the MEC and Mercyagree that the Disqualifying Conflict of Interest is notmaterial11.2.6.2 A member of the MEC will resign from the MEC if he/shesubsequently develops a Disqualifying Conflict of Interest. Theresignation will be automatic and will be effective upon effectivedate of the Disqualifying Conflict of Interest.Inform the staff of the accreditation program and the accreditation statusof the Hospital.Actions of the Executive Committee5 Actions of the Executive Committee can be called for by referendum- 50 -

5.2 By a majority of the voting members at a regular or special meeting of the MedicalStaff, or5.3 By mail referendum in which a majority of voting members casts a vote for the issue6 Actions of the Executive Committee can be reversed only by a vote of two-thirds (2/3) of themembers present at a Medical Staff meetingRemoval of Members of the MEC7. Members of the MEC may be removed by a 2/3 vote of the MEC for any of the following:7.1. Failure to perform the duties of the “office” in a timely and appropriatemanner7.2. Failure to continuously satisfy the qualifications for and the responsibilities ofthe “office”7.3. Physical or mental infirmity that renders the member incapable of fulfilling theduties of the “office”7.4. Conviction of a felony7.5. or other actions as deemed detrimental by a 2/3 vote of the MECTerm Of OfficeNominationsElectionThe members of the Executive Committee of the Medical Staff shall servea term of office as follows:8. The twelve (12) members-at-large, elected from the Medical Staffshall be for three (3) years9. The Director of Internal Medicine and the Director of Surgery areex officio10. The President and President-Elect shall be for two (2) years11. The Senior Vice President is ex officio12. An ad hoc committee may be appointed by the Medical ExecutiveCommittee to act in matters of credentialing.Nominations for membership to the Executive Committee shall be by theprocedure described in Section 11.1-3, of this Code (THIS IS THEIRSECTION ON OFFICER NOMINATIONS)Election for membership to the Executive Committee shall be by theprocedure described in Section 11.1-4, except that the elections will occuron certain odd years as well as even years since some members areelected for a three year term. (THIS IS THEIR SECTION ONELECTION)Vacancies in the Executive Committee- 51 -

In the event of a vacancy among the at-large members of the ExecutiveCommittee, the same shall be appointed by the President of the MedicalStaff for the interim.11.3 Joint Review Committee11.3.1 Composition: The members of the JRC shall be the Chiefs of Staff ofeach Mercy Medical Staff, or their designees. The JRC may add suchadditional voting members, and for such periods, as it deems necessary.11.3.2 Meetings: The JRC shall meet as often as necessary to carry out itsfunctions.11.3.3Functions: The functions of the JRC are:11.3.3.1 To assist the MECs and PC in credentialing, quality and peerreview matters. where the affected Physician holds or seeks Membershipor Clinical Privileges on more than one Mercy Medical Staff. In thesecircumstances, the following rules apply:11.3.3.2 The JRC representatives of each such staff meet, investigate,hear and deliberate on a matter. The JRC shall forward their unifiedrecommendations to the requesting body their respective Hospital MECsand then on to the Board for approval or to hearing, as appropriate.11.3.3.3 The Board as Final Authority: Notwithstanding theconsultations described in 11.3.3.1 9.3.3.1, each MEC retains itsindividual and independent power and responsibility to make its ownfinal recommendations to the Board.11.3.3.4 Removal: The JRC may remove any member of thecommittee for Reasonable Cause.11.4 Bylaws CommitteeA Bylaws Committee consisting of the Chiefs of Staff of each Mercy MedicalStaff, or their designees, shall meet as often as necessary to review and proposeamendments to the Medical Staff Bylaws, Credentialing Manual, Rules andRegulations and other Medical Staff documents. The Bylaws Committee may addadditional members as needed to perform its function. This committee makes itsrecommendations to each Medical Staff’s MEC for further action in accordancewith these Bylaws.The Regulations CommitteeMembership shall consist of five (5) members of the Medical Staff. The chairmanshall be the President-Elect. In addition, the Senior Vice President or his designee,shall also be a member of this committee. The Regulations Committee shall meetat least annually. It shall be the function of this committee to:12 Conduct an annual review of the Code of Regulations and the rules, regulations, procedures,and form promulgated in connection therewith- 52 -

13 Submit recommendations to the Staff Executive Committee and to the Board for changes inthese documents.14 Act upon all matters specified in subparagraph (a), as may be referred by the Board, theStaff Executive Committee, the departments, the President of the Staff, the Senior VicePresident and committees of the Staff.11.5 Characteristics Common to All Other Committees12. MEETINGSStanding committees (other than the MEC) and other committees created by theMEC have the following characteristics, unless the MEC or these Bylaws provideotherwise:11.5.1 All Medical Staff committees shall report directly to the MedicalExecutive Committee.11.5.2 Composition: All committees must be composed of at least twoActive (Associate) or Associate Members .Active and Associate members hold avote. Committee chairpersons and members are appointed by the Chief of Staff.11.5.3 Non-Medical Staff committee members may serve without vote.The Chief of Staff and the Chief Hospital Executive Administrative Officer (ortheir designees) are ex officio members of each committee without vote. Non-Medical Staff committee members are appointed by the Chief HospitalAdministrative Officer. (unless otherwise expressly provided). The MedicalStaff members and chairperson shall be appointed by the President of the MedicalStaff; management personnel members shall be appointed by the HospitalAdministrative Officer.11.5.4 Term, Removal and Vacancies: Committee members serve for aterm of two years unless they resign or are removed (commencing with hisappointment by the incoming President and terminating when the term of thePresident expires). The MEC may remove any member from a committee by amajority vote. A management personnel committee member may be removed byaction of the Senior Vice President. A committee vacancy is filled in the samemanner as the member was appointed. Non-Medical Staff committee membersmay be removed by action of the Chief Hospital Administrative Officer.12.1 Medical Staff Meetings12.1.1 Regular Meeting: The Medical Staff must meet at least annually (twice ayear, including the annual staff meeting which is in February). It may meetmore frequently, as the MEC may determine.12.1.2 Special Meetings: The (Board), Chief of Staff, MEC or at least 20% (notless than 15%) 25% of the Active Members of the Medical Staff (by writtenpetition) may call a special meeting. Special meetings are may be called todiscuss a specific issue or topic.- 53 -

13 At least fifteen (15) days’ notice must be given to all active and associate members of theMedical Staff14 No business shall be transacted at any special meeting except that stated in the meeting notice12.2 Committee and Department Meetings12.2.1 Regular Meetings: Departments may establish regular meeting dates andtimes by resolution, requiring no further notice.Except as otherwise set forthin these Bylaws, committees, Sections (TJH only Committees) andDepartments must meet as often as necessary (Departments at least fourtimes) to carry out their responsibilities (They shall not replace meetingsof the Medical Staff. Medical Staff meetings may serve in lieu ofdepartmental meetings if the meeting meets the criteria set forth by theJCAHO. Joint meetings may be held by two (2) or more departments).They12.2.2 Special Meetings: May be called by (or at the request of the directorthereof) the (the Board, The President of the Medical Staff or by one-third(1/3) of the department’s current voting members) chairperson of anycommittee or Department. Special meetings must be called when requestedby the Chief of Staff, the MEC or by at least 50 20 percent of the group’sMembers (but not fewer than two). No business shall be transacted at anyspecial meeting except that stated in the meeting notice. Special meetingsmay be are called to discuss a specific issue or topic.12.2.3 Executive Session: All committees and Departments may sit in executivesession and meet with only voting Members who are members of thatcommittee or department present. At the discretion of the chairperson ofthe meeting committee chairperson or Department Chair, otherindividuals may be permitted to attend executive sessions with no vote.12.2.4 Representation on Interdisciplinary Hospital Management CommitteesWhere interdisciplinary committees require Medical Staff participation,such Medical Staff will be appointed by the Chief of Staff. Staff functionsand responsibilities relating to liaison with the Board and the hospitalmanagement, hospital accreditation, and disaster planning shall bedischarged by the appointment of Medical Staff members to such hospitalmanagement committees as are established to perform those functions. Oneof the Medical Staff representatives to each such committee shall bedesignated as the chairman of the "medical staff delegation" to thatcommittee. Appointments of Medical Staff members to any hospitalmanagement committee shall be made by the Chief of Staff. , and suchcommittees shall operate in accordance with the corporate regulations andbylaws and the written policies of the Hospital and of the staff.12.3 Requirements for Conducting Business12.3.1 Notification of Meetings: Notification of any special meeting mustcommunicate purpose, date, time and place. Proper notification of allmeetings (unless called by resolution) must be communicated within a- 54 -

easonable time delivered (either personally or by mail, to each personentitled to be present thereat, not less than fifteen days before the date ofsuch meeting), stating the date, time, place and purpose of any special themeeting. Notice of department or committee meetings may be given orally.If mailed, the notice of the meeting shall be deemed delivered 48 hours afterdeposited, postage prepaid, in the United States mail, addressed to eachperson entitled to such notice at his address as it appears on the records ofthe Hospital. Personal attendance at a meeting shall constitute a waiver ofnotice of such meeting. Cancellation of regularly scheduled meetingsshould be given in the same manner.12.3.2 Attendance: Members are strongly encouraged to attend Medical Staffmeetings and meetings of the Committees and Departments of which theyare members. Members are strongly encouraged to attend as many MedicalStaff meetings and meetings of the committees and Departments of whichthey are members. Failure of a Member without good cause to attend ameeting called for the purpose of inquiring into his or her care of patients,his or her competence or professional conduct are grounds for correctiveaction or termination in accordance with these Bylaws. A practitionerwhose patient's clinical course of treatment is scheduled for review at aregular department, service or committee meeting shall be so notified.Whenever apparent or suspected deviation from standard clinical practice isinvolved, special notice shall be given and shall include a statement of theissue involved and that the practitioner's appearance is mandatory. Thechairman of the meeting shall give the practitioner at least seven (7) daysadvance written notice of the time and place of the meeting. Failure of apractitioner to appear at any meeting with respect to which he was givensuch special notice, shall unless excused by the Staff Executive Committeeupon a showing of good cause, result in an automatic suspension of all orsuch portion of the practitioner's clinical privileges as the ExecutiveCommittee may direct. Such suspension shall remain in effect until thematter is resolved by subsequent action of the Staff Executive Committee orof the Board, or through professional review action if necessary.12.3.3 Special Appearance: A practitioner may be requested to attend a meetingcalled for the purpose of inquiring into his or her care of patients, his or hercompetence, or his or her professional conduct. A practitioner requested toattend a meeting called for such purpose shall be so notified. Notice shallinclude a statement of the issue involved and that the practitioner'sappearance is mandatory. The Committee Chairperson shall give thepractitioner at least seven (7) days advance written notice of the time andplace of the meeting.Failure of a Member, without good cause as determined by the MedicalExecutive Committee, to attend a meeting called for the purpose(s) notedabove is grounds immediate for temporary suspension and for correctiveaction or termination in accordance with these Bylaws.12.3.4 Quorum: Requirements for Quorum are as follows:12.3.4.1 Medical Executive Committee: Attendance by 50percent or more of the voting members of the MEC shall- 55 -

12.3.5 Meeting Proceduresconstitute a quorum and shall be required to conduct a voteat a duly-called or scheduled meeting is sufficient toconduct business. (Majority of voting members of theExecutive Committee)12.3.4.2 Review of credentials activity may be performedapplications by the MEC. Review requires not fewer thantwo (2) voting members. This may be performed in ameeting or by electronic means.Review requires not fewerthan at least 2 voting members.12.3.4.3 For all other duly-called general and special MedicalStaff, Department and committee meetings, a quorumconsists of a sufficient number of voting members toconduct business, but not fewer than two (2).Except as otherwise specified, the action of a majority of themembers present and voting at a meeting shall be the actionof the group. Action may be taken without a meeting by thedepartment or committee by a writing, setting forth theaction so taken, signed by each member entitled to votethereat. Any person who is entitled to attend or to vote at ameeting of the members of the Medical Staff may berepresented and vote at such meeting by proxy or proxiesgiven to another member appointed by a writing signed bysuch person, and such person shall be deemed to be presentat the meeting12.3.5.1 Chairperson:12.3.5.1.1 The Chief of Staff or Chief Elect presides at MedicalStaff meetings and Medical Executive Committee. In theabsence of the Chief of Staff or Chief Elect, the Chief ofStaff will designate the Chair.12.3.5.1.2 The chairperson of a committee or designee presides atcommittee meetings.12.3.5.1.3 The Department Chairperson or designee presides atDepartment meetings.12.3.5.2 The presiding official determines the order of business at a meeting.At a minimum, the agenda must include approval of the previousmeeting’s minutes, reports, old business and new business, theelection of officers and of representatives to Staff committees, whenrequired by this Code; Reports by responsible officers, committees,and departments on the overall results of the quality review andimprovement program and other quality maintenance activities of theStaff, and on the fulfillment of the other required Staff functions;Recommendations for improving patient care within the Hospital.- 56 -

12.3.5.3 Minutes of meetings must be taken, reflecting attendance andbusiness conducted (prepared by the Secretary of the meeting).Access to minutes is available upon request, subject to confidentialityrestrictions. The Medical Staff Office will maintain a file of minutesfor each Medical Staff, committee and Department meeting.12.3.5.4 A majority vote of those present at a meeting at which quorumrequirements are satisfied constitutes action of the group. Action maybe taken without a meeting by the department or committee by awriting, setting forth the action so taken, signed by each memberentitled to vote thereat. Any person who is entitled to attend or tovote at a meeting of the members of the Medical Staff may berepresented and vote at such meeting by proxy or proxies given toanother member appointed by a writing signed by such person, andsuch person shall be deemed to be present at the meeting. A Membermay join the meeting and act by electronic media telephoneconference.12.3.5.5 A virtual meeting may be held via electronic means.12.3.5.6 A group may also act without a meeting via written or email ballot,which must be approved by the majority of Members eligible to vote.13. RESOLVING PROFESSIONAL COMPETENCE, CONDUCT ORDISCIPLINE ISSUES AGAINST MEMBERS OF THE MEDICAL STAFF13.1 Education and ImprovementThe proper functioning of the Medical Staff requires that each Member cooperatewith Mercy, each Mercy Medical Staff, the Hospital, Medical Staff officers, andMedical Staff committees in an effort to continuously improve individual andcollective performance related to quality of care. From time to time, these entities,functions or persons may need to hold routine discussions with individual Membersin order to educate them, assist them in providing better quality medical care, helpthem be more valuable Medical Staff contributors or achieve quality improvement,resource management or other objectives of the Hospital. Neither these discussionsnor the routine functioning of quality improvement, resource management or otherprograms, by themselves, are to be construed as “Investigations” of a Member. Freeflow and use of credentialing and peer review information amongst each MercyMedical staff will occur to allow enhanced performance improvement.13.2 Routine Corrective Actions13.2.1 What Is Covered: Corrective action may be taken in accordance with theprovisions of these Bylaws against involving a Member whose conduct is ormay be:13.2.1.1 Detrimental to the health or welfare of any patient(s);- 57 -

13.2.1.2 Below accepted standards of care within the Member’sprofessional discipline;13.2.1.3 Disruptive to health care facility operations or patient care;or13.2.1.4 Not in compliance with the Bylaws, Rules and Regulationsor policies of the Medical Staff, of the Hospital or of Mercy.13.2.2 Who May Raise: A Medical Staff officer, the Chief Executive HospitalAdministrative Officer, the MEC, Physicians Council, or the Board(“Complainant”) may, upon his or her own knowledge or upon theknowledge of any third party, initiate an inquiry into the need for a possiblecorrective action. Where the physician subject to the inquiry holds ClinicalPrivileges at more than one Mercy Hospital, the Hospital must be notified,and representatives at each such Hospital may initiate separate inquiries andcorrective action either simultaneously or sequentially, upon suchconsultation with each other as time and circumstances may permit.Credentialing and peer review information will be shared between MedicalStaffs. Each MEC initiating an inquiry will notify all such MECs of itsdecision whether or not to proceed with a corrective action and the outcomeof any corrective action.13.2.3 How Handled: When a Complainant has reason to believe that a correctiveaction may be necessary:13.2.3.1 Request: The Complainant (other than the MEC itself)submits a written request for an inquiry into the need for correctiveaction to the MEC, detailing the specific conduct that precipitatesthe request.13.2.3.2 Discussions: Before submitting the request, anyComplainant may, but need not, discuss the matter with theMember. Such a discussion does not constitute an Investigation.13.2.3.3 When commenced: An Investigation does not begin untilsuch time as the MEC formally declares that one is warranted.13.2.3.4 MEC Action Without Investigation: The MEC mayrecommend any corrective action without first conducting anInvestigation if it believes it has an adequate factual basis for doingso.13.2.3.5 Investigation: If the MEC determines that an Investigation iswarranted, it must conduct one.13.2.3.5.1 The MEC may investigate on its own, or it mayassign refer the task to the JRC or an investigativead hoc committee (acting on behalf of one or moreMedical Staffs) consisting of two or more persons.Ad hoc committee members need not be- 58 -

physicians, Members of the Medical Staff orassociated with the Hospital.13.2.3.5.2 The investigating committee may use appropriatelyqualified parties who need not be physicianMembers of the Medical Staff or associated withthe Hospital. Outside consultants may be used.13.2.3.5.3 The investigating committee may, should it sodecide, request the attendance of the Member, uponreasonable Notice, for purposes of an interview.13.2.3.5.4 No person who performs any part of anInvestigation may be in direct economiccompetition with the Member.13.2.3.5.5 If a committee other than the MEC conducts theInvestigation, it must submit a written report to theMEC detailing the results of the Investigation.13.2.3.6 Opportunity to be Heard: Before making a recommendationthat would constitute a Professional Review Action or any otherdisciplinary measure, the MEC must extend a reasonableopportunity to the Member, by Notice, to be heard. A practitionermay be requested to attend a meeting for the purpose of inquiringinto his or her care of patients, competence, or professional conduct.A practitioner requested to attend a meeting for such purpose shallbe so notified. Notice shall include a statement of the issue involvedand that the practitioner’s appearance is mandatory. The CommitteeChairperson shall give the practitioner at least seven (7) daysadvance written notice of the time and place of the meeting. Failureof a member, without good cause as determined by the MedicalExecutive Committee, to attend a meeting for the purpose(s) notedabove is grounds for temporary suspension and for corrective actionor termination in accordance with these Bylaws.13.2.3.7 Not A Hearing: Neither initial discussions with the Membernor any subsequent interview, meeting or appearance under theabove procedures constitutes a hearing and does not entitle theMember to any rights under the Fair Hearing Plan.13.2.3.8 Types of Corrective Action which may be consideredinclude but are not limited to:13.2.3.8.1 A warning, letter of admonition or reprimand;13.2.3.8.2 Time limited terms of probation which shallrequire monitoring of the Practitioner’s actionswith additional episodes of the basis for CorrectiveAction;- 59 -

13.2.3.8.3 Requirement for remedial activity includingadditional education;13.2.3.8.4 Referral to the impaired physician committeePractitioner Effectiveness Committee (See PECpolicy);13.2.3.8.5 Suspension pending medicalconsultation/evaluation by a physician orhealthcare provider mutually acceptable to thePractitioner and Medical Executive Committee;13.2.3.8.6 Involuntary reduction, suspension or revocation ofClinical Privileges;13.2.3.8.7 Sustaining or suspending an already imposedcorrective action, including suspension of ClinicalPrivileges pending investigation;13.2.3.8.8 Requirement for clinical supervising of care,consultation on categories of care, or co-privilegeswith another Practitioner;13.2.3.8.9 Suspension or revocation of Medical StaffMembership;13.2.3.8.10 Modification of an already imposed correctiveaction not consistent with actions set forth at 5through 8;13.2.3.8.11 Other specific snctions as appropriate to thecircumstances13.2.3.9 Recommendation: The MEC must prepare a writtenrecommendation with supporting documentation, sending a copy tothe Member, either:13.2.3.9.1 Concluding that the request is without merit andforwarding the MEC recommendation anddocumentation to the Board for ratification inaccordance with the provisions of this Article;13.2.3.9.2 Recommending no action, action that does notAffect Adversely the Member’s Membership orClinical Privileges or action that does not pertain tothe Member’s competence or professional conductand forwarding the recommendation anddocumentation to the Board for ratification inaccordance with the provisions of this Article; or- 60 -

13.2.3.9.3 Recommending the taking of a ProfessionalReview Action, in which event it must give theMember Notice in accordance with the FairHearing Plan.13.2.3.10 No member of the MEC may take part in the considerationor vote on the recommendation if he or she is in direct economiccompetition with the Member affected.13.3 Temporary Suspensions13.3.1 Imposition: A Member’s voting and Clinical Privileges will may besuspended in accordance with the Rules and Regulations for the following:13.3.1.1 failure to properly complete medical records in accordancewith the Rules and Regulations;13.3.1.2 failure to pay Medical Staff dues;13.3.1.3 failure of a Practitioner to tender written proof of currentTuberculin Testing within three (3) working days of a demand forsuch proof by the Medical Staff Office;13.3.1.4 failure of a Practitioner to carry the minimum level ofprofessional liability insurance or and to tender written proof ofcurrent coverage within three (3) working days of a demand forsuch proof by the Medical Staff Office (A staff member or affiliatewho fails to maintain medical liability insurance as specified inMedical Staff policy, shall immediately and automatically besuspended from practicing in the Hospital);13.3.1.5 failure of a Practitioner after Notice to make a specialappearance at any duly called meeting after notice in accordancewith Article 12.3.3 of the MEC, or an investigating committee or ofthe Board called to discuss the proposed taking of a professionalreview action or any other disciplinary action in accordance withArticle 12, 12.3.3;13.3.1.6 failure of a Practitioner after Notice, to appear at a meetingof the MEC, or an investigating committee or of the Board called todiscuss the proposed taking of a professional review action or anyother disciplinary action (A practitioner who fails to satisfy therequirements of Section 13.7-3 shall immediately and automaticallybe suspended from exercising all or such portion of his clinicalprivileges in accordance with the provisions of said Section 13.7-3);13.3.1.7 a felony indictment, pending further action by the MEC.13.3.2 Duration: Temporary suspensions remain in effect until the deficiency isresolved, the MEC takes action, or until the Membership is terminated byadministrative action.- 61 -

13.3.3 Appeal: A Member may appeal a suspension to the MEC. The MEC’sdetermination is final and is not subject to further review.13.3.4 Exceptions: The Chief of Staff may allow exceptions and permit exerciseof Clinical Privileges upon a showing by the Member of specialcircumstances patient care needs.13.3.5 The Chief of Staff shall submit a report to the Medical ExecutiveCommittee of all suspensions, exceptions and terminations.13.4 Automatic Termination (suspension) of Medical Staff Membership13.4.1 Events Resulting in Automatic Termination: The following events result,without further notice or action, in an automatic termination of a Member’s(or affiliate) Medical Staff membership:13.4.1.1 Revocation or suspension or restriction of a Practitioner’slicense to practice for reasons other than impairment(automatically be suspended from practicing in the Hospital for theduration of the suspension imposed by the State authority);13.4.1.1.1 In the event that a Practitioner’s license topractice is suspended pursuant to Ohio’sImpaired Practitioner statute, the Practitionershall be automatically deemed to be on aLeave of Absence and provisions of BylawsSection 3.4.5 for reinstatement shall apply.Revocation, suspension or restriction of a Practitioner’s DEA certificate(shall immediately and automatically be divested of his right to prescribemedications covered by such registration. As soon as possible after suchautomatic suspension, the Staff Executive Committee shall convene toreview and consider the facts under which the DEA registration was revokedor suspended. The Staff Executive Committee may then take such furtherprofessional review action as is appropriate to the facts disclosed in itsinvestigation);13.4.1.2 exclusion from a Federal Health Program;13.4.1.3 A felony conviction by plea or verdict (upon exhaustion ofappeals after conviction). Revocation pursuant to this section of thecode does not preclude the staff member from subsequentlyapplying for staff appointment13.4.1.4 failure to pay Medical Staff dues13.4.2 No Hearing Right: Automatic terminations do not entitle a Practitioner toany hearing or appeal rights.- 62 -

13.4.3 Care of Patients: The Chairperson of the Department (or President ofStaff) in which a suspended Practitioner holds Privileges must arrange forappropriate alternate care, taking into account to the extent feasible, thewishes of the patient(s). The suspended staff member shall confer with thesubstitute practitioner to the extent necessary to safeguard the patient.13.5 SUMMARY SUSPENSION OF MEMBERS OF THE MEDICAL STAFF:13.5.1 Imposition: Either the MEC (Executive Committee of the Board) or anytwo of the following – the Chief of Staff, Chief Elect, Immediate PastChief, a Department Chairperson or the Chief Executive HospitalAdministrative Officer (Sr. VP) may summarily suspend all or any part ofa Practitioner’s (or affiliate)Medical Staff membership or ClinicalPrivileges where the failure to take such an action may result in imminentdanger to the health of any individual or whenever a practitioner or affiliatewillfully disregards this Code or other hospital policies.13.5.2 Notification: The persons taking action must promptly inform thePractitioner of a summary suspension and the basis for suspension byNotice. The suspension is effective immediately.13.5.3 Care of Patients: The Chairperson of the Department (or President of Staff)in which a suspended Practitioner holds Privileges must arrange forappropriate alternate care, taking into account to the extent feasible, thewishes of the patient(s). The suspended staff member shall confer with thesubstitute practitioner(s) to the extent necessary to safeguard the patient.13.5.4 Physicians Practitioners on Multiple Medical Staffs: Where the PhysicianPractitioner who is summarily suspended holds Clinical Privileges at morethan one Mercy Hospital, the other Hospital(s) must be notified, andrepresentatives who hold suspension powers at each such Hospital mayimpose separate suspensions either simultaneously or sequentially, uponsuch consultation with each other as time and circumstances may permit.Credentialing and peer review information will be shared betweenHospitals. Each Hospital shall advise the other Hospital(s) of its actionpursuant to Section 13.5.5.13.5.5 Procedure After Notification: Within fourteen days after summarysuspension a MEC meeting must occur. The MEC must convene as soonas possible, and in no event later than 30 days after a summary suspension,to review its imposition. The MEC or an investigating committee shouldmake every effort to interview the Practitioner involved. Where thePractitioner under review holds Clinical Privileges at more than one MercyHospital, the affected MEC who initiated the action may submit refer thematter to the JRC for Investigation and/or may meet in a joint session tohear, deliberate and decide on an appropriate action. The initiating MECmay be designated by the other MECs to conduct the investigation. Basedupon the information reasonably available at the time of reconsideration,each MEC must take one of the following actions and notify the Practitionerof its decision: (Exec Cte may recommend modification, continuation, ortermination of the terms of the summary suspension):- 63 -

13.5.5.1 Dissolve the suspension; or13.5.5.2 Modify it to an action that does not Affect Adversely thePractitioner’s Medical Staff membership or Clinical Privileges andpromptly forward its action to the Board for ratification. Suchdissolution or modification has the effect of restoring allmembership rights and Clinical Privileges, subject to further Boardaction; or13.5.5.3 Continue Uphold the suspension or modify it as necessarywhere failure to continue the suspension may result in imminentdanger to the health of any individual.13.5.6 Special Procedure for MEC Suspensions: If the MEC is one of thesuspending entities under 13.5.1, it may recommend a Professional ReviewAction and give the required notice of hearing pursuant to Section 13.5.7below, without the need to reconvene and reconsider its own suspension, ifit believes it has already conducted an adequate Investigation.13.5.7 Right to a Hearing: If, following the reconsideration steps in Section13.5.5, the MEC or the Board takes or recommends a Professional ReviewAction as a result of a summary suspension –13.6 Board Ratification13.5.7.1 against a Physician, Dentist, Podiatrist or psychologist theacting body must give the individual prompt Notice of his or herrights to request a hearing under the Fair Hearing Plan;13.5.7.2 against an AHP, the action body must give the AHP and thesupervising physician prompt Notice or his or her right to request ahearing under Article 13.13.6.1 If the MEC recommends action to the Board under this Article that does notAffect Adversely the membership or Clinical Privileges of a Practitioner –13.6.1.1 and the Board approves the recommendation, it becomesfinal.13.6.1.2 and the Board disagrees with the recommendation:13.6.1.2.1 but takes action that is not a Professional ReviewAction, the decision is final.13.6.1.2.2 and takes a Professional Review Action, it mustgive the Practitioner Notice of his or her right to ahearing under the Fair Hearing Plan or Article 13,as appropriate.- 64 -

13.6.2 The Board must promptly notify the Practitioner and the MEC of anydecision it makes under this Article.14. FAIR HEARING PLAN14.1. Recommendations or Actions14.1.1. The following recommendations or actions shall, if deemed adversepursuant to Section 14.2. of this Article, entitle the Member affectedthereby to a hearing:14.1.1.1.Denial of initial Medical Staff appointment (except failure to meetthe minimum requirements to obtain an application forappointment);14.1.1.2.Denial of requested professional privileges (except temporaryprivileges);14.1.1.3.Denial of reappointment;14.1.1.4.Suspension of Staff membership;14.1.1.5.Revocation of Staff membership;14.1.1.6.Denial of requested advancement in staff membership category;14.1.1.7.Reduction in Staff category or Hospital privileges;14.1.1.8.Reduction in professional and/or Hospital privileges(excepttemporary privileges);14.1.1.9.Suspension of professional and/or Hospital privileges(excepttemporary privileges);14.1.1.10.Revocation of professional and/or Hospital privileges(excepttemporary privileges);14.1.1.11.Terms of probation;14.1.1.12.Involuntary imposition of consultation, co-admission ormonitoring requirements (excluding monitoring incidental toprovisional status) or involuntary imposition of requirements ofadditional education or personal counseling.14.2. When Deemed Adverse14.2.1. A recommendation or action listed in Section 14.114.2.2. of this Article shall be deemed adverse only when it has been:14.2.2.1.Recommended by the Medical Executive Committee; or14.2.2.2.Continued in effect after review by the Medical ExecutiveCommittee and/or the Board; or14.2.2.3.Taken by the Board contrary to a favorable recommendation by theMedical Executive Committee under circumstances where no rightto hearing existed; or14.2.2.4.Taken by the Board on its own initiative without benefit of a priorrecommendation by the Medical Executive Committee; or14.2.2.5.Imposed automatically.- 65 -Deleted: StaffDeleted: StaffDeleted: StaffDeleted: Staff

14.3. Notice of Adverse Recommendation or Action14.3.1. A Member against whom an adverse recommendation or action has beentaken pursuant to Section 14.2 of this Plan shall promptly be given specialnotice of such action. Such notice shall:14.3.1.1.State that an adverse recommendation has been made or adverseaction proposed to be taken against the Member, and the reasonstherefore;14.3.1.2.Advise the Member of his right to request a hearing pursuant to theprovisions of the Code of Regulations Bylaws of the Medical Staffand this Fair Hearing Plan, including a summary of the rights in thehearing;14.3.1.3.Specify the number of days following the date of receipt of noticewithin which a request for a hearing must be submitted;14.3.1.4.State that failure to request a hearing within the specified timeperiod shall constitute a waiver of rights to a hearing and to anappellate review on the matter;14.3.1.5.State that the Member has the right to representation at the hearingand at any appellate review;14.3.1.6.Inform the Member that to the extent required by Ohio and FederalLaw, adverse actions will be reported to the Ohio State MedicalBoard and the National Practitioner Data Bank.14.3.2. Where two or more Mercy Hospitals take or recommend action against asingle Physician based upon the same or similar facts and circumstances,only one Notice that satisfies Bylaws is required.Deleted: 1.2Deleted: practitionerFormatted: Heading 3, Indent: Left:0"14.3.3. Where two or more Mercy Hospitals take or recommend action against asingle Physician based upon the same or similar facts and circumstances,one request for a hearing that satisfies Bylaws is sufficient.14.4. Request for Hearing14.4.1. A Member shall have thirty (30) days following his receipt of a noticepursuant to Article 14.3 to file a written request for a hearing. Such requestshall be delivered to the Senior Vice President Hospital AdministrativeOfficer of the Hospital either in person or by certified or registered mail.14.5. Waiver by Failure to Request a Hearing14.5.1. A Member who fails to request a hearing within the time and in the mannerspecified in Article 14.4 waives any right to such hearing and to anyappellate review to which he might otherwise have been entitled. Suchwaiver in connection with an adverse action by the Board shall constituteacceptance of that action, which shall thereupon become effective as thefinal decision of such Board. Such waiver in connection with an adverserecommendation by the Medical Executive Committee shall result in suchrecommendation being considered by the Board of the Hospital at its nextregular meeting following waiver. In its deliberations, the Board shallreview all the information and material considered by the Medical Execu-- 66 -

tive Committee, and may consider all other relevant information receivedfrom any source. The Board's action on the matter shall constitute a finaldecision of the Board. The Senior Vice President Hospital AdministrativeOfficer of the Hospital governed by such Board shall promptly send theMember special notice informing him of each action taken pursuant to thisSection 1.5 and shall notify the President Chief of Staff of the Medical Staff14.6. Hearing Prerequisites14.6.1. Notice of Time and Place for Hearing14.6.1.1.Upon receipt of a timely request for hearing, the Senior VicePresident Hospital Administrative Officer of the Hospital receivingthe request shall deliver such request to the President Chief of Staffof the Medical Staff or to the Board of such Hospital, depending onwhose recommendation or action prompted the request for hearing.Within thirty (30) days after receipt of such request, the President ofthe Staff Chief of Staff or the Board shall schedule and arrange for ahearing. At least thirty (30) days prior to the hearing, the SeniorVice President Hospital Administrative Officer of the Hospital shallsend the Member special notice of the time, place and date of thehearing. The hearing shall be not less than thirty (30) days nor morethan sixty (60) days from the date of receipt of the request forhearing; provided, however, that a hearing for a Member who isunder suspension then in effect shall be held as soon as thearrangements for it may reasonably be made, but not later thanforty-five (45) days from the date of receipt of the request forhearing14.6.1.2.Where two or more Mercy Hospitals take or recommend actionagainst a single Physician based upon the same or similar facts andcircumstances, the Chiefs of Staff and the Chief Executive Officersof the affected Hospitals will jointly arrange and schedule thehearing and determine the composition and leadership of the hearingpanel. A single notice of hearing to the Member is sufficient.14.6.2. Statement of Issues and Events14.6.2.1.The notice of hearing required by Article 14.6 shall contain aconcise statement of the Member’s alleged acts or omissions, a listby number of the specific or representative patient records inquestion and/or the other reasons or subject matter forming the basisfor the adverse recommendation or action which is the subject of thehearing, and a list of witnesses (if any) expected to testify at thehearing on behalf of the professional review body14.6.3. Appointment of Hearing Committee14.6.3.1.By Medical Staff- 67 -

14.6.3.1.1.A hearing occasioned by an adverse Medical ExecutiveCommittee recommendation pursuant to Articles 14.2.1.1or 14.2.1.2 1.2(a) or (b) shall be conducted by a hearingcommittee appointed by the President Chief of Staff of theMedical Staff and composed of not less than five (5) three(3) Members of the Medical Staff, a majority of whomshall not have actively participated in the consideration ofthe adverse recommendation. All Members of the hearingpanel must be physicians but need not be Medical StaffMembers. If the Member is an allopathic physician, atleast one Member of the hearing committee shall be anallopathic physician; if the Member is an osteopathicphysician, at least one Member of the hearing committeeshall be an osteopathic physician. One of the Members soappointed shall be designated as the Chair by the Chief ofStaff14.6.3.1.2.By BoardDeleted: memberDeleted: memberDeleted: memberDeleted: memberDeleted: man14.6.3.1.2.1.A hearing occasioned by an adverse action ofthe Board pursuant to Article 14.2.1.2, 14.2.1.3 or14.2.1.4 Section 1.2(b), (c), or (d) shall beconducted by that Board or its Appeals Committee14.6.3.2.Service on Hearing Committee14.6.3.2.1.A Staff or Board member shall not be disqualified fromserving on a hearing committee merely because heparticipated in initiating or investigating the underlyingmatter at issue, or because he has heard of the case, or hasknowledge of the facts involved or what he supposes to bethe facts. or a practitioner who has either requested, or hasserved on a body that has, recommended the adverseaction. No Member of a hearing committee shall be aMember in direct economic competition with the Memberfor whom the hearing is held, play any part in presentingthe case against the Member or have participated ininvestigating or deciding a prior phase of the case. Priorknowledge of the facts if not a disqualifying circumstance.Deleted: member14.7. Hearing Procedures14.7.1. Personal Presence14.7.1.1.The personal presence of the Member who requested the hearingshall be required. A Member who fails without good cause toappear and proceed at such hearing shall be deemed to have waivedhis rights in the same manner and with the same consequence asprovided in Article 14.514.7.2. Presiding Officer- 68 -

14.7.2.1.The Chair of the hearing committee shall be the presiding officer.The presiding officer shall act to maintain decorum and to assurethat all participants in the hearing have a reasonable opportunity topresent relevant oral and documentary evidence. He shall beentitled to determine the order of procedure during the hearing andshall make all rulings on matters of law, procedure, and theadmissibility of evidenceDeleted: Either theDeleted: hearing officer, if one isappointed pursuant to Article 14.12.3Section 8.3, or the chairman14.7.3. Representation14.7.3.1.The Member who requested the hearing and the Medical ExecutiveCommittee or the Board, depending on whose recommendation oraction prompted the hearing, shall be entitled to be accompanied andrepresented at the hearing by an attorney or other person of itschoice14.7.4. Rights of Parties14.7.4.1.During a hearing, each of the parties shall have the right to:14.7.4.1.1.1.Call and examine witnesses;14.7.4.1.1.2.Introduce exhibits;14.7.4.1.1.3.Cross-examine any witness on any matter relevant tothe issue;14.7.4.1.1.4.Impeach any witness;14.7.4.1.1.5.Rebut any evidence;14.7.4.1.1.6.Request that the record of the hearing be made by use ofa court reporter or an electronic recording unit;14.7.4.1.1.7.If the Member who requested the hearing does nottestify in his own behalf, he may be called and examined asif under cross-examination.Deleted: practitioner14.7.5. Procedure and Evidence14.7.5.1.The hearing need not be conducted strictly according to rules oflaw relating to the examination of witnesses or presentation ofevidence. Any evidence determined to be relevant by the presidingofficer shall be admitted, regardless of the admissibility of suchevidence in a court of law. Each party shall, prior to or during thehearing, be entitled to submit memoranda concerning any issue oflaw or fact and a written statement at the close of the hearing, andsuch memoranda and statements shall become part of the hearingrecord. The hearing committee may require one or both parties toprepare and submit to the committee written statements of theirposition on the issues, prior to, or after, the hearing. The presidingofficer may, but shall not be required to, order that oral evidence betaken only on oath or affirmation administered by any persondesignated by him and entitled to notarize documents in the state- 69 -

14.7.6. Official Noticewhere the hearing is held or that written submissions be in affidavitform14.7.6.1.In reaching a decision, the hearing committee may take officialnotice, either before or after submission of the matter for decision,of any generally accepted technical or scientific matter relating tothe issues under consideration and of any facts that may be judiciallynoticed by the courts of the state where the hearing is held. Partiespresent at the hearing shall be informed of the matters to be noticedand those matters shall be noted in the hearing record. Any partyshall be given opportunity, on timely request, to request that a matterbe officially noticed and to refute the officially noticed matters byevidence or by written or oral presentation of authority, the mannerof such refutation to be determined by the hearing committee. Thecommittee shall also be entitled to consider all other informationthat can be considered, pursuant to the Code of Regulations Bylawsof the Medical Staff or Medical Staff policies Rules andRegulations, in connection with applications for appointment orreappointment to the Staff and for professional privilegesDeleted: r14.7.7. Burden of Proof14.7.7.1.When a hearing relates to Section 1.1(a) or (b) Articles 14.1.1.1 or14.1.1.2 the Mermber who requested the hearing shall have theburden of providing, by clear and convincing evidence, that theadverse recommendation or action lacks any substantial factual basisor that such basis or the conclusions drawn therefrom are eitherarbitrary, unreasonable, or capricious. When the hearing relates toSection 1.1(c)-(l), 14.1.1.3 the body whose adverse recommendationor action occasioned the hearing shall have the initial obligation topresent evidence in support thereof; but the Member shall thereafterbe responsible for supporting his challenge to the adverserecommendation or action by a preponderance of the evidence thatthe grounds therefore lack any substantial factual basis or that suchbasis or the conclusions drawn therefrom are either arbitrary,unreasonable, or capricious14.7.8. Record of Hearing14.7.8.1.A record of the hearing shall be kept that is of sufficient accuracyto permit an informed and valid judgment to be made by any groupthat may later be called upon to review the record and render arecommendation or decision in the matter. The hearing committeemay select the method to be used for making the record, such ascourt reporter, electronic recording unit, detailed transcription, orminutes of the proceedings. A copy of the record may be obtainedby the Member upon payment of any reasonable charges associatedwith the preparation thereof14.7.9. Postponement- 70 -

14.7.9.1.Requests for postponement of a hearing shall be granted by thehearing committee or the Chair thereof only upon a showing of goodcause and only if the request therefore is made as soon as isreasonably practicalDeleted: chairman14.7.10.Presence of Hearing Committee Members and Vote14.7.10.1.A majority of the hearing committee must be present throughoutthe hearing and deliberations. If a committee Member is absentfrom any part of the proceedings, he shall not be permitted toparticipate in the deliberations or the decisionDeleted: member14.7.11.Recesses and Adjournment14.7.11.1.The hearing committee may recess the hearing and reconvene thesame without additional notice for the convenience of theparticipants or for the purpose of obtaining new or additionalevidence or consultation. Upon conclusion of its deliberations, thehearing shall be declared finally adjourned14.8. Hearing Committee Report and Further Action14.8.1. Hearing Committee Report14.8.1.1.Within thirty (30) days after final adjournment of the hearing, thehearing committee shall make a written report of its findings andrecommendations in the matter, including a statement of the basisfor its recommendations, and shall forward the same, together withthe hearing record and all other documentation considered by it, tothe body whose adverse recommendation or action occasioned thehearing. The affected Member shall have the right upon request toreceive a copy of the written recommendations of the hearingcommittee, including the statement of the basis for therecommendations14.8.2. Action on Hearing Committee Report14.8.2.1.Within thirty (30) days after receipt of the report of the hearingcommittee, the Medical Executive Committee or the Board, as thecase may be, shall consider the same and affirm, modify or reserveits recommendation or action in the matter. It shall transmit thedecision in writing, including a statement of the basis for thedecision, together with the hearing record, the report of the hearingcommittee and all other documentation considered, to the SeniorVice President Hospital Administrative Officer of the Hospital14.8.3. Notice and Effect of Result14.8.3.1.Notice- 71 -

14.8.3.1.1.1.The Senior Vice President Hospital AdministrativeOfficer of the Hospital receiving the request for hearing shallpromptly send a copy of the written decision, including thestatement of the basis for the decision, to the Member byspecial notice, to the President Chief of Staff of the MedicalStaff, to the Medical Executive Committee, and to thePresident(s) Hospital Administrative Officer(s) of the otherHospital(s)14.8.3.2.Effect of Favorable Result14.8.3.2.1.1.Adopted by the Board: If the Board's result pursuant toArticle 14.8.2 Section 4.2 is favorable to the Member, suchresult shall become the final decision of the Board and thematter shall be considered finally closed14.8.3.2.1.2.Adopted by the Executive Committee: If the MedicalExecutive Committee's result is favorable to the Member, theSenior Vice President Hospital Administrative Officer of theHospital shall promptly forward it, together with allsupporting documentation, to the Board for its final action.The Board shall take action thereon by adopting or rejectingthe Medical Executive Committee's result in whole or inpart, or by referring the matter back to the Medical ExecutiveCommittee for further reconsideration. Any such referralback shall set a time limit within which a subsequentrecommendation to the Board must be made. After receiptof such subsequent recommendation and any new evidencein the matter, the Board shall take final action. The SeniorVice President Hospital Administrative Officer of theHospital shall promptly send the Member special noticeinforming him of each action taken pursuant to this Section4.3-2(b) Article 14.8.3.2.1.2. Favorable action shall becomethe final decision of the Board, and the matter shall beconsidered finally closed. If the Board's action is adverse inany of the respects listed in Section 1.1 Article 14.1 of thisPlan, the special notice shall inform the Member of his rightto request an appellate review by the Board as provided inArticle 14.9.2 Section 5.1 of this Plan14.8.3.3.Effect of Adverse Result14.8.3.3.1.1.If the result of the Medical Executive Committee or ofthe Board continues to be adverse to the Member in any ofthe respects listed in Article 14.1 Section 1.1 of this Plan, thespecial notice required by Article 14.8.3.1 4.3-1 shall inform- 72 -

the Member of his right to request an appellate review by theBoard as provided in Section 5.1 Article 14.9.1 of this Plan.In addition, the notification of an adverse result shall informthe Member that to the extent required by Ohio and Federallaw, adverse actions will be reported to the Ohio StateMedical BoardDeleted: practitioner14.9. Initiation and Prerequisites of Appellate Review14.9.1. Request for Appellate Review14.9.1.1.A Member shall have thirty (30) days following his receipt of anotice pursuant to Article 14.8.3.2.1.2 or Article 14.8.3.3 Section4.3-2(b) or Section 4.3-3 to file a written request for an appellatereview. Such request shall be delivered to the Senior Vice PresidentHospital Administrative Officer of the Hospital receiving the initialrequest for a hearing either in person or by certified or registeredmail and may include a request for a copy of the report and record ofthe hearing committee14.9.2. Waiver by Failure to Request Appellate Review14.9.2.1.A Member who fails to request an appellate review within the timeand in the manner specified in Article 14.9.1 Section 5.1 above,waives any right to such review. Such waiver shall have the sameforce and effect as that provided in Article 14.5 Section 1.5 of thisPlan14.9.3. Notice of Time and Place for Appellate Review14.9.3.1.Upon receipt of a timely request for appellate review, the SeniorVice President Hospital Administrative Officer of the Hospitalreceiving the request for appellate review shall deliver such requestto the Board of such Hospital. As soon as practicable, the Boardshall schedule and arrange for an appellate review which shall be notless than thirty (30) days nor more than sixty (60) days from the dateof receipt of the appellate review request; provided, however, that anappellate review for a Member who is under a suspension then ineffect shall be held as soon as the arrangements for it mayreasonably be made, but not later than thirty (30) days from the dateof receipt of the request for review. At least thirty (30) days prior tothe appellate review, the Senior Vice President HospitalAdministrative Officer of the Hospital shall send the Memberspecial notice of time, place and date of the review. The time for theappellate review may be extended by the Appellate Review Body orthe Chair thereof for good cause and if the request therefore is madeas soon as is reasonably practicalDeleted: appellate review bodyDeleted: chairman14.9.4. Appellate Review Body- 73 -

14.9.4.1.The Board shall determine whether the appellate review shall beconducted by the Board as a whole, or by the Appeals Committee ofthe Board14.10. Appellate Review Procedures14.10.1.Nature of Proceedings14.10.1.1.The proceedings by the review body shall be in the nature of anappellate review based upon the record of the hearing before thehearing committee, that committee's report, and all subsequentresults and actions thereon. The Appellate Review Body shall alsoconsider the written statements, if any, submitted pursuant to Article14.10.2 Section 6.2 of this Plan and such other material as may bepresented and accepted under Article 14.10.4 and 14.10.5 Section6.4 and Section 6.5 of this PlanDeleted: appellate review body14.10.2.Written Statements14.10.2.1.The Member seeking the review may submit a written statementdetailing the findings of fact, conclusions and procedural matterswith which he disagrees and his reasons for such disagreement.This written statement may cover any matters raised at any step inthe hearing process. The statement shall be submitted to theAppellate Review Body through the President HospitalAdministrative Officer of the Hospital at least ten (10) days prior tothe scheduled date of the appellate review, except if such time limitis waived by the appellate body. A written statement in reply maybe submitted by the Medical Executive Committee or by the Board,and if submitted, the President Hospital Administrative Officer ofthe Hospital shall provide a copy thereof to the Member at leastthree (3) days prior to the scheduled date of the appellate review14.10.3.Presiding Officer14.10.3.1.The Chair of the Appellate Review Body shall be the presidingofficer. He shall determine the order of procedure during the review,make all required rulings and maintain decorum14.10.4.Oral Statement14.10.4.1.The Appellate Review Body, in its sole discretion, may allow theparties or their representative to personally appear and make oralstatements in favor of their positions. Any party or representative soappearing shall be required to answer questions put to him by anyMember of the Appellate Review Body14.10.5.Consideration of New or Additional MattersDeleted: appellate review bodyDeleted: chairmanDeleted: appellate review bodyDeleted: appellate review bodyDeleted: memberDeleted: appellate review bodyFormatted: Underline14.10.5.1.New or additional matters or evidence not raised or presentedduring the original hearing or in the hearing report and not otherwise- 74 -

14.10.6.Powersreflected in the record shall be introduced at the appellate reviewonly in the discretion of the Appellate Review Body, following anexplanation by the party requesting the consideration of such matteror evidence as to why it was not presented earlier14.10.6.1.The Appellate Review Body shall have all the powers granted tothe hearing committee, and such additional powers as are reasonablyappropriate to the discharge of its responsibilities14.10.7.Presence of Members and Vote14.10.7.1.A majority of the Appellate Review Body must be presentthroughout the review and deliberations. If a Member of the reviewbody is absent from any part of the proceedings, he shall not bepermitted to participate in the deliberations or the decision14.10.8.Recesses and Adjournment14.10.8.1.The Appellate Review Body may recess the review proceedingsand reconvene the same without additional notice for theconvenience of the participants or for the purpose of obtaining newor additional evidence or consultation. Upon the conclusion of oralstatements, if allowed, the appellate review shall be closed. TheAppellate Review Body shall thereupon, at a time convenient toitself, conduct its deliberations outside the presence of the parties.Upon the conclusion of those deliberations, the appellate reviewshall be declared finally adjourned14.10.9.Action Taken14.10.9.1.The Appellate Review Body may recommend that the Boardaffirm, modify or reverse the adverse result or action taken by theMedical Executive Committee or by the Board pursuant to Article14.8.2 or Article 14.8.3.1 Section 4.2 or 4.3-2(b) or, in its discretion,may refer the matter back to the hearing committee for furtherreview and recommendation to be returned to it within thirty (30)days and in accordance with its instructions. Within thirty (30) daysafter receipt of such recommendations after referral, the AppellateReview Body shall make its recommendation to the Board asprovided in this Article 14.10.9 Section 6.9Deleted: appellate review bodyDeleted: appellate review bodyDeleted: appellate review bodyDeleted: memberDeleted: appellate review bodyDeleted: appellate review bodyDeleted: appellate review bodyDeleted: appellate review body14.10.10.Conclusion14.11. Board Action14.10.10.1.The appellate review shall not be deemed to be concluded untilall of the procedural steps provided herein have been completed orwaived- 75 -

14.11.1.Within sixty (60) days after the conclusion of the appellate review, theBoard shall render its final decision in the matter in writing and shall sendnotice thereof to the Member by special notice, to the President Chief ofStaff of the Medical Staff, and to the Medical Executive Committee. TheBoard's action shall be immediately effective and final.14.12. General Provisions14.12.1.Time Periods14.12.1.1.The time periods specified herein are to assist those named inaccomplishing their tasks and shall serve as guidelines only; suchtime periods shall not be deemed to create any right for the Memberto have any action taken within those periodsDeleted: practitioner14.12.2.Special Notice14.12.2.1.Special notice means written notification sent by certified orregistered mail, return receipt requested14.12.3.Number of Hearings and Reviews14.12.3.1.Notwithstanding any other provision of the Code of RegulationsBylaws of the Medical Staff, no Member shall be entitled as a rightto more than one evidentiary hearing and appellate review withrespect to an adverse recommendation or action14.12.4.ReleaseDeleted: Hearing OfficerAppointment and Duties The use of a hearing officer to presideat an evidentiary hearing is optional. Theuse and appointment of such officer shallbe determined by the hearing committeeafter consultation with the PresidentHospital Administrative Officer of theHospital. A hearing officer may or maynot be an attorney at law. He shall act asthe presiding officer of the hearing14.12.4.1.By requesting a hearing or appellate review under this Article FairHearing Plan, a Member agrees to be bound by the provisions ofArticle 15 XIV of the Code of Regulations Bylaws of the MedicalStaff relating to confidentiality, releases and immunity from liabilityin all matters relating thereto.14.12.5.Waiver14.12.5.1.If at any time after receipt of special notice of an adverserecommendation, action or result, a Member fails to make a requiredrequest or appearance or otherwise fails to comply with this Articleor to proceed with the matter, he shall be deemed to have consentedto such adverse recommendation, action or result and to havevoluntarily waived all rights to which he might otherwise have beenentitled under the Code of Regulations Bylaws of the Medical Staffthen in effect or under this Fair Hearing Plan Article with respect tothe matter involved14.12.6.Effect on Hospitals- 76 -

14.12.6.1.A single notice of right to hearing to the Physician is sufficient aslong as one of the bodies that took or recommend actioncomprehensively identifies each Hospital affected, all actions takenand the grounds for each action.14.12.6.2.A request for hearing and all other Notices from the Physician toone Hospital Administrative Officer is deemed sufficient notice toall Hospital Administrative Officers affected.14.12.6.3.The Chiefs of Staff and Hospital Administrative Officers of theaffected Hospitals will jointly arrange and schedule the hearing andselect the hearing officer or determine the composition andleadership of the hearing panel. A single notice of hearing to theMember is sufficient if issues by the Hospital Administrative Officerof one of the Hospitals affected.14.12.6.4.Any adverse action taken by the Board shall be applicable withrespect to privileges at all of the Hospitals14.13. ADOPTION AND AMENDMENT (NOT SURE WE NEED THIS)ALLIED HEALTH PROFESSIONALSComment: Moved to AHP Manual15. CONFIDENTIALITY, IMMUNITY AND RELEASEBy submitting an application for Medical Staff appointment or a request for ClinicalPrivileges, each Practitioner agrees to be bound by the specific provisions of this Article.15.1. Information Collection and Handling15.1.1. “Mercy Representatives” (defined in this article to mean the Board, eachBoard member, each Board committee, the Chief Executive HospitalAdministrative Officer, each Hospital employee, each Hospitalcommittee, the Medical Staff, each Member, officer and committeethereof, each Mercy employee, and each other individual who isauthorized to gather, analyze, use or disseminate information concerningPractitioners) are specifically authorized within the reasonable scope oftheir responsibilities to solicit, receive and act upon information relatingto a Practitioner’s qualifications;15.1.2. Third parties are specifically authorized to release information about aPractitioner’s qualifications to Mercy Representatives.15.1.3. Mercy Representatives are specifically authorized to release informationabout a Practitioner’s qualifications to other hospitals, health care entities,authorized health care licensing, data collection or reporting agencies, tothe extent consented to in the next section or to the extent required orpermitted by law.15.2. Confidentiality in Professional Review Activities- 77 -

15.2.1. Members who serve on Professional Review Bodies are entitled to theconfidentiality of their Professional Review Activities in order to fostercandid and complete assessments of professional qualifications.Practitioners whose qualifications are reviewed are likewise entitled toconfidentiality and disclosure of information about them to others only inthe manner permitted by law and by these Bylaws.15.2.2. Practitioners are forbidden to disclose Peer Review Matter to any otherperson, except as expressly provided in this section.15.2.3. “Peer Review Matter” includes:15.2.3.1.information, data, reports or records supplied by anyperson to a Mercy Representative in furtherance of aProfessional Review Activity;15.2.3.2.information, data, reports or records created by aProfessional Review Body or by any of its members,employees, assistants or persons under contract in thecourse of a Professional Review Activity;15.2.3.3.conversations, discussions, deliberations, testimony orother oral communications relating to Professional ReviewActivities;15.2.4. Peer Review Matter may be disclosed to others only:15.3. Immunity and Release15.2.4.1.as may be permitted or required by law or by a court ofcompetent jurisdiction; or15.2.4.2.as may be specifically authorized in a written consent byboth the Practitioner and the unanimous approval of theProfessional Review Body.15.3.1. Each of the following persons acting in good faith is immune from civilliability for damages or other relief, and each Practitioner specificallyreleases:15.3.1.1.Each person who provides information to a MercyRepresentative in furtherance of a Professional ReviewActivity;15.3.1.2.Each Mercy Representative who participates in aProfessional Review Activity, including, but not limited to,each Professional Review Body; each person acting as amember or staff to the body; each person under contract orother formal arrangement with either a MercyRepresentative or the body; and each person whoparticipates with or assists the body; and- 78 -

15.3.1.3.Each third person to whom a Mercy Representativereleases information.15.3.2. In the event that a Mercy Representative takes or investigates the takingof a Professional Review Action, each Practitioner agrees to exhaust allsteps set forth in these Bylaws, including administrative review and theexercise of his or her rights, if any, under the Fair Hearing Plan as his orher exclusive remedy respecting that action.15.3.3. The immunities provided in this Article are cumulative and do not limit orrestrict immunities that are otherwise available under law.15.3.4. Each respective Hospital will indemnify each Mercy Representative foracts performed within the scope of the activities described in this Article.16. RULES AND REGULATIONSThe Medical Executive Committee acting on behalf of the Medical Staff must adopt andamend the Rules and Regulations as necessary to implement more specifically the generalprinciples found in these Bylaws. Rules and regulations may be adopted or amended bythe MEC. Rules and regulations are effective upon approval by a majority vote of theBoard. Neither the Medical Staff nor the Board may adopt or amend Rules andRegulations unilaterally. If significant changes are made, the MEC must provide revisedtexts to Members and others affected by the change.If the Members eligible to vote of the organized Medical Staff propose to adopt a rule, orregulation, or an amendment thereto, they first communicate the proposal to the MedicalExecutive Committee. If the Medical Executive Committee proposes to adopt a rule orregulation, or an amendment thereto, it first communicates the proposal to the MedicalStaff; when it adopts a policy or an amendment thereto, it communicates this to theMedical Staff.In cases of a documented need for an urgent amendment to rules and regulations necessaryto comply with law or regulation, there is a process by which the Medical ExecutiveCommittee, if delegated to do so by the Members eligible to vote of the organized MedicalStaff, may provisionally adopt and the Board may provisionally approve an urgentamendment without prior notification of the Medical Staff. In such cases, the MedicalStaff will be immediately notified by the Medical Executive Committee. The MedicalStaff has the opportunity for retrospective review of and comment on the provisionalamendment. If there is no conflict between the organized Medical Staff and the MedicalExecutive Committee, the provisional amendment stands. If there is conflict over theprovisional amendment, the process for resolving conflict between the organized MedicalStaff and the Medical Executive Committee is implemented. If necessary, a revisedamendment is then submitted to the Board for action.The organized Medical Staff has the ability to adopt Medical Staff rules and regulationsand amendments thereto, and to propose them directly to the Board.17. CONFLICT MANAGEMENT- 79 -

17.1. The organized Medical Staff has a process which is implemented to manageconflict between the Medical Staff and the Medical Executive Committee onissues including, but not limited to, proposals to adopt a rule, regulations orpolicy or an amendment thereto. Nothing in the foregoing is intended toprevent Medical Staff members from communicating with the Board on a rule,regulation or policy adopted by the organized Medical Staff or the MedicalExecutive Committee. The Board determines the method of communication.17.2. In the event of conflict between the Medical Executive Committee and themedical Staff as represented by a written petition signed by at least 33%(thirty-three percent) of the Members eligible to vote of the Medical Staffregarding a proposed or adopted bylaw, rule or policy, or other issue ofsignificance to the Medical Staff, the Chief of Staff shall convene a meetingwith up to 5 of the petitioners and an equal number of voting MedicalExecutive Committee Members.17.3. The representatives of the Medical Executive Committee and the petitionersshall exchange information relevant to the conflict and shall work in good faithin a manner that respects the positions of the Medical Staff, leadershipresponsibilities of the Medical Executive Committee, and the safety andquality of patient care at the Hospital. Differences which remain unresolved atthe conclusions of the process shall be submitted to the Board for itsconsideration in making a final decision with respect to the proposed rule,policy or issue.18. History and Physical Exams18.1. The medical history and physical examination must be completed by aPhysician, by an appropriately privileged oral surgeon or other qualifiedlicensed individual as permitted by Clinical Privileges and in accordance withState Law and Hospital policy. The Member may confirm and incorporate thefindings of others into the history and physical required by this section to theextent he or she believes such findings trustworthy.18.2. Those practitioners who do not have Clinical Privileges to perform a fullhistory and physical podiatrists, and psychologists are responsible for the partof their patient’s history and physical examination that relates to theirspecialty.18.3. For all observation patients, a pertinent H&P exam is required including thereason for observation.18.4. The patient receives a medical history and physical examination no more than30 days prior to, or within 24 hours after, registration or inpatient admission,but prior to surgery or procedure requiring anesthesia services.- 80 -

18.5. For a medical history & physical examination that was completed within 30days prior to registration or inpatient admission, an update documenting anychanges in the patient’s condition is completed within 24 hours afterregistration or inpatient admission, but prior to surgery or a procedurerequiring anesthesia services.18.6. An Emergency Department Evaluation may be accepted as a H&P forpurposes of emergency procedures provided that entry documenting anexamination for any changes in the patient’s condition is complete an19. ADOPTION AND AMENDMENT - BYLAWS19.1. ResponsibilityThe Medical Staffs have the responsibility to formulate and propose Bylaws andBylaws amendments and to review and revise them when necessary. Bylaws arenot effective until they are approved by both the Medical Staffs and the Board. Atall times, the Medical Staff Bylaws, Rules and Regulations, Policies of the MedicalStaff, shall not conflict with any governing documents of Mercy Health Partners.Neither the organized Medical Staff nor the Board may unilaterally amend theMedical Staff Bylaws, Rules and Regulations.19.2. ProcedureFor Bylaws changes affecting all MHP facilities, all Bylaws revisions andamendments must first be considered by the Bylaws Committee, which submits itsproposals to the MECs. The MEC must then circulate to Members all changes theyrecommend. If significant changes are made, the MEC must provide revised textsto Members and others affected by the change. For Bylaws changes affecting oneMHP facility, the Bylaws revision must first be considered by the BylawsCommittee; the Bylaws change is then submitted to the MEC of the respectiveHospital, and can be submitted to other Hospitals for information. The approvalprocess in this case is the same.If the Members eligible to vote of the organized Medical Staff propose to adoptBylaws, or an amendment thereto, they first communicate the proposal to theMedical Executive Committee. If the Medical Executive Committee proposes toadopt a Bylaws, or an amendment thereto, it first communicates the proposal to theMedical Staff; when it adopts a policy or an amendment thereto, it communicatesthis to the Medical Staff.The organized Medical Staff has the ability to adopt Medical Staff Bylaws, andamendments thereto, and to propose them directly to the Board.Approval by two-thirds of those Members eligible to vote who return a mail ballotwithin 30 days constitutes approval by the Medical Staff. Approval by a majority ofthe Board constitutes approval and compliance by the Board with the Medical StaffBylaws, Rules and Regulations.19.3. Adoption- 81 -

The adoption of these Bylaws supersedes the bylaws of the respective MercyHospitals 09/27/2007 April 6, 2011 revision.APPROVED by the Medical Executive Committee on the dates indicatedbelow.________________________________________________Chief of StaffMercy Hospital Anderson: March 2, 2011Mercy Hospital Clermont: February 10, 2011Mercy Hospital Fairfield: March 3, 2011Mercy Franciscan - Mt. Airy: February 27, 2011Mercy Franciscan - Western Hills: February 21, 2011Mercy WestAPPROVED by the Board of Trustees on April 6, 2011- 82 -