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CON2008062 Appendix J Appendix J Required Financial Accessibility Documentation . Admissions Policy . Medical Staff Bylaws . 2006 Hospital Financial Survey . Charity Care Policy Appendix J Admissions Policy WEL!STAR Standard Policy and Procedure ~-l<H"IIh""" Subject: I ADMISSION OF PATIENTS TO ACUTE CARE SETTING Function: Continuum of Care I spp#: CC-25 I Policy Replaces: CH-203 DH-1216,2011 KH/WH-13 Reference - Standards: AMHCN CC.4-4.2, 4.5 AMH CC.I, 2-2.1; PE.1.4; TX.I.I Key Words: Admission (to Hospital) Effective Date ReviewedIRevised June I, 1999 October, 2003 PURPOSE: To establish a procedure for the admission of patients to assure appropriate utilization of available accommodations and to facilitate access to health care services. DEFINITION(S): Emerflencv Admissions: Patients admitted for immediate attention. Urflent Admission: Patients designated by the attending physician as requiring direct admission to the hospital. Pre-overative/Elective Admissions: Scheduled admissions for services. POLICY: All patients entering a WellStar hospital are admitted only by order of a member ofthe hospital's Medical Staff who has admission privileges. L Admission Requirements: A. Patients are admitted based on an individual's need for and on the availability of services without regard to race, creed, age, sex, religion, national origin, disability, ability to pay, or any other grounds. B. Except in an emergency, no patient shall be admitted to the hospital until a provisional diagnosis or valid reason for admission has been provided. In the case of an emergency, the admitting physician is required to give PAS a valid diagnosis, which will be recorded as soon as possible. C. For the purpose of bed assignment, all admissions must be called in to the Patient Access Services Department as ordered by a member of the Medical Staff, or their appropriate representative. This includes all admissions: Emergency, Urgent or Direct. D. When a patient, who does not have a private practitioner or primary care physician, is admitted on an emergency basis, a member ofthe Active Staff on call for the department assumes responsibility for the patient's care. E. When a patient is considered to be harmful to himself/herself or others, the admitting physician is responsible for providing information necessary to assure the protection of the patient and others. F. For the protection of patients, the Medical Staff and all hospital personnel, the following requirements must be met in the care of the potentially suicidal patient: · Any patient known or suspected to be suicidal in intent will be admitted to a monitored unit of the hospital (e.g. Behavioral Health, ICU, CCU, or as designated by the physician.) If there is no accommodation available, the patient will be referred to another institution where suitable facilities are available. If there is no available facility to which the patient can be transferred, then the patient will be admitted to an appropriate treatment area with constant attendance required. · When potentially suicidal patients are admitted to a non-monitored Acute Care unit, someone must be in constant attendance. G. A general consent form, signed by or on behalf of every patient admitted to the hospital, is obtained at the time of admission. H. Each patient/family member is given written information regarding patient rights and responsibilities (SPP RI-02). Information regarding the right to formulate Advanced Directives is given to the patient during the intake process by the clinical staff or Disposition Planning staff. II. Admission Priorities: The Patient Access Services Department will admit patients based on the following order of priority: A. EMERGENCY Admissions B. URGENT Admissions C. PRE-OPERATIVE and ELECTIVE Admissions During any bed shortage period, the administrative nursing supervisor on duty will prioritize patient placement. III. Assessment: A. The physician is responsible for completing an assessment of acuity and essential clinical services B. During the admitting process, information is obtained which complements the physician's assessment and includes: 1. Determination of internal patient type; e.g., IP, IPM, OBV,OSS, OP, etc. 2. Appropriate accommodation; e.g., Critical Care, Private, Observation, Isolation, Telemetry. 3. Special needs, to include special transportation needs, interpretive services, services for the hearing impaired, etc. 4. Financial assessment. IV. Bed Placement: A. Patient Access Services personnel, in collaboration with the Administrative Nursing Supervisor or Nursing Unit Bed Coordinator, facilitate patient placement in a bed. B. Patients are assigned accommodations based on assessed service, diagnosis, procedure, patient sex and age, special needs, physician orders and patient requests. C. Patients placed in private rooms are informed they will be responsible for any portion of room cost not covered by insurance, based on verified insurance coverage. V. Special Services: A. A "NO INFORMATION" status is provided for patients with psychiatric diagnosis, prisoners, protective custody per police request or for any patient by personal request. Refer to SPP IM-77 B. Before admission to the Behavioral Health unit at Cobb, consenting patients must sign an Authorization for Voluntary Admission form (form #1009). Personnel from the Behavioral Health unit assume responsibility for this signature. Admission of non-consenting patients follows state statute and unit admission policies, as well as requirements for psychiatric care. C. At Cobb and Kennestone, members of the Medical Staff Pediatric Department with appropriate admitting privileges may admit neonates to the Neonatal Intensive Care Units. SITE SPECIFIC V ARIATION(S): Note: If there is no variation of this policy at the site, indicate none. If the policy does not apply at the site, indicate N/ A. For variation of the system policy at a site, list the variation(s). Cobb Hospital: None Home Care: N/A Douglas Hospital: None Hospice: N/A Kennestone Hospital: None Long Term Care: N/A Paulding Hospital: None Physician Group: N/A Windy Hill Hospital: None Atherton Place: N/A Policy Maintenance: The WellStar Utilization Management Committee is responsible for the interpretation and maintenance of this policy. Approved by: Robert Lipson, MD, CEO WellStar Health System Pursuant to SPP LD-Ol this policy has been authorized and approved as a Standard Policy and Procedure throughout WellStar Health System. Authorizing signatures are maintained in the System Accreditation Office. Attachments: 1 Georgia Department of Human Resources PATIENT IDENTIFICATION Aoolication For Voluntarv Admission BY AUTHORITY OF SECTIONS 88-503-1 AND 88-503-4, GEORGIA HEALTH CODE, GEORGIA LAWS, pp. 1789-1875 .1 request admission to WellStar Behavioral Health Center !iV Cobb Hosoital on a volunteer basis. I understand that if the staff finds I show signs of mental illness and that I am suitable for treatment. I may be given care and treatment at the hospital named above. If I am under 18 years old 1 understand that I may be admitted for observation and diagnosis, but treatment may be given only with the written consent of my parents or guardian. I agree to follow the rules and regulations of the hospital. I understand that the Medical Staff of the hospital may discharge me when they believe I no longer need to stay in the hospital. I may ask to leave the hospital according to the procedures that are explained on this form. I make this request for voluntary admission willingly. I have read this application including my rights to discharge on this form and have had a chance to ask any questions. Witness Title Signature of Applicant (if 12 years of age or older) ,20 .20 Address NOTE: Parent or guardian must sign below if application is for someone under age 18 and is made by his or her parent or guardian or if the person for whom hospitalization is sought has been declared legally incompetent and the application is being made by the legal guardian. As parent or guardian of the above named person, I agree to the provisions ofthis application and I consent to the treatment of the above named person. I have had the chance to ask any questions. Witness Title Signature of Applicant (if 12 years of age or older) ,20 .20 Address NOTICE OF A VOLUNTARY PATIENT'S RIGHT TO DISCHARGE You may ask for your discharge at any time. Your representative, legal guardian, parent, wife or husband, lawyer or adult next of kin may also ask for your discharge at any time. You may not ask for your own discharge if you are under age 18 and your parent or guardian signed you into the hospital. If you signed yourself in and someone else ask for your release, you must agree in order to be discharged. If you have been found by a court to be incompetent and your legal guardian signed you in, your guardian must agree to your discharge. The request for discharge must be in writing. If you need assistance doing this, ask the unit staff for help. Within 72 hours (not counting Sundays and legal holidays) after the chief medical officer ofthe hospital gets your written request, you will be discharged unless he believes your discharge would be unsafe to you or others. If you are not released, the process for involuntary hospitalization will begin. If this happens you will be told of your rights. You may also be discharged without asking for release if the chief medical officer feels that you no longer need to be in the hospital. Attachment 1: Facsimile of Form 1009 WS item # 66818 (04/02) CC-25 SPP APPROVAL RECORD FUNCTION TEAM: Continuum of Care FUNCTION TEAM LEADER: Claire Housholder, RN & Re!!ina Hasan. LMSW FUNCTION COMMITTEE: Utilization Committee STANDARD POLICY NAMEINUMBER: ADMISSION OF PATIENTS TO ACUTE CARE SETTING/CC-25 DATE OF DEVELOPMENTIREVISION: _10/2003 DATE TO STAKEHOLDERS: 10/2003 DATE OF COMMITTEE APPROVAL: October 2003 ARE ALL STAKEHOLDER SIGNATURES ATTACHED OR SIGNED OFF BELOW: ELECTRONIC COPY OF POLICY EMAILED TO ACCREDITATION: IF IT IS IMPERATIVE THIS POLICY BE DISTRIBLTED IMMEDIATELY PLEASE INDICATE. IF :\lOT INDICATED THIS POLICY WILL BE DISTRIBUTED WITH THE NEXT QUARTER'S REVISION: _Distribute with Next Quarter's Revision _Please Distribute Immediately SYNOPSIS OF POLICYIREVISION: KEY STAKEHOLDER SIGN-OFF By signing-olT on this policy, through actual signature, em ail or verbal approval to the Policy Owner or Accreditation Department, I am affirmin!! mv approval to this Dolicv as written or have provided mv variations to the Function Team OwnerlPolicv Owner. TITLE NAME SIGNATURE DATE (all stakeholders of this policy (there must be a signature on this line or must be listed below) documentation showing how this policy was approved if accomplished through email communication) Function Team Leader Regina Hasan & Claire Housholder Committee Chair Dr. Richard Hart DON KH Ruth Burgess DON KH Susan Kill DON CH Martha Seaborn Site Administrator DH Teresa Reynolds Site Administrator PH John Law Site Administrator KH Linda Clark Site Administrator CH Randy Cook Site Administrator WH Lou Little Director PAS Judv Askins Accreditation Medical Director Dr Marcia Delk CEO Signature on Policy? Dr. Robert Lipson All policies must have the review of the identified Key-Stakeholders. These individuals will have I week from the date of receipt to review and respond to the owner of the policy. Other individuals may be requested to review the policy for application to their individual department but not be identified as a Key-Stakeholder. It is the responsibility of the Key-Stakeholders to review the policy based upon their area of responsibility for WellStar Health System. Stakeholders are provided with a I week deadline for review of policies. A lack of response by the deadline date implies the stakeholder has no recommended changes to the policy. ACCREDITATION: Date Received: Distribution Date: Revision #: Appendix J Medical Staff Bylaws WELLSTAR KENNESTONE HOSPITAL MARIETTA, GEORGIA MEDICAL STAFF BYLAWS @ WellStar Health System, Inc. 2005. All Rights Reserved. MEDICAL STAFF BYLAWS OF WELLSTAR KENNESTONE HOSPITAL PREAMBLE.. ..... ...... ....... ...... ....... ...... ....... ....... ..... ....... ...... ..... ... ........ ........ ...... ....... ....... ... ....... ......... .............4 DEFINITIONS. ...... ....... ....... ....... ..... ....... ....... ...... ..... ....... ....... ........ ........ ........ ........ .... .............. ........ .............4 ARTICLE 1. NAME...... ........ ....... ............ ...... ....... ..... ....... ....... ........ ......... ....... ............ ............... ......... .........6 ARTICLE 2. PURPOSES.. ...... ..... ....... ....... ..... ....... ...... ....... ........ ........ ........ ........ ..... ....... ................. ...........6 ARTICLE 3. MEDICAL STAFF MEMBERSHIP ..........................................................................................7 Section 1. Nature of Medical Staff Membership......................................................................................7 Section 2. Qualifications for Membership... ....... .... ... ....... ........ ..... ... ..... ... ............. ........ ... .......... .... ..........7 Section 3. Conditions and Duration of Appointment ...............................................................................8 Section 4. Medical Staff Dues .................................................................................................................8 ARTICLE 4. CATEGORIES OF THE MEDICAL STAFF ............................................................................ 9 Section 1. The Medical Staff ................................................................................................................... 9 Section 2. Provisional Staff ... ........ ...... .............. ....... ..... ........ ....... .... .... ......... ........ ....... ......... .... .......... ....9 Section 3. The Active Medical Staff....................................................................................................... 10 Section 4. The Courtesy Medical Staff.................................................................................................. 10 Section 5. The Covering Medical Staff.................................................................................................. 11 Section 6. The Senior Staff ...................................................................................................................11 Section 7. The Emeritus Medical Staff ..................................................................................................11 Section 8. Hospital Based Medical Staff Members ............................................................................... 11 Section 9. Allied Health Professionals.......... ....... ........ ....... ..... ... ................. ........ ...... ............. ............... 11 Section 10. Leave of Absence................................................................................................................. 11 Section 11. Residents and Fellows .........................................................................................................12 ARTICLE 5. PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT ..........................................12 ARTICLE 6. CLINICAL PRIVILEGES .......................................................................................................12 Section 1. Clinical Privilege Delineation ................................................................................................ 12 Section 2. Temporary Privileges.... ..... ...... ...... ....... ............... ..... ... ........ ........ ........ ......... ......... ......... ..... 12 Section 3. Emergency Privileges.. ...... ....... ...... ..... ............... ....... ......... ........ ........ ........ ........... .......... .....14 Section 4. Emergency and Short Term Privileges for Non-Staff Members........................................... 14 Section 5. Disaster Privileges.. ....... .... ....... ...... .... ........... .... ........ ........ ........ ....... ........ ........ ........ ......... ... 14 ARTICLE 7. CORRECTIVE ACTION..... ...... .... ....... ........ ....... ...... .......... ...... ....... .... .... ........ ............. ......... 15 Section 1. Procedure for Medical Staff Members..................................................................................15 Section 2. Summary Suspension .... ....... ...... ....... ........ ............ ........ ........ ................ ....... .......... .......... ... 16 Section 3. Automatic Termination ... ....... ..... ....... ........ ............ ........ ........ ........ ........ ....... ......... ............... 17 Section 4. Procedure for Allied Health Professionals............................................................................18 Section 5. Governing Body Action.. ................. ........ ....... ....... ................ ........ ........ ..... ........ ........ ... ........ 18 ARTICLE 8. HEARING AND APPELLATE REVIEW PROCEDURE........................................................ 19 ARTICLE 9. OFFiCERS...... ........ ..... ...... ....... ..... ...... ......... ..... ........ ........ ........ ....... ........ ..... ................. ...... 19 Section 1. Officers of the Medical Staff .................................................................................................19 Section 2. Qualifications of Officers ......................................................................................................19 Section 3. Election of Officers ...............................................................................................................19 Section 4. Term of Office. ....... ....... ..... ............. ........ ........ ..... ........ ... ..... ........ ........ ....... ...... ..... .... ........... 19 Section 5. Vacancies in Office............ ...... ....... ........ ........ ....... ........ ........ ..... ........ ....... .... .... ......... .......... 19 Section 6. Duties of Officers ....... ....... ....... ............ ....... ......... ........ ....... ........ ........ ....... ................. ..........20 Section 7. Removal from Office............................................................................................................. 22 ARTICLE 10. DEPARTMENTS.. ....... ....... ....... ..... ........ ....... ........ ........ ..... .... .... ......... ....... ........ ........ .... .......22 Section 1. Organization of Departments ............................................................................................... 22 Section 2. Assignment to Departments... ...... ........ ........ ....... ......... ....... ........ ........ ...... .......... .................23 Section 3. Section and Subsections of Departments............................................................................23 The infonnation contained herein is confidential and proprietary to WeJlStar Health System, Jnc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this infonnation without the express prior written consent of WellStar is explicitly prohibited WellStar Kennestone Hospital Medical Staff Bylaws Page 2 Section 4. Qualifications, Selection, and Tenure of Department Chair................................................. 24 Section 5. Duties of Department Chair..... ..... ....... ....... ....... .... ....... .......... ........ ....... ....... .... ........ ............24 Section 6. Qualification, Selection, Duties and Tenure of Department Vice-Chair ...............................25 Section 7. Department Functions. ....... ...... .... ....... ....... ....... ..... ........ ......... ....... ..... ..... ...... .......... .... ........26 ARTICLE 11. COMMITTEES ..... ... ..... ....... .......... ....... ....... ....... ........ ........ ........ ..... ..... ....... ..... ....... ..... .........26 Section 1. Executive Committee ...... .... ...... ....... ..... ....... ....... ........ ......... ....... .... ...... ....... ......... ......... ......26 Section 2. Credentials Committee. ...... ...... .... .... ... ........ ....... ....... ......... ....... ...... ..... ....... ........ ........... ......28 Section 3. Quality Review Committee..... ....... ..... ...... .... .... ....... ........ ........ ............. ..... ........... ............ .... 29 Section 4. Emergency Services Committee..... .... ........ ....... ..... ... .................... .... ........ ........ ..... ...... .......29 Section 5. Sentinel Event Committee.. ...... ....... .... ....... ........ ........ ........ ....... ....... ....... .......... ........ ...........29 Section 6. Special Committees..... ...... .... ...... ....... ....... ....... ........ ........ ........ ....... ..... ............ ..... ..............29 ARTICLE 12. COMMITTEE, SUBSECTION, SECTION AND DEPARTMENT MEETINGS ...................... 30 Section 1. Regular Meetings.... ........................ ............. ........ ........ ........ ........ ....... ........ ............... ..........30 Section 2. Special Meetings .... ....... ....... ...... ..... ...... ....... ........ ........ ........ ........ ....... ......... .............. ..........30 Section 3. Notice of Special Meetings ....... .... ... .... ....... ........ ................ ........ ....... ........ ......... ..................30 Section 4. Quorum...... ....... ..... ........ ...... ..... ...... ....... ....... ........ ................ ...... ....... ........ .... ............... ........30 Section 5. Manner of Action... ........ ..... ..... ....... ....... ...... ....... ....... ........ ......... ....... ........ ................ ...........30 Section 6. Rights of Ex Officio Members...............................................................................................30 Section 7. Minutes...... ..... ....... ........ ...... .... ....... ....... ............... ..... ........ ......... ....... ........ .......... ......... ........30 Section 8. Attendance Requirements... ...... ....... ..... ....... ........ ....... ......... ........ ....... ........ .......... ...............31 ARTICLE 13. MEDICAL STAFF MEETINGS...... ....... ........ ........ ....... ..... ........... ..... ....... ......... .......... ........... 31 Section 1. Regular Meetings.. ........ ...... ..... ...... ....... ........ ..... ....... ........ ......... .............. .............. .............. 31 Section 2. Special Meetings... ........ ...... ..... ...... ....... ........ ....... ....... ........ ......... ....... ........ ............. ........ ....31 Section 3. Quorum/Action........... ..... ...... ........... ....... ........ ..... ....... ........ ......... ....... ...... ... ............. ...........31 Section 4. Minutes ....... ..... ... .... ....... ....... .... ....... ...... ........ ........ .... ........ .... ..... ....... ........ ........... ......... .... ...31 Section 5. Attendance Requirements.... ...... ...... ...... ........ ....... ....... ....... ......... ....... ......... .......... ..............31 ARTICLE 14. IMMUNITY FROM LIABILITY ...............................................................................................32 ARTICLE 15. RULES, REGULATIONS AND POLICiES............................................................................ 32 ARTICLE 16. AMENDMENTS. ........ ....... .... ...... ....... ....... ...... ....... ....... ........ ......... ........ ........ .......... ...... .......33 ARTICLE 17. MiSCELLANEOUS.... ....... .... ...... ....... ..... ........ ........ ...... ........ ......... ........ ........ .......... .............33 Section 1. Proxies/Absentee Ballots by Medical Staff Members ..........................................................33 Section 2. Conflicts..... ...... ........ ....... .... ...... ....... ....... ........ ..... ....... ........ ......... ...... ..... ....... ............. ..........34 Section 3. Actions by a Professional Review Body ............................................................................... 34 Section 4. Severability. ....... ......................... ....... ........ ..... ....... ....... ........ ........ ........ ....... ........ ......... ........34 Section 5. Time Limits.... ..... ....... ....... .... ...... ............ ........ ............... ........ ...... ....... ........ ........... ......... ......34 The information contained herein is confidential and proprietary to WellStar Health System. Inc. and its affiliates ('WelIStar'), and is protected by applicable copyright and other la.vs and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 3 PREAMBLE WHEREAS, Kennestone Hospital, Inc. is a non-profit corporation organized under the laws of the State of Georgia which operates WellStar Kennestone Hospital (the "Hospital" or "Kennestone Hospital"); and WHEREAS, the purpose of the Hospital is to serve as a general hospital providing patient care, education, and research; and WHEREAS, it is recognized that the Medical Staff is responsible for the quality of medical care in the Hospital and must accept and discharge this responsibility, subject to the ultimate authority of the Hospital's Governing Body, and that the cooperative efforts of the Medical Staff, the Chief Executive Officer, and the Governing Body are necessary to fulfill the Hospital's obligations to its patients and community. THEREFORE, the physicians, podiatrists and dentists practicing in the Hospital hereby organize themselves into a Medical Staff in conformity with these Bylaws. DEFINITIONS 1. The term "Act" shall mean the Health Care Quality Improvement Act of 1986, 42 U.S.C. S 11101 et seq. 2. The term "Adverse Action(s)" shall mean those actions which may impact an Applicant or Medical Staff Member's membership on the Medical Staff as are more fully described in the WellStar Fair Hearing Policy. 3. The term "Adversely Affect" or "Adversely Affecting" shall mean the reduction, restriction, suspension, revocation, denial, or the failure to renew clinical privileges or membership on the Medical Staff of Kennestone Hospital, as more fully described in the WellStar Fair Hearing Policy. 4. The term "Affected Medical Staff(s)" shall mean the Medical Staff of each WellStar Hospital on which the affected Applicant or Medical Staff Member has, or has requested, privileges. 5. The term "Allied Health Professional(s)" shall mean (i) those persons who regularly assist a Medical Staff Member and who are not employees of the Hospital, and (ii) psychologists. 6. The term "Appellate Review" shall mean an appeal to the Governing Body as provided for in the WellStar Fair Hearing Policy. 7. The term "Applicant" shall mean a physician, dentist, or podiatrist who has submitted either an Application or a Request for Application form for membership on the Medical Staff of Kennestone Hospital. 8. The term "Application(s)" shall mean the form, as is more fully described in the WellStar Appointment Policy, as established by the Governing Body and in effect on the date on which a Practitioner requests initial appointment or reappointment, as the case may be, to the membership of the Medical Staff of Kennestone Hospital and which shall be used for such purposes. The information contained herein is confidential and proprietary to WellSlar Health System, Inc. and its affiliates ('WellStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 4 9. The term "Chief Executive Officer" shall mean the individual appointed by the Governing Body to act as its chief executive officer. 10. The term "Credentials Committee" means the Credentials Committee of the Medical Staff. 11. The term "Executive Committee" or "Medical Executive Committee" means the Executive Committee of the Medical Staff. 12. The term "Governing Body" means the Board of Trustees of WellStar Health System, Inc. 13. The term "Hearing" shall mean a de novo hearing before (i) an ad hoc committee of the Medical Staff, (ii) an ad hoc committee of the Affected Medical Staffs, or (iii) a committee appointed by the Governing Body as provided in the WellStar Fair Hearing Policy. 14. The term "Medical Affairs Committee" shall mean the Medical Affairs Committee established pursuant to the bylaws of the Governing Body. 15. The term "Medical Director" shall mean the individual appointed by the Chief Executive Officer to serve as the Medical Director for the WellStar Health System. 16. The term "Medical Staff" shall mean physicians, dentists and podiatrists who are privileged to attend patients of Kennestone Hospital. 17. The term "Medical Staff Member," "Staff Member" or "Member" shall mean a Practitioner who has membership on the Medical Staff of Kennestone Hospital. 18. The term "Medical Staff Services Office" shall mean the WellStar Medical Staff Services Office which bears the responsibility for administrative processing of Requests for Application and Applications submitted to Kennestone Hospital as is more fully described in the WellStar Appointment Policy. 19. The term "Medical Staff Year" shall mean the period from July 1 through June 30. 20. The term "Practitioner" means an appropriately licensed physician, dentist or podiatrist who has or seeks clinical privileges at Kennestone Hospital. 21. The term "Professional Review Activity" shall mean, as more fully described in the WellStar Fair Hearing Policy, any activity of Kennestone Hospital with respect to an individual Practitioner or Medical Staff Member (i) to determine whether he or she may have clinical privileges at Kennestone Hospital or membership on the Medical Staff of Kennestone Hospital, (ii) to determine the scope or conditions of such privileges or membership, or (iii) to change or modify such privileges or membership. 22. The term "Professional Review Body" shall mean, as appropriate to the circumstances, and as more fully described in the WellStar Fair Hearing Policy, the Executive Committee, the Governing Body, the Credentials Committee, any ad hoc investigation committee, any Hearing Committee, any Appellate Review Committee, the Chief Executive Officer, any officer of the Medical Staff, any Department Chair and any other person, committee or entity having authority to take an Adverse Action with respect to, or to take or propose to take an Adverse Action against, any Applicant or Medical Staff Member when assisting in a Professional Review Activity. 23. The term "WeIlStar," "WellStar Health System" or "System" shall mean WellStar Health System, Inc. and its wholly-owned subsidiaries including, but not limited to, Cobb Hospital, Inc., The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates {'WeIlStar"), and is protected by applicable copyright and other Jaws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WeU$tar is explicitly prohibited WellStar Kennestone Hospital Medical Staff Bylaws Page 5 Douglas Hospital, Inc., Kennestone Hospital, Inc., Paulding Medical Center, Inc., and any other entity which WellStar Health System, Inc., now or hereafter, directly or indirectly controls. 24. The term 'WellStar Appointment Policy" shall mean the WellStar Appointment Policy in effect from time to time. 25. The term "WellStar Clinical Privileging Criteria Policy" shall mean the WellStar Clinical Privileging Criteria Policy in effect from time to time. 26. The term "WellStar Disruptive Conduct Policy" shall mean the WellStar Disruptive Conduct Policy in effect from time to time. 27. The term "WellStar Fair Hearing Policy" shall mean the WellStar Fair Hearing Policy in effect from time to time. 28. The term "WellStar Health System Policy" or "WellStar Standard Policies and Procedures" shall mean such standard policies and procedures approved by the Chief Executive Officer from time to time which affect the operation of the WellStar Hospitals. 29. The term "WellStar Hospital" or "WellStar Hospitals" shall mean Cobb Hospital, Douglas Hospital, Kennestone Hospital, Paulding Hospital and Windy Hill Hospital and any other hospital which is or may hereafter become part of the WellStar Health System. 30. The term "WellStar Impaired Provider Policy" shall mean the WellStar Impaired Provider Policy in effect from time to time. 31. The term "WellStar Medical Staff Peer Review Policy" shall mean the WellStar Peer Review Policy in effect from time to time. 32. The term "WellStar Medical Staff Sexual Harassment Policy" shall mean the WellStar Medical Staff Sexual Harassment Policy in effect from time to time. ARTICLE 1. NAME The name of this organization shall be the WellStar Kennestone Hospital Medical Staff. ARTICLE 2. PURPOSES The purposes of this organization are: A. To ensure that all patients admitted to or treated in any of the facilities of the Hospital shall receive necessary care; B. To ensure a high level of professional performance of all Medical Staff Members and Allied Health Professional(s) authorized to practice in the Hospital through the appropriate delineation of the clinical privileges that each of these persons may exercise in the Hospital and through an ongoing review and evaluation of the performance of each of these individuals in the Hospital; C. To provide an appropriate educational setting that will enhance knowledge and that will lead to continuous advancement in professional knowledge and skill; The infonnation contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates {'WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 6 D. To promote a safe environment for patients; E. To initiate and maintain rules and regulations for self-government of the Medical Staff; and F. To provide means whereby issues concerning the Medical Staff and the WellStar Hospital may be discussed by the Medical Staff with the Governing Body and the Chief Executive Officer. ARTICLE 3. MEDICAL STAFF MEMBERSHIP Section 1. Nature of Medical Staff Membership Membership on the Medical Staff of WellStar Kennestone Hospital is a privilege which shall be extended only to professionally competent physicians, dentists and podiatrists who meet the qualifications, standards, and requirements set forth in these Bylaws. The Medical Staff is a constituent part of WellStar Kennestone Hospital and not a separate entity, and its Members act on behalf of the Hospital in peer review, performance improvement, credentialing, utilization review and other appropriate matters. Section 2. Qualifications for Membership A. Only physicians, dentists and podiatrists licensed to practice in the State of Georgia, who can document their background, experience, training and demonstrated competence; their adherence to the ethics of their profession; their good reputation; and their ability to work with others, with sufficient adequacy to assure the Medical Staff and the Governing Body that any patient treated by them in the Hospital will be given necessary and appropriate quality of medical care, shall be qualified for membership on the Medical Staff. Gender, race, creed, and/or national origin are not used in making decisions regarding the granting or denying of Medical Staff membership or clinical privileges. No Practitioner shall be entitled to membership on the Medical Staff or to the exercise of particular clinical privileges in the Hospital merely by virtue of the fact that he/she is duly licensed to practice medicine, podiatry or dentistry in this or in any other state, or that he/she is a member of any professional organization, or that he/she had in the past or presently has such privileges at another Hospital. B. Physician, podiatrist, and oral and maxillofacial surgeon Applicants for Medical Staff membership must have successfully completed an appropriate, approved residency program in his/her specialty area of practice and must, except as is otherwise required by law, be, at the time of initial application, board certified or obtain initial board certification by the appropriate American Board of Medical Specialties or American Osteopathic Board (or the American Board of Oral and Maxillofacial Surgery for oral and maxillofacial surgeons or the American Board of Podiatric Surgery for podiatrists) within six years of completion of training. With respect to Board certification and residency criteria, current Medical Staff Members shall abide by such criteria in effect at the time of their respective initial appointment. C. Notwithstanding any provision herein to the contrary, all Medical Staff Members whose membership on the Medical Staff is automatically terminated for failure to complete medical records, may reapply for appointment to the Medical Staff within three (3) months of date of termination. If the Practitioner reapplies for appointment to the Medical Staff within such three (3) month period, the Practitioner shall be deemed to have satisfied the requirements of Article 3, Section 2, paragraph B, based upon board certification status and training received by such Practitioner at the time he/she first applied for initial appointment to the Medical Staff. D. Acceptance of membership on the Medical Staff shall constitute the Medical Staff Member's certification that Practitioner has in the past, and Practitioner's agreement that Practitioner will in The infonnation contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WellStar"), and is protected by applicable copyright and other laws and regUlations. Any reuse, recopying, redistribution, republication or dissemination of this infonnation without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 7 the future, strictly abide by the Code of Ethics of the Member's relevant professional organization and by ethical standards as may be adopted by the Executive Committee and the Governing Body, and by the statutes and rules and regulations of the United States and the State of Georgia. Section 3. Conditions and Duration of Appointment A. Initial appointments and reappointments to the Medical Staff shall be made by the Governing Body, or its designee. B. Initial appointments shall be provisional and, subject to Article 4, Section 2. E below, shall be for a period of twenty four (24) calendar months. Reappointment shall be for a period of not more than two years. C. Appointments to the Medical Staff shall confer on the appointee a privilege in the nature of a license to exercise only such clinical privileges as have been granted by the Medical Staff with the approval of the Governing Body, in accordance with these Bylaws and the WellStar Appointment Policy. A Medical Staff Member is neither an employee nor an independent contractor of Kennestone Hospital, unless such a relationship is separately established between Kennestone Hospital and such Medical Staff Member. Each Medical Staff Member shall exercise his/her clinical privileges within the Hospital subject to the provisions contained within these Bylaws and the Medical Staff Rules, Regulations and Policies and subject to the policies, procedures and directives of the Governing Body and any restrictions or limitations attached to his/her appointment. D. Each Application for staff appointment shall be signed by the Applicant and shall contain the Applicant's specific acknowledgment and agreement to comply with every Medical Staff Member's obligation to provide continuous care and supervision of his/her patients; to abide by the Medical Staff Rules, Regulations and Policies, the Hospital bylaws, and the Governing Body bylaws; and to accept committee assignments; and to accept consultation assignments on clinic patients. All Members of the Provisional Active Staff shall be assigned by the Chair of the primary Department or section in which he/she has privileges to provide services in the outpatient clinics and to participate in the Department staff call roster for emergency services. E. As a condition of Medical Staff membership, each Medical Staff Member shall acquire and maintain adequate malpractice insurance as specified by the Governing Body from time to time. Section 4. Medical Staff Dues A fund will be established for the benefit of the Medical Staff, financed by Medical Staff dues. A. Medical Staff dues may be assessed to each Applicant upon the granting of Medical Staff membership, or thereafter, by the Medical Executive Committee from time to time. If assessed, the payment of such Medical Staff dues will be required for Medical Staff reappointment. B. Any additional source of financing this fund may be initiated by the Medical Staff or the Executive Committee. C. The use of these funds shall be for the purpose of legal or business representation of or consultation to the Medical Staff in matters of interaction between the Medical Staff and the Hospital or for such other purposes as approved by the Executive Committee. D. The President of the Medical Staff shall have the fiduciary responsibility for this fund which may The information contained herein is confidential and proprietary to WellStar Health System. Inc. and its affiliates ('WeIlSts!"'), and is protected by applicable copyright and other laws and regulations, Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 8 be administered through the Medical Staff Services Office. Only the President of the Medical Staff or his/her specific designee may obligate the payment of these funds for representation or consultation. The accounting for this fund shall be available to any Medical Staff Member upon written request. ARTICLE 4: CATEGORIES OF THE MEDICAL STAFF Section 1. The Medical Staff The Medical Staff shall be divided into Active, Courtesy, Covering, Senior and Emeritus members. All initial appointments shall be to either the Active or Covering category of the Medical Staff and shall be provisional for a period not to exceed twenty four (24) calendar months ("Provisional Staff"). Section 2. Provisional Staff A. Members of the Provisional Staff shall be assigned to a Department where their performance shall be carefully monitored by the Chair of the Department or his/her representative to determine the eligibility of such Provisional Staff Members for regular Medical Staff membership and for exercising the clinical privileges provisionally granted to them. They shall be ineligible to hold office in the Medical Staff organization or vote on general matters. Provisional Active Staff Members shall be eligible to serve on committees and to vote on matters before such committees. B. A Provisional Active Staff Member shall not serve on more than four (4) other hospital active staffs other than WellStar Kennestone Hospital and shall be located closely enough to the Hospital to provide continuous care to his or her patients. Provisional Active Staff Members shall be required to participate and demonstrate proficiency in no less than 24 documented patient "Encounters" at the Hospital during the provisional period. For Provisional Active Staff Members in the Department of Surgery, at least 16 of these 24 "Encounters" shall involve surgical case management. (For the purpose of this Section 2. B and Section 3. B of this Article 4, "Encounter" for surgical cases shall be defined as the provision of patient care during which the Practitioner assumes direct care of a patient and provides direct evaluation and/or treatment of the patient which is subsequently documented in the medical record, not including care provided on routine "rounds" for call coverage. For all other cases, "Encounter" includes emergency room care, inpatient and outpatient surgical procedures, and consultations where substantial care is provided.) C. Upon approval of the Executive Committee and the Governing Body, any Department or Section of a Department may be exempt from satisfying the total Encounter requirements for advancement to the Active Staff. If such exemptions are granted, the involved Provisional Active Staff Member will be required to make available a sampling of their office charts for review by the Department Chair or the Chair's designee if they desire to be considered for reappointment. Enough charts to bring the Provisional Active Staff Member's activity level up to 24 Encounters must be provided and should be representative of the kinds of patients and procedures seen in the Provisional Active Staff Member's office. The reviewed Provisional Staff Member has the right to request review by a board certified Medical Staff Member of his/her specialty, if any. D. Provisional Staff Members and their performance shall be reviewed/assessed through the peer review process pursuant to the WellStar Medical Staff Peer Review Policy. The Chair of the Department will then evaluate these data to determine eligibility to such Provisional Staff Member for regular staff membership and for exercising the clinical privileges granted to him/her. The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of Well$tar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 9 E. The Credentials Committee will review the credentials of all Provisional Active and Covering Staff Members after twelve months and, after consultation with the Chair of the Department to which the Provisional Staff Member was assigned, will recommend to the Executive Committee whether to advance the Provisional Staff Member to regular Active, Courtesy or Covering status or to extend the provisional period for up to an additional twelve months. Failure to extend a Provisional Staff appointment at the expiration of the twelve month appointment or failure to advance a Provisional Staff Member from Provisional to regular Active, Courtesy or Covering Staff within two (2) years, excluding an official leave of absence, shall be deemed a termination of Practitioner's staff appointment. A Provisional Staff Member whose membership on the Medical Staff is terminated may have the right to a Hearing and Appellate Review as provided in the WellStar Fair Hearing Policy. Section 3. The Active Medical Staff A. The Active Medical Staff shall consist of physicians, podiatrists and dentists who regularly admit patients to this hospital and who are located closely enough to the Hospital to provide continuous care to their patients, and who assume all the functions and responsibilities of membership on the Active Staff including emergency service care, clinic assignments and consultation assignments in accordance with applicable Medical Staff Rules, Regulations and Policies. Members of the Active Staff shall be appointed to an appropriate Department; shall be eligible to vote, to hold office, and to serve on Medical Staff committees. B. A Member of the Active Staff shall not serve on more than four (4) other hospital active medical staffs other than WellStar Kennestone Hospital. Each Member of the Active Staff shall be required to participate and demonstrate proficiency in at least 24 patient Encounters at the Hospital each twenty-four (24) month period of membership. For Active Staff Members in the Department of Surgery, at least 16 of these 24 Encounters shall involve surgical case management in the inpatient or outpatient setting. Upon approval of the Executive Committee and the Governing Body, appropriate exceptions to the minimum Encounter requirements for Active Staff membership will be made for those Practitioners whose surgical or medical specialty is such that participation on the Medical Staff is determined, through the prescribed credentialing process, to be desirable and necessary for optimal patient care. C. Upon approval of the Executive Committee and the Governing Body, a Department or Section of a Department may be exempt from the Encounter requirements for reappointment to the Active Staff. If such exemptions are granted, the involved Medical Staff Members will be required to make available a sampling of their office charts for review by the Department Chair or the Chair's designee if they desire to be considered for reappointment. Enough charts to bring the Medical Staff Member's activity level up to 24 Encounters must be provided and should be representative of the kinds of patients and procedures seen in the Medical Staff Member's office. The reviewed Practitioner has the right to request review by a board certified Medical Staff Member of his/her specialty, if any. Section 4. The Courtesy Medical Staff The Courtesy Medical Staff shall consist of physicians, podiatrists, and dentists qualified for Medical Staff membership but who only occasionally admit or utilize outpatient or emergency room services. These Medical Staff Members shall have served on the Provisional Active Staff for one (1) year. Courtesy Medical Staff Members shall be appointed to a specific Department but shall not be eligible to vote or hold office in this Medical Staff organization. Courtesy Medical Staff Members may not admit or attend more than ten (10) patients per appointment cycle. In the event a Courtesy Staff Member admits or attends The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of Wetl$tar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 10 more than ten (10) patients per appointment cycle, he or she shall automatically be deemed to be a member of the Active Staff with each of the rights and responsibilities attendant thereto. Section 5. The Covering Medical Staff The Covering Medical Staff shall consist of physicians, dentists and podiatrists qualified for staff membership but who admit and/or care for patients only in the name of their Active Staff sponsoring physician, dentist or podiatrist. They shall provide patient care only when covering and/or taking call for their Active sponsoring physician, dentist or podiatrist. Patient admission and/or surgery shall be only on an emergency basis under the name of their sponsoring physician, dentist or podiatrist. The Covering Staff member may act as an assistant in surgery at the request of the sponsoring physician, dentist or podiatrist. The Covering physician may follow in conjunction with the Active Staff sponsoring physician, dentist or podiatrist any surgical/medical cases in which he/she participated. He/She must be a member in good standing of the active staff of another hospital. A Covering Medical Staff Member shall be appointed to a specific Department, but shall not be eligible to vote or hold office in this Medical Staff organization. They are encouraged to attend Medical Staff meetings, to expedite the dispersal of information. Section 6. The Senior Staff At the age of 70, all Members of the Medical Staff shall be promoted to the Senior Staff. Senior Staff membership shall be reviewed via the reappointment process on an annual basis. Except as otherwise provided herein, Senior Staff Members shall have the same rights as such Member had in his or her previous category. Section 7. The Emeritus Medical Staff The Emeritus Medical Staff shall consist of Medical Staff Members who have retired from Active Staff membership after at least twenty years of service at WellStar Kennestone Hospital. Emeritus Staff membership shall not be eligible to provide clinical services, to vote, hold office or serve on committees. They may, however, attend general and departmental Medical Staff meetings and CME presentations. Section 8. Hospital Based Medical Staff Members Physicians engaged in the practice of Anesthesia, Emergency Medicine, Pathology, and Radiology, who are on the Provisional Staff, Active Medical Staff, or the Courtesy Medical Staff may not admit inpatients to the Hospital. Section 9. Allied Health Professionals Allied Health Professionals in this category shall not be Members of the Medical Staff and shall not be eligible to vote or hold office. Appointment and reappointment of Allied Health Professionals shall be as defined in the Rules and Regulations for Allied Health Professionals. Section 10. Leave of Absence The Executive Committee may, at its discretion upon recommendation of the Credentials Committee, place any Medical Staff Member on Leave of Absence for up to one year, for reasons of health or other compelling reasons. The Executive Committee, through the Medical Staff Services Office, shall notify each Affected Medical Staff of such leave. During the leave of absence, the Medical Staff Member shall not exercise his or her clinical privileges. In the event the duration of a leave of absence equals or exceeds six months, the Medical Staff Member shall submit an Application for Reappointment and shall not exercise his or her clinical privileges until granted pursuant to the appointment process as set forth in The information contained herein is confidential and proprietary to WellStar Health System. Inc. and its affiliates ('WeIlSts!"'), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution. republication or dissemination of this information without the express prior written consent of Welt$tar is explicitly prohibited. WellSlar Kenneslone Hospital Medical Staff Bylaws Page 11 the WellStar Appointment Policy. Section 11. Residents and Fellows Residents and Fellows shall not be Members of the Medical Staff and shall not be eligible to vote or hold office. Appointment and reappointment of Residents and Fellows shall be as defined in the Rules and Regulations for Residents and Fellows. ARTICLE 5. PROCEDURE FOR APPOINTMENT AND REAPPOINTMENT The appointment or reappointment of a Practitioner to the Medical Staff of Kennestone Hospital shall be governed by and in accordance with the provisions of the WellStar Appointment Policy as may be in effect from time to time. ARTICLE 6. CLINICAL PRIVILEGES Section 1. Clinical Privilege Delineation A. Clinical privileging criteria shall be developed and established pursuant to the WellStar Clinical Privileging Criteria Policy, as amended from time to time. B. Every Practitioner practicing at this Hospital by virtue of Medical Staff membership or otherwise shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him/her by the Governing Body or its designee except as provided in Sections 2 and 3 of this Article 6. C. As more particularly set forth in the WellStar Appointment Policy, every initial application for Medical Staff membership appointment must contain a request for the specific clinical privileges desired by the Applicant. The evaluation of such requests shall be based upon the Applicant's education, training, experience, demonstrated competence and judgment, references and other relevant information, including an appraisal by the clinical department in which privileges are sought as more specifically provided for in the WellStar Appointment Policy. The Applicant shall have the burden of establishing his/her qualifications and competency in the clinical privileges he/she requests, as set forth in the WellStar Appointment Policy. The scope and extent of privileges and procedures that each such Practitioner may perform shall be specifically delineated and shall be subject to the Medical Staff Rules, Regulations and Policies promulgated hereunder. D. Periodic redetermination of clinical privileges and the increase or curtailment of same shall be based upon the direct observation of care provided, review of the records of patients treated in this or other hospitals, review of the records of the Medical Staff Member which document the evaluation of the Applicant's participation in the delivery of medical care and such other information and evidence as set forth in the WellStar Appointment Policy. Section 2. Temporary Privileges A. When appropriate, upon (i) the written request of an appropriately licensed Practitioner for temporary admitting and/or clinical privileges ("Temporary Privileges"); and (ii) the receipt of a completed Application for Medical Staff membership appointment, as more particularly set forth in the WellStar Appointment Policy, the Chief Executive Officer, or his or her designee, may grant Temporary Privileges to such Practitioner on the written recommendation of the Departmental The information contained herein is confidential and proprietary to WellStar Health System. Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WeHStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 12 Chair concerned when available, or the President of the Medical Staff in all other circumstances. Temporary Privileges granted to a Practitioner pursuant to this provision shall not exceed one hundred twenty (120) days and shall automatically terminate in the event of a recommendation for denial of a Practitioner's Application by the Credentials Committee or the Executive Committee, or action on the Practitioner's Application by the Governing Body, whichever first occurs. B. An Applicant is ineligible for temporary privileges if the Applicant (i) submits an incomplete Application; (ii) the Medical Executive Committee makes a recommendation that is adverse or has limitations; (iii) there is current challenge or previously successful challenge to licensure or registration; (iv) the Applicant has received an involuntary termination of medical staff membership at another organization; (v) the Applicant has received involuntary limitation, reduction, denial, or loss of clinical privileges; or (vi) the Hospital determines that there has been either an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the Applicant. C. Upon the written request of a Medical Staff Member, the Chief Executive Officer, or his or her designee, and with the written concurrence of the Department Chair concerned or the President of the Medical Staff, may grant emergency temporary privileges to a Medical Staff Member to perform a specific clinical privilege for the purpose of seeing and/or treating a specific patient. Said Medical Staff Member shall be required to submit documentation establishing his/her qualifications and competency to perform said procedure. Such emergency privileges shall be restricted to the treatment of that specific patient, and shall terminate when no longer needed by that patient or upon the discharge or release of said patient, whichever first occurs. Notwithstanding any provision of these Bylaws to the contrary, if there is a recurring need for this procedure, the Medical Staff Member must request the addition of such specific clinical privilege to current delineated privileges and shall have the burden of establishing his/her qualifications and competency to perform said procedures. D. Special requirements of supervision and reporting may be imposed by the Department Chair concerned on any Practitioner granted Temporary Privileges. Temporary Privileges shall be immediately terminated by the Chief Executive Officer, or his/her designee, upon notice of any failure to comply with such special requirements. E. The Chief Executive Officer, or his or her designee, may, at any time, upon the recommendation of the President of the Medical Staff or the Department Chair concerned, terminate a Practitioner's Temporary Privileges effective as of the discharge or release from the Hospital of the Practitioner's patient(s) then under his/her care in the Hospital. However, where it is determined that the life or health of such patient(s) would be endangered by continued treatment by the Practitioner, the termination may be imposed by any person entitled to impose a summary suspension pursuant to Section 2. A of Article 7 of these Bylaws, and the same shall be effective immediately. If a Practitioner does not have patients currently under his/her care in the Hospital, such termination shall be effective immediately. The appropriate Department Chair or, in his/her absence, the President of the Medical Staff, shall assign a Medical Staff Member to assume responsibility for the care of such terminated Practitioner's patient(s) until they are discharged from the Hospital. The wishes of the patient(s) shall be considered, where feasible, in selection of such substitute Practitioner. F. A Practitioner whose Temporary Privileges are terminated prior to the Governing Body's final action on the Practitioner's Application for Appointment may have the right to a Hearing and Appellate Review as provided in the WellStar Fair Hearing Policy as defined in Article 8 below. The infonnation contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 13 Section 3. Emergency Privileges In the case of an emergency, any Medical Staff Member with clinical privileges, regardless of service or staff status, or lack of it, shall be permitted to provide any type of patient care, treatment, and services necessary as a life-saving measure or to prevent serious harm, using every facility of the Hospital necessary, including the calling for any consultation necessary or desirable, until such time as the patient is assigned to a qualified Medical Staff Member ("Emergency Privileges"), provided that the care, treatment, and services provided are within the scope of the Medical Staff Member's license. When an emergency situation no longer exists, the Emergency Privileges shall automatically terminate. Section 4. Emergency and Short Term Privileges for Non-Staff Members A. Upon the request of an Active Staff Member, the Chief Executive Officer, or his or her designee, with the written concurrence of the Department Chair concerned or the President of the Medical Staff, may grant emergency temporary privileges, for the purpose of seeing and/or treating a specific patient, to a recognized, appropriately licensed, medical, dental or podiatric practitioner who has active staff privileges at another hospital. Said practitioner shall be required to apply for emergency temporary privileges in accordance with the WellStar Appointment Policy and shall sign a statement that he/she will comply with and be bound by all of the Bylaws, Rules, Regulations and Policies of the Medical Staff, the Hospital and of the Governing Body. Such emergency privileges shall be restricted to the treatment of that specific patient, and shall terminate when no longer needed by that patient or upon the discharge or release of said patient, whichever first occurs. Notwithstanding any provision of these Bylaws to the contrary, if there is a recurring need for such a specialty, he or she must apply for Medical Staff membership. B. The Chief Executive Officer, or his or her designee, with the written concurrence of the Department Chair concerned, or by the President of the Medical Staff, may permit a practitioner who desires to serve as a locum tenens for a Member of the Medical Staff to attend patients for a period not to exceed 90 days, without becoming a Medical Staff Member, providing all of his/her credentials, from an Application which is complete, as set forth in the WellStar Appointment Policy. C. Special requirements of supervision and reporting may be imposed by the Department Chair concerned on any practitioner granted such privileges. Emergency privileges granted hereunder shall be immediately terminated by the Chief Executive Officer, or his/her designee, upon notice of any failure by the practitioner to comply with such special conditions. D. Any termination of such emergency privileges based on professional competence or conduct shall entitle the practitioner to a Hearing and Appellate Review in accordance with the WellStar Fair Hearing Policy. In all other cases, the expiration or termination of such privileges shall not entitle the practitioner to any Hearing or Appellate Review as may otherwise be afforded by the WellStar Fair Hearing Policy. Section 5. Disaster Privileges A. Upon the declaration of a major disaster and activation of the WellStar Emergency Management Plan, the Chief Executive Officer, or his or her designee, or the Medical Staff President, or his or her designee, has the option to grant Disaster Privileges upon presentation of any of the following: 1. A current license to practice and a valid picture identification issued by a state, federal, or regulatory agency; The infonnation contained herein is confidential and proprietary to WeJl$tar Health System, Inc. and its affiliates ('WeIlStar"'), and is protected by applicable copyright and other Jaws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 14 2. A current hospital picture identification card; 3. Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT); 4. Identification indicating that the individual has been granted authority to render patient care in emergency circumstances. Such authority having been granted by a federal, state, or municipal authority; or 5. Presentation by current hospital or medical staff member(s) with personal knowledge regarding the individual's identity. B. Those individuals granted Disaster Privileges upon the declaration of a major disaster will be given patient care assignments and identification as outlined in the WellStar Emergency Management plan. C. Once the immediate situation is under control, initiation of verification of credentials of those individuals granted Disaster Privileges will begin as soon as possible. This verification process will follow the established requirements as outlined in the WellStar Appointment Policy, Section 6.7. D. Such Disaster Privileges shall terminate upon completion of the disaster state with notification to these individuals as outlined in the WellStar Emergency Management Plan. ARTICLE 7. CORRECTIVE ACTION Section 1. Procedure for Medical Staff Members A. Whenever the activities or professional conduct of any Medical Staff Member with clinical privileges are considered to be lower than the standards or goals of the Medical Staff, or to be disruptive to the operations of the Hospital, corrective action against such Member may be requested by any officer of the Medical Staff, by a Department Chair, by the Chief Executive Officer, by the Executive Committee, or by the Governing Body or its designee. Except for requests by the Executive Committee, all requests for corrective action shall be in writing, shall be made to the Executive Committee, and shall be supported by reference to the specific activities or conduct which constitutes the grounds for the request. The Executive Committee, through the Chief Executive Officer, shall release and disclose any information related to professional competence, professional conduct or character of any Medical Staff Member which gives rise to a request for corrective action under this Article 7 to the other WellStar Hospitals, or their designees, the Medical Affairs Committee and/or the Governing Body. The Executive Committee may utilize any information received from a WellStar Hospital, Medical Affairs Committee, and/or the Governing Body related to the professional competence, professional conduct or character of a Medical Staff Member at another WellStar Hospital as a basis for instituting corrective action pursuant to th is Article 7. B. Whenever the Executive Committee concludes an investigation is warranted, it shall direct an investigation be undertaken. The Executive Committee may conduct the investigation itself or may, at its option, appoint an ad hoc committee to investigate the matter. C. If an investigation is initiated, it shall proceed promptly, and if an ad hoc committee conducts the investigation, it shall forward a written report of its investigation to the Executive Committee as soon as practical. The report may include recommendations for appropriate corrective action. The Medical Staff Member against whom corrective action has been requested shall be notified that an investigation is being conducted and shall be given an opportunity to provide information in a manner and upon such terms as the investigating body deems appropriate. The individual or The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 15 body investigating the matter may, but is not obligated to, conduct interviews with persons involved; however, such investigation shall not constitute a "Hearing" as that term is used in these Bylaws and the WellStar Fair Hearing Policy, nor shall the procedural rules with respect to Hearings or Appeals apply. Despite the status of any investigation, at all times the Executive Committee shall retain authority and discretion to take whatever action may be warranted by the circumstances, including summary suspension, termination of the investigative process, or other action. D. As soon as practical after the conclusion of an investigation undertaken by the Executive Committee, the receipt of a request for corrective action if an investigation is not undertaken, or receipt of a report from the ad hoc committee if established, whichever is later, the Executive Committee will evaluate and make recommendations regarding the request. If the corrective action constitutes an Adverse Action, the Affected medical Staff member shall be permitted to make an appearance before the Executive Committee prior to its taking action on such request. This appearance shall not constitute a Hearing, but rather shall be preliminary in nature, and none of the procedural rules provided in these Bylaws with respect to Hearings shall apply thereto. The Executive Committee shall make a record of such appearance. A Medical Staff Member and the Executive Committee shall be entitled to have legal counsel present during any meetings or discussions between the Member and the members of the Executive Committee. E. The action of the Executive Committee on a request for corrective action may be to extend the time in which the Executive Committee shall (i) act, reject or modify the request for corrective action, (ii) issue a warning, a letter of admonition, censure, or a letter of reprimand (although nothing herein shall be deemed to preclude the issuance of informal written or oral warnings outside the mechanism for corrective action pursuant to the WellStar Medical Staff Peer Review Policy), (iii) impose terms of probation or a requirement for consultation, co-admission or monitoring; (iv) recommend that an already imposed summary suspension of clinical privileges be terminated, modified or sustained; (v) recommend that Medical Staff membership be suspended or revoked; or (vi) take any other action as determined appropriate by the Executive Committee. F. Any recommendation or action by the Executive Committee which Adversely Affects the clinical privileges of a Medical Staff Member and which constitutes an Adverse Action shall be reported to the Medical Staff Services Office and shall entitle the Affected Medical Staff Member to the procedural rights provided in the WellStar Fair Hearing Policy. G. The President of the Medical Staff shall promptly notify the Chief Executive Officer and the other Presidents of the Medical Staffs of WellStar Hospitals at which the Medical Staff Member has clinical privileges, through the Chief Executive Officer, of all requests for corrective action received by the Executive Committee and shall continue to keep the Chief Executive Officer and each other Medical Staff President, through the Chief Executive Officer, fully informed of all actions taken in connection therewith. If the Executive Committee's final recommendation or action does not entitle the Medical Staff Member to the procedural rights provided in the Fair Hearing Policy, the recommendation or action shall be reported, through the Chief Executive Officer, to the Governing Body. H. Notwithstanding any provision herein to the contrary, any Professional Review Body shall have the power to conduct an informal investigation of a Medical Staff Member and conduct corrective counseling, issue a letter of warning, admonition or reprimand, which letter shall become part of the Medical Staff Member's credentialing file. Section 2. Summary Suspension A. Notwithstanding any provision herein to the contrary, whenever there are reasonable grounds to believe that the conduct or activities of a Practitioner pose a threat to the life, health or safety of The information contained herein is confidential and proprietary to WellStar Health System. Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of Well$tar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 16 any patient, employee, or other person present at Kennestone Hospital and that the failure to take prompt action may result in imminent danger to the life, health or safety of any such person, the President of the Medical Staff, the President Elect of the Medical Staff, the Executive Committee or the Governing Body shall each, after consultation with the Chief Executive Officer, or his or her designee, have the authority to summarily terminate the appointment of such Practitioner to the Medical Staff and/or to summarily suspend or restrict all or any portion of his or her clinical privileges. Unless otherwise stated, such summary restriction or suspension shall become effective immediately upon imposition, and the person or body imposing this suspension shall promptly give written notice to the Chief Executive Officer, Governing Body, Executive Committee and each other WellStar Hospital at which the Practitioner is a Medical Staff Member or has a pending application for Medical Staff membership that the suspension was imposed and the terms thereof. Any modification to the terms of such suspension shall also be promptly delivered to the Chief Executive Officer, Governing Body, the Executive Committee and each other applicable WellStar Hospital. The summary restriction or suspension may be limited in duration, and if so, such suspension shall remain in effect for the period stated. In the event a summary suspension or other summary action is imposed at another WellStar Hospital pursuant to a corrective action, the clinical privileges and/or Medical Staff membership held by the affected Practitioner at Kennestone Hospital shall automatically be suspended or terminated under the same terms as the summary suspension or other action imposed at another WellStar Hospital. The Chief Executive Officer shall immediately notify the affected Practitioner of the imposed summary suspension and the terms thereof. B. A Medical Staff Member whose clinical privileges have been summarily suspended or restricted pursuant to this Section 2 shall have a right to the procedural rights as provided in the WellStar Fair Hearing Policy, if any. C. Immediately upon the imposition of a summary suspension, the President of the Medical Staff or responsible Department Chair shall have authority to provide for alternative medical coverage for the patients of the suspended Medical Staff Member still in the Hospital at the time of such suspension. The wishes of the patients shall be considered in the selection of such alternative Medical Staff Member. Section 3. Automatic Termination A. An appointment to the Medical Staff, as well as all clinical privileges, shall be automatically terminated upon the occurrence of any of the following events: 1. A Medical Staff Member shall lose his or her license to practice his or her profession; 2. A Medical Staff Member is temporarily suspended in accordance with the Medical Staff Rules, Regulations and Policies due to his or her failure to report to the Medical Staff Services Office, in writing, within fifteen (15) days, any of the following (i) any warning, sanction, or reprimand, whether public or private, issued by the applicable Licensure Board related to the Medical Staff Member's license or any restriction or condition imposed on, or probation of, his or her license, whether publiC or private, by the applicable Licensure Board, or (ii) the revocation or suspension of a Medical Staff Member's right to prescribe or administer any controlled substances (collectively, a "Board Action") and either (i) after review of the action taken, the Medical Executive Committee determines, in its judgment, that the underlying facts and circumstances which gave rise to the action are material and significantly impacted patient care; or (ii) the temporary suspension is the second temporary suspension received by the Medical Staff Member for failure to report a Board Action; The information contained herein is oonfidential and proprietary to WellStar Health System. Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of Well$tar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 17 3. A Medical Staff Member is convicted or is found to have been convicted of a felony as defined by the laws of the United States or any state; 4. A Medical Staff Member is temporarily suspended a fifth time during a calendar year for failure to complete medical records in accordance with the Medical Staff Rules, Regulations and Policies; 5. A Medical Staff Member shall fail to maintain or otherwise meet any other Minimum Objective Criteria, as defined in the WellStar Appointment Policy from time to time; 6. A Medical Staff Member's clinical privileges or Medical Staff membership are summarily suspended or terminated at any other WellStar Hospital pursuant to the WellStar Impaired Provider Policy; or 7. A covering Staff Member no longer has Active Medical Staff sponsorship. B. An automatic review by the Executive Committee as to whether the Medical Staff Member's clinical privileges and/or Medical Staff membership should be revoked shall occur in the event of: 1. The conviction of a misdemeanor, except for minor traffic offenses, as defined by the laws of the United States or of any state; 2. The placement of a restriction or condition of any sort upon a Medical Staff Member's license; 3. The placement of a restriction or condition of any sort upon a Medical Staff Member's right to prescribe or administer any controlled substances; 4. In the event of any investigation by a Medical Staff Member's applicable Licensure Board occurs; 5. A Medical Staff Member who has been requested to appear at a meeting of any committee of the Medical Staff or Hospital in order to discuss proposed corrective action shall fail to appear except with good cause as determined by the applicable committee; or 6. An Adverse Action at any other hospital. C. It shall be the duty of the President of the Medical Staff to cooperate with the Chief Executive Officer in enforcing all automatic terminations. Section 4. Procedure for Allied Health Professionals Corrective action of Allied Health Professionals shall be as is specified in the Rules and Regulations for Allied Health Professionals. Section 5. Governing Body Action The procedures specified herein shall not preclude the Governing Body from taking any direct action or utilizing other methods for dealing with disruptive or other Practitioner conduct. The infonnation contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WelIStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 18 ARTICLE 8. HEARING AND APPELLATE REVIEW PROCEDURE The right of an Applicant or Medical Staff Member to a Hearing and Appellate Review, and the procedures governing any applicable Hearing and Appellate Review, shall be determined by, and shall be in accordance with, the terms and provisions of the WellStar Fair Hearing Policy as may be in effect from time to time. ARTICLE 9. OFFICERS Section 1. Officers of the Medical Staff The officers of the Medical Staff shall be: 1. President 2. President Elect 3. Immediate Past President 4. Secretary Section 2. Qualifications of Officers Officers must be members of the Active Medical Staff at the time of nomination and election and must remain members in good standing of the Active Medical Staff during their term of office. Failure to maintain such status shall immediately create a vacancy in the office involved. The officers must also be certified by an appropriate specialty board, or affirmatively establish, through the delineation process, that he/she possesses comparable competence. Section 3. Election of Officers A. Officers shall be elected annually at a meeting of the Medical Staff. Only members of the Active Medical Staff shall be eligible to vote. If there are three or more candidates for one office and no candidate receives a majority, the name of the candidate receiving the fewest votes is omitted from each successive slate until a majority vote is obtained by one candidate. B. Nominations for officers shall be submitted by the Executive Committee; provided, however, nominations may also be made from the floor at the time of the meeting. Section 4. Term of Office Elected officers shall serve a one year term commencing at the beginning of the Medical Staff Year or until a successor is elected. The President Elect shall automatically advance to the office of President after serving a term as President Elect. The President shall advance to the office of Immediate Past President after completing the term of President. The Secretary shall advance to the office of President Elect after completing the term of Secretary. Officers shall take office on the first day of the Medical Staff Year. Section 5. Vacancies in Office Vacancies in office during the Medical Staff term shall be filled by each of the remaining officers in order of succession to complete the remaining term, in addition to their term, and the Executive Committee shall appoint a Secretary to serve until the next annual election. The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WelIStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited WellStar Kennestone Hospital Medical Staff Bylaws Page 19 Section 6. Duties of Officers A. President: The President shall serve as the chief administrative officer of the Medical Staff to: 1. Act in coordination and cooperation with the Chief Executive Officer in matters of mutual concern within the Hospital; 2. Serve on and Chair the Executive Committee and serve on the WellStar Medical Affairs Committee established by the Governing Body; 3. Call, preside at, and be responsible for the agenda of all general meetings of the Medical Staff and the Executive Committee meetings; 4. Serve as ex officio member without vote of any other Medical Staff committee as necessary as determined by the President; 5. Be responsible for the enforcement of Medical Staff Bylaws, Rules, Regulations and Policies; for implementation of sanctions where indicated; and for the Medical Staff's compliance with procedural safeguards in all instances where corrective action has been requested against a Practitioner; 6. Appoint members to, and designate the chair of, each Medical Staff committee unless otherwise specified in these Bylaws; 7. Appoint members to serve on an ad hoc Hearing Committee of the Medical Staff of the Hospital formed pursuant to the Fair Hearing Policy; 8. Appoint representatives to any Joint Medical Executive Committee formed pursuant to the WellStar Fair Hearing Policy; 9. Represent the views, interests, policies, needs and grievances of the Medical Staff to the Governing Body and to the Chief Executive Officer; 10. Receive and interpret the policies of the Governing Body to the Medical Staff and report to the Governing Body on the performance, maintenance and improvement of quality with respect to the Medical Staff's delegated responsibility to provide medical care; 11. Be responsible for the educational activities of the Medical Staff; 12. Be the spokesperson for the Medical Staff in its external and professional public relations; 13. Appoint members of the Medical Staff to serve on performance improvement committees including, but not limited to, interdisciplinary Hospital, interdisciplinary System-wide function/special committees, and System committees or ad hoc committees, which fulfill the Medical Staff's responsibility for the following: i. Monitoring, evaluating, and improving care provided in and developing clinical policies for special care areas, such as intensive or coronary care units; patient care support services, such as respiratory therapy, physical medicine, and anesthesia; and emergency, outpatient, home care, and other ambulatory care services; The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStal'''), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 20 ii. Conducting or coordinating quality, appropriateness, patient safety and improvement activities, including invasive procedures, blood usage, medication usage, clinical laboratory usage, medical records, and other reviews; iii. Conducting or coordinating utilization review activities; iv. Providing for continuing education opportunities in response to quality improvement activities, new state-of-the-art developments, and other perceived needs, and supervision of the Hospital's professional library services; v. Developing and maintaining surveillance over drug utilization policies and practices; vi. Investigating and controlling nosocomial infections and monitoring of the Hospital's infection control program; vii. Planning for the response to fire and other disasters, for Hospital growth and development and for the provision of services required to meet the needs of the community; viii. Coordinating the care provided by Members of the Medical Staff with the care provided by the nursing service and with the activities of other Hospital patient care and administrative services; and ix. Engaging in other functions reasonably requested by the Executive Committee or the Governing Body, or its designee. 14. Appoint ad hoc committees to deal with specific issues as they may arise. B. President Elect: 1. In the absence of the President of the Medical Staff, he/she shall assume all of the duties and have the authority of the President; 2. Shall be a member of the Executive Committee; 3. Shall serve on the Quality Review Committee; 4. Shall automatically succeed the President for a one year term at the end of the President's term of office or when the latter fails to serve for any reason; and 5. Performs such reasonable duties as may be assigned to him/her by the President. C. Immediate Past President: 1. Shall be a member of the Executive Committee of the Medical Staff; and 2. Duties are advisory in nature. D. Secretary: 1. Shall be a member of the Executive Committee; The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellSlar Kennestone Hospital Medical Staff Bylaws Page 21 2. Shall be responsible for maintaining minutes of all Medical Staff meetings; and 3. Perform such other duties as ordinarily pertain to this office. Section 7. Removal from Office Failure of an officer to maintain Active Status results in automatic removal from office. Failure to carry out the prescribed duties and responsibilities of the office or dereliction of duty may result in removal from office. Removal may be initiated by a minimum of a two-thirds vote of total Executive Committee members followed by a two-thirds vote of the Active Members of Medical Staff and ratification by the Governing Body. ARTICLE 10. DEPARTMENTS Section 1. Organization of Departments The Medical Staff shall be organized into Departments. Each Department shall have a Chair who shall be responsible for the overall supervision of the work within the Department. Departments of the Medical Staff shall be as follows: A. DEPARTMENT OF ANESTHESIOLOGY B. DEPARTMENT OF EMERGENCY MEDICINE C. DEPARTMENT OF FAMILY PRACTICE D. DEPARTMENT OF MEDICINE 1. Internal Medicine a. Allergy b. Cardiovascular Disease c. Endocrinology d. Gastroenterology e. General Medicine f. Hematology/Oncology g. Hospitalists h. Infectious Disease i. Nephrology j. Neurology k. Pulmonary Disease I. Rheumatology 2. Dermatology 3. Hyperbaric Medicine 4. Physical Medicine and Rehabilitation 5. Psychiatry E. DEPARTMENT OF OBSTETRICS & GYNECOLOGY 1. Gynecology 2. Gynecologic Oncology 3. Maternal Fetal Medicine 4. Obstetrics and Gynecology The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 22 F. DEPARTMENT OF PATHOLOGY G. DEPARTMENT OF PEDIATRICS 1 . Neonatology 2. Pediatric Allergy 3. Pediatric Cardiology H. DEPARTMENT OF RADIOLOGY 1. Diagnostic 2. Radiation Oncology 3. Interventional 4. Neuroradiology I. DEPARTMENT OF SURGERY 1. General Surgery 2. Neurological Surgery 3. Ophthalmology 4. Oral & Maxillofacial Surgery/Subsection of Dentistry 5. Orthopedic Surgery a. Podiatry 6. Otorhinolaryngology 7. Plastic Surgery 8. Thoracic and Cardiovascular Surgery 9. Urology 10. Vascular Surgery Section 2. Assignment to Departments The Executive Committee shall, after consideration of the recommendations of the Departments as transmitted through the Credentials Committee, recommend to the Governing Body Department assignments for all Medical Staff Members. Based on education, training, experience, and demonstrated competence, a Medical Staff Member may have clinical privileges in one or more Departments other than the Department assigned to the Medical Staff Member. In such event, he/she shall be subject to all of the rules and regulations of such Departments related to his/her clinical privileges. Section 3. Section and Subsections of Departments A. Each Department, subject to the approval of the Executive Committee and the Governing Body, may establish such other Sections or Subsections as deemed necessary or appropriate. B. Each Section of the Department or Subsection of the Section shall have a Section or Subsection Chair and may have a Vice-Chair as the case may be, who shall be elected by a majority vote of the Active Staff Members of the applicable Section or Subsection in attendance at the Section or Subsection meeting. Each Chair shall serve for such terms as specified in the resolution electing such Chair. Any Chair may be removed with or without cause by the majority vote of the Active Staff Members of the applicable Section or Subsection subject to approval of the Executive Committee. C. Each Chair of the Section or Subsection, as the case may be, shall report on the activities of the The infonnation contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates CWeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited WellStar Kennestone Hospital Medical Staff Bylaws Page 23 Section or Subsection at the following Department meeting. These reports will include findings from, and conclusions of, monitoring, evaluating, and problem solving activities, actions taken, and impact of actions taken. Section 4. Qualifications, Selection, and Tenure of Department Chair A. Each Chair shall be a member of the Active Staff in good standing of that Department. The Department Chair must also be certified by an appropriate specialty board, or affirmatively establish, through the delineation process that he/she possesses comparable competence. B. Each Chair, with the exception of the Medicine, Obstetrics and Gynecology, Pediatrics and Surgery Department Chairs, shall be elected by the Active Staff Members of the Department for a two-year term commencing at the beginning of a Medical Staff Year or until his or her successor is elected, subject to the approval of the Governing Body. There is no limitation as to the number of consecutive terms a Chair may serve. The Departments of Emergency Medicine and Family Practice shall hold their elections on even years. The Departments of Anesthesia, Pathology and Radiology shall hold their elections on odd years. The Medicine, Obstetrics and Gynecology, Pediatrics, and Surgery Department Chairs shall be elected by the Active Staff Members of the Department annually. C. Failure to carry out the prescribed duties and responsibilities of the office or dereliction of duty may result in removal from office. A Chair may be removed during his/her term of office by a two- thirds majority vote of all Active Staff Members of the Department, but no such removal shall be effective unless and until it has been ratified by the Executive Committee and by the Governing Body. Section 5. Duties of Department Chair Each Chair shall be accountable for the following professional and administrative activities within the Department including, but not limited to: A. Recommending, together with the Executive Committee and the Governing Body, the type and scope of services required to meet the needs of the patients of the Hospital, including safety of the patients, and for off site services provided to Hospital patients; B. In accordance with the WellStar Medical Staff Peer Review Policy, maintaining an on-going, planned and systematic process for monitoring and evaluating (i) the quality of clinical care and services provided by the Department in order to effect continuous improvement in the processes affecting provision of that care, and (ii) the professional performance, judgment, and clinical or technical skills of all Medical Staff Members with clinical privileges in the Department and reporting regularly thereon to the Executive Committee in accordance with the WellStar Medical Staff Peer Review Policy; C. Developing and implementing policies and procedures that guide and support the provision of services in the Department; D. Transmitting to the Credentials Committee his/her recommendations for the appointment of and the delineation of clinical privileges for all Medical Staff Members assigned to the Department, and recommending to the Credentials Committee the criteria for clinical privileges that are relevant to the care provided in the Department in accordance with the WellStar Clinical Privileging Criteria Policy; The information contained herein is confidential and proprietaf)' to WellStar Health System, Inc. and its affiliates ('WelIStsr"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of Well$tar is explicitly prohibited WellStar Kennestone Hospital Medical Staff Bylaws Page 24 E. Enforcing and implementing Hospital Bylaws, Governing Body Bylaws, WellStar Health System Policies, and Medical Staff Bylaws, Rules, Regulations and Policies within the Department; F. Serving as a Member of the Executive Committee, making specific recommendations and suggestions regarding the Department and giving guidance on the development of overall medical policies of the Hospital and procedures that guide and support the provision of services; G. Implementing in the Department any applicable actions taken by Executive Committee, assisting in the integration of the Department into the primary functions of the Hospital and System as well as interdepartmental and intradepartmental services; H. Participating in every phase of administration in the Department through cooperation with all clinical and support services and the Hospital administration in matters affecting patient care, recommending a sufficient number of qualified and competent persons to provide care or service, recommending appropriate space and other resources needed by the Department, and maintaining quality control programs as appropriate; I. Assisting in the preparation of such annual reports, including budgetary planning, pertaining to the Department as may be required by the Executive Committee, the Chief Executive Officer, or the Governing Body; J. Being responsible for the Department orientation, teaching, education, and research programs of all persons in the Department; and K. Such other duties or responsibilities as reasonably requested by the Executive Committee, Medical Affairs Committee, or the Governing Body. Section 6. Qualification, Selection, Duties and Tenure of Department Vice-Chair A. Each Vice-Chair shall be a Member of the Active Staff and shall be elected by the Active Staff Members of the Department for a two-year term, with the exception of the Medicine, Obstetrics and Gynecology, Pediatrics and Surgery Department Vice-Chairs, subject to the approval of the Governing Body. Each Vice-Chair must also be certified by an appropriate specialty board, or affirmatively establish, through the delineation process that he/she possesses comparable competence. B. The Departments of Emergency Medicine and Family Practice shall hold their elections for Vice- Chair on even years. The Departments of Anesthesia, Pathology and Radiology shall hold their elections for Vice-Chair on odd years. The Medicine, Obstetrics and Gynecology, Pediatrics and Surgery Department Vice-Chairs shall be elected by the Active Staff Members of the Department annually. C. Failure to carry out the prescribed duties and responsibilities of the office or dereliction of duty may result in removal from office. A Vice-Chair may be removed during the Vice-Chair's term of office by a two-thirds majority vote of all Active Staff Members of the Department, but no such removal shall be effective unless and until it has been ratified by the Executive Committee and by the Governing Body. D. The duties of the Department Vice-Chair shall be to serve in the absence of the Department Chair and to serve as the primary reviewer for peer review activities within the Department. The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellSlar Kenneslone Hospital Medical Staff Bylaws Page 25 Section 7. Department Functions Each Department has responsibility for the following functions: A. The credentialing of all Applicants including the review of and recommendation for membership and delineation of clinical privileges in accordance with Article 5 of these Bylaws. A report from the applicable Department on each Applicant shall be made to the Credentials Committee. All available information regarding competence and conduct of Medical Staff Members shall be periodically reviewed and as a result of such reviews, recommendations for reappointment shall be made to the Credentials Committee in accordance with Article 5 of these Bylaws; B. Recommending to the Medical Staff privileging criteria for the granting of clinical privileges in the Department consistent with the WellStar Clinical Privileging Criteria Policy as may be in effect from time to time; C. Establishing the type and scope of services required to meet the needs of the patients and the Hospital, and working with administration; D. Developing and implementing policies and procedures that guide and support the provision of services in the Department; E. Assessing and improving the quality of care and services provided in the Department; F. Each Department may establish a Medical Care Evaluation Committee. If established, the Medical Care Evaluation Committee shall be a subcommittee of the Quality Review Committee as more particularly set forth in Article 11, Section 3. Members will be the Department Chair, Department Vice-Chair, the Peer Reviewers as specified in the WellStar Medical Staff Peer Review Policy, and any other Members as deemed necessary and appointed by the Department Chair. For Surgery and Obstetrics and Gynecology Departments, a pathologist is an ex officio member. The Medical Care Evaluation Committee Chair will be appointed by the Department Chair. This committee is responsible for maintaining an on-going, planned and systematic process for (i) monitoring and evaluating the quality of clinical care and services provided by the Department in order to effect continuous improvement in the processes affecting provision of that care, and (ii) the monitoring and evaluation of the professional performance, judgment, and clinical or technical skills of all Medical Staff Members with clinical privileges in the Department. Written reports of findings, conclusions, recommendations, actions, and results of actions taken shall be maintained and shall be reported to the Quality Review Committee. ARTICLE 11. COMMITTEES Section 1. Executive Committee A. The Executive Committee shall consist of the Medical Staff officers, Credentials Committee Chair, each Department Chair, and one additional member from each Department for every twenty-five (25) Active Members up to maximum of three additional Department members which shall be appointed by the Department Chair. In the event a designated member is unable to attend a meeting, the Chair of that member's Department may appoint a surrogate, in writing, to be a voting member for that meeting only. Ex officio, non-voting members will be the Chair of the Emergency Services Committee, the Chief Executive Officer or his/her designee, the System Vice President of Nursing or his/her designee, and the Medical Director who has responsibility for the Hospital or his/her designee. The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited WellStar Kennestone Hospital Medical Staff Bylaws Page 26 B. The duties of the Executive Committee shall be: 1. To represent and to act on behalf of the Medical Staff, subject to such limitations as may be imposed by these Bylaws; 2. To coordinate the activities and general policies of the Medical Staff; 3. To receive, review, and act upon reports of Hospital committees, Medical Staff Committees, Departments and other assigned activity groups or committees; 4. To implement policies of the Medical Staff not otherwise the responsibility of the Medical Staff Departments; 5. To direct Medical Staff activities and to provide liaison among the Medical Staff, the Chief Executive Officer, and the Governing Body; 6. To make recommendations on Hospital management matters (for example, long-range planning) to the Chief Executive Officer and Medical Affairs Committee; 7. To fulfill the Medical Staff organization's accountability to the Medical Affairs Committee and Governing Body for the medical care rendered to patients in the Hospital; 8. To ensure that the Medical Staff is kept abreast of the accreditation program and informed of the accreditation status of the Hospital, and assist the Hospital in maintaining JCAHO accreditation; 9. To review the credentials of all Applicants and make recommendations for Medical Staff membership, Medical Staff Department assignments, and delineation of clinical privileges; 10. To review all information available regarding the performance, quality and clinical competence of Medical Staff Members and other Practitioners with clinical privileges and as a result of such review to make recommendations for reappointment and renewal or changes in clinical privileges to the Medical Affairs Committee; 11. To review and make recommendations related to privileging criteria as set forth in the WellStar Clinical Privileging Criteria Policy; 12. To evaluate the quality, safety and efficiency of services ordered or performed by Medical Staff Members and other Practitioners and to receive, review, act and recommend on the findings of such performance improvement activities and report such actions or recommendations to the Medical Affairs Committee or its designee; 13. In recognition of the peer review and quality improvement responsibilities of the Governing Body and Medical Affairs Committee, to provide or allow access to such information as reasonably requested to enable the Governing Body and Medical Affairs Committee, or their respective designees, to perform and accomplish such responsibilities; 14. To take all reasonable steps to ensure professionally ethical conduct and competent clinical performance for all Members with clinical privileges, including the initiation of and/or participation in Medical Staff corrective or review measures when warranted; The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of Well$tar is explidtly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 27 15. To appoint such special committees including but not limited to Bylaws, Nominating, subcommittees or task forces as may be necessary or desirable to perform such functions as designated by the Executive Committee; 16. Review and either approve, reject or modify proposed amendments to these Bylaws; 17. To receive, evaluate, and respond to grievances from any Medical Staff Member; 18. To conduct such other functions as are necessary for the effective operation of the Medical Staff; and 19. To report to each General Staff meeting. C. Except under extraordinary circumstances, the Executive Committee shall meet at least quarterly and maintain a record of its proceedings and actions. D. Failure to carry out the prescribed duties and responsibilities or dereliction of duty may result in removal from Executive Committee membership. Such member may be removed during his/her term of office by a 2/3 majority vote of all Executive Committee Members, but no such removal shall be effective unless and until it has been ratified by the Governing Body. Section 2. Credentials Committee A. The Credentials Committee shall consist of Members of the Active Staff selected on a basis that will ensure representation of the major clinical specialties, the hospital-based specialties, and the Medical Staff at large. The Credentials Committee Chair shall be appointed by the Medical Staff President and Credentials Committee members shall be appointed by the applicable Department Chairs with approval of the Medical Executive Committee. Ex officio, non-voting members will be the Medical Director, or his or her designee, and a Medical Staff Coordinator. B. The duties of the Credentials Committee shall be as follows: 1. To review the credentials of all Applicants and to make recommendations for Medical Staff membership and the delineation of clinical privileges in compliance with Articles 4, 5 and 6 of these Bylaws; 2. To make a report to the Executive Committee on each Applicant for Medical Staff membership or clinical privileges, including specific consideration of the recommendations from the Departments in which such Applicant requests privileges; and 3. To review periodically all information available regarding the competence, ethics and character of Medical Staff Members received from the Medical Affairs Committee or any other source and as a result of such reviews to make recommendations for the granting of privileges, reappointment, and the assignment of Medical Staff Members and Allied Health Professionals to the various Departments or services as provided in Articles 4, 5, and 6 of these Bylaws. C. Except under extraordinary circumstances, the Credentials Committee shall meet at least quarterly and maintain a record of its proceedings and actions. D. This committee shall report directly to the Executive Committee of the Medical Staff. The Chair of this Committee shall be the representative to the Executive Committee with the Vice-Chair being the representative in the absence of the Chair. The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WellStsr"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 28 Section 3. Quality Review Committee The Executive Committee may establish a Quality Review Committee ("QRC"). Members shall include the Secretary of the Medical Staff, the President Elect of the Medical Staff, the Chair of each of the Hospital's Medical Care Evaluation Committees and the applicable Hospital Department Chair(s) for the WellStar Health System Medical Care Evaluation Committees. Ex officio members shall be the Chief Executive Officer, or his/her designee, the Medical Director assigned responsibility for the Hospital, appropriate Quality Improvement Analysts in accordance with the WellStar Medical Staff Peer Review Policy, and Nursing Directors. The Quality Review Committee Chair shall be appointed by the Medical Staff President with Medical Executive Committee approval. The QRC shall oversee performance improvement activities related to services provided by Medical Staff Members and other Practitioners in accordance with the WellStar Medical Staff Peer Review Policy and shall coordinate and oversee the peer review function carried out by the Medical Care Evaluation Committees as set forth in the WellStar Medical Staff Peer Review Policy. The QRC will make recommendations and report its findings to the Executive Committee, and/or the Department Chairs as appropriate. The QRC shall meet at least quarterly and maintain a record of its proceedings and actions. The QRC shall report directly to the Executive Committee of the Medical Staff and the QRC Chair, or his or her designee, shall be the QRC representative to the Executive Committee. Section 4. Emergency Services Committee This committee will be appointed by the President and will include seven members: two from the Emergency Medicine Department and five from the general Medical Staff. Ex officio members will be the Chief Executive Officer, or his/her designee, and the appropriate Emergency Services person. The Chair of the Emergency Services Committee will be an ex officio member of the Executive Committee. The committee's purpose will be to review and analyze, on a regular basis, emergency services rendered. Specific duties will be to review and evaluate emergency services data pertaining to patient care delivered in the emergency center. Additionally, the committee will formulate rules and regulations pertaining to the emergency center, subject to the approval of Executive Committee and the Governing Body. The committee will meet and report to the Executive Committee at least quarterly and maintain a record of its proceedings and actions. Section 5. Sentinel Event Committee When a possible Sentinel Event has been suspected of occurring at the Hospital, the President of the Medical Staff, or his or her designee, shall appoint an ad hoc committee for the purpose of conducting an investigation and review of the event. Members of the ad hoc committee shall include but not be limited to the Site Administrator of the Hospital who shall act as Chair of the ad hoc committee, the assigned Medical Director, the Quality Improvement staff responsible for investigating the event, applicable representatives of the Hospital and applicable Departmental Medical Staff Members. Upon completion of the investigation and review, each ad hoc committee shall report its findings to the Executive Committee. Section 6. Special Committees The President shall appoint such special committees, sub-committees or task forces as may be necessary or desirable and which are not in conflict with other provisions of these Medical Staff Bylaws. Each member of the committee shall continue to serve until his or her successor is appointed or until the committee is terminated, whichever shall first occur. The President may remove any member serving on any such committee, sub-committee or task force, in his or her discretion. The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 29 ARTICLE 12. COMMITTEE, SUBSECTION, SECTION AND DEPARTMENT MEETINGS Section 1. Regular Meetings Committees, Sections and Subsections may, by resolution, provide the time for holding regular meetings without notice. Department meetings shall be held at least quarterly, at a time and place to be determined by each Department, to consider findings from the ongoing monitoring and evaluation of the quality and appropriateness of care and treatment provided to patients. Section 2. Special Meetings A special meeting of any Committee, Department, Section or Subsection may be called by or at the request of the Chair thereof, by the President of the Medical Staff, or by one-third of the group's then members, but not less than two members. Section 3. Notice of Special Meetings Written or oral notice stating the place, day and hour of any special meeting shall be given to each member of the Committee, Department, Section or Subsection either personally, by mail, by facsimile, e- mail, or by placement of a written notice in a Practitioner's Medical Staff mailbox not less than twenty-four hours before the time of such meeting, by the person or persons calling the meeting. If mailed, the notice of the meeting shall be deemed delivered when deposited, postage pre-paid, in the United States mail addressed to each member at his/her address as it appears on the records of the Hospital. The attendance of a member at a meeting shall constitute a waiver of notice of such meeting. Section 4. Quorum The voting members of a Committee, Department, Section, or Subsection present but not less than two voting members, shall constitute a quorum at any meeting. With respect to the Executive Committee, twenty-five percent (25%) of the voting members shall constitute a quorum at any Executive Committee meeting. Section 5. Manner of Action Except as provided in Section 7 of Article 9, the action of a simple majority of the members present at a meeting shall be the action of a Committee or Department. Action may be taken without a meeting by unanimous consent in writing (setting forth the action so taken), and signed by each member entitled to vote thereat. Voting by proxy or absentee ballot shall not be allowed. Section 6. Rights of Ex Officio Members Persons serving under these Bylaws as ex officio members of a Committee shall have all rights and privileges of regular members except they shall not be counted in determining the existence of a quorum, and may not vote unless specified in these Bylaws. Section 7. Minutes Minutes of each regular and special meeting of a Committee, Department, Section, or Subsection may be prepared and approved by the applicable Committee, Department, Section or Subsection. The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited WellStar Kennestone Hospital Medical Staff Bylaws Page 30 Section 8. Attendance Requirements Attendance at Department. Committee, Section, and Subsection meetings is encouraged in order to facilitate the timely dispersion of information throughout the Medical Staff. ARTICLE 13. MEDICAL STAFF MEETINGS Section 1. Regular Meetings Medical Staff Meetings shall be held quarterly and shall be held at such time and place as determined by the Executive Committee from time to time. Annual and regular staff meetings may be held without notice of the date, time, place or purpose of the meeting. The Executive Committee shall establish the annual meeting of the Medical Staff by resolution from time to time. Section 2. Special Meetings A. Special meetings of the Medical Staff may be called by the President of the Medical Staff, the Executive Committee, or shall be called by the President of the Medical Staff in the event of his or her receipt of a written request for a special meeting signed by not less than one-fourth of the Active Staff and stating the purpose for such meeting. The President of the Medical Staff or the Executive Committee, whomever called the special meeting, shall designate the time and place of any called special meeting. B. Notice stating the place, day, hour and purpose of any special meeting of the Medical Staff shall be delivered, either personally, by mail, by facsimile, bye-mail, or by placement of a written notice in a Practitioner's Medical Staff mailbox, to each member of the Active Staff not less than five nor more than fifteen days before the date of such meeting. If mailed, the notice of the meeting shall be deemed delivered when deposited, postage prepaid, in the United States mail, addressed to each Medical Staff Member at his/her address as it appears on the records of the Hospital. The attendance of a member of the Medical Staff at a meeting shall constitute a waiver of notice of such meeting. No business shall be transacted at any special meeting except that stated in the notice calling the meeting. Section 3. Quorum/Action Except as provided in Section 4 of Article 12, the members of the Active Medical Staff present at any regular or special meeting shall constitute a quorum at any meeting. Except as provided in Article 9, Section 7 and Article 16, the action of a majority of the Medical Staff Members present, shall be the action of the Medical Staff. Voting by proxy or by absentee ballot by Medical Staff Members, except for the consideration of an amendment to the Bylaws as provided in Article 16, shall not be allowed. Each Medical Staff Member shall be entitled to one vote on any action brought before the Medical Staff. Section 4. Minutes Minutes of each meeting shall be prepared and, after approval, the minutes shall be maintained by the Medical Staff Services Office. Section 5. Attendance Requirements Attendance at Medical Staff meetings is encouraged to facilitate the timely dispersion of information throughout the Medical Staff. The infonnation contained herein is confidential and proprietary to Well$tar Health System, Inc, and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellSlar Kennestone Hospital Medical Staff Bylaws Page 31 ARTICLE 14. IMMUNITY FROM LIABILITY The following shall be express conditions to any Practitioner's application for, or exercise of, clinical privileges at this Hospital. These provisions shall not restrict or abridge any immunity provisions contained in WellStar's Appointment Policy or WellStar's Fair Hearing Policy; rather, such immunity provisions shall supplement any immunity which may be provided by WellStar's or the Hospital's policies as may be in effect from time to time. First. that any act, communication, report, recommendation, or disclosure, with respect to any such Practitioner, performed or made in good faith and without malice to a WellStar Hospital and at the request of an authorized representative of this or any other health care facility, for the purpose of achieving and maintaining quality patient care in this or any other health care facility, shall be privileged to the fullest extent permitted by law. Second. that such privilege shall extend to members of the Hospital's Medical Staff, the Executive Committee, the Governing Body, its other Practitioners, its Chief Executive Officer, and his/her representatives, and to any Professional Review Body or any third parties, who supply information to any of the foregoing authorized to receive, release, or act upon the same. Third. that there shall, to the fullest extent permitted by law, be absolute immunity from civil liability arising from any such act, communication, report, recommendation, or disclosure, even when the information involved would otherwise be deemed privileged. Fourth. that such immunity shall apply to all acts, communications, reports, recommendations, or disclosures performed or made in connection with this or any other health care institution's activities related, but not limited to: (i) applications for appointment or clinical privileges, (ii) periodic reappraisals for reappointment or clinical privileges, (iii) corrective action, including summary suspension, (iv) hearings and appellate reviews, (v) medical care evaluations, (vi) utilization reviews, and (vii) other Hospital, Department or committee activities related to quality patient care and professional conduct. Fifth. that the acts, communications, reports, recommendations and disclosures referred to in this Article 14 may relate to a Practitioner's professional qualifications, clinical competency, character, mental, medical or emotional stability, physical condition, ethics or any other matter that might directly or indirectly have an effect on patient care. Sixth. that in furtherance of the foregoing, each Practitioner shall, upon request of the Hospital, execute releases in accordance with the tenor and import of this Article 14 in favor of the individuals and organizations specified in paragraph second, subject to such requirements, including those of good faith, absence of malice, and the exercise of a reasonable effort to ascertain truthfulness, as may be applicable under the laws of this State. ARTICLE 15. RULES, REGULATIONS AND POLICIES The Medical Staff shall initially adopt such rules. regulations and policies as may be necessary to implement more specifically the general principles found within these Bylaws, subject to the approval of the Governing Body (the "Medical Staff Rules, Regulations and Policies"). These shall relate to the proper conduct of Medical Staff organizational activities as well as embody the level of practice that is to be required of each Practitioner in the Hospital. Such rules, regulations and policies shall be a part of these Bylaws. Subject to any express provisions for amendment contained in a specific Medical Staff Policy including, but not limited to, the WellStar Fair Hearing Policy, the WellStar Appointment Policy, the WellStar Disruptive Conduct Policy, the WellStar Medical Staff Sexual Harassment Policy, the WellStar Clinical Privileging Criteria Policy, the WellStar Impaired Provider Policy and the WellStar Medical Staff The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 32 Peer Review Policy, the Medical Staff Rules, Regulations and Policies and the Rules and Regulations for Allied Health Professionals may be amended or repealed at any regular or special meeting of the Executive Committee, subject to the approval of the Governing Body. Any amendments to the Medical Staff Rules, Regulations and Policies, and the Rules and Regulations for Allied Health Professionals shall be effective when approved by the Governing Body. Each Department, Section or Subsection may formulate rules and regulations, subject to the approval of the Executive Committee and the Governing Body. Such changes shall become effective when approved by the Governing Body. ARTICLE 16. AMENDMENTS A. Amendments to these Bylaws may be proposed by a Medical Staff Member, the Executive Committee, the Medical Director or the Governing Body. Such proposed amendment shall be in writing and submitted to the Executive Committee. The Executive Committee may, at its option, refer a proposed amendment to a Special Committee for review and evaluation. In such event, the Special Committee shall, upon consideration, give its recommendation, in writing, to the Executive Committee. Thereafter, the Executive Committee shall consider the proposed amendment and the recommendation of the Special Committee, if any, and either approve, reject or modify the proposed amendment. All amendments approved by the Executive Committee shall thereafter be submitted to the Active Staff Members for consideration as specified below. B. Upon approval of a Bylaw amendment by the Executive Committee, the President of the Medical Staff shall present the proposed amendment to the Medical Staff at the Medical Staff's next regularly scheduled meeting or at a special meeting called for such purpose. The President of the Medical Staff shall either provide a copy of the proposed Bylaw amendment to each Medical Staff Member or shall make a copy of the proposed amendment available for each Medical Staff Member's inspection and review prior to the Medical Staff meeting at which the proposed Bylaw amendment shall be considered. To be adopted by the Medical Staff, an amendment shall require a two-thirds vote of the Active Staff present at a meeting, either in person, by proxy or by absentee ballot. C. Upon approval of the proposed Bylaw amendment by both the Executive Committee and the Active Staff Members as provided in this Article 16, the amendment shall be submitted to the Governing Body for consideration. The proposed Bylaw amendment shall be effective upon the approval and adoption of the amendment by the Governing Body. The decision of the Governing Body shall be final. ARTICLE 17. MISCELLANEOUS Section 1. Proxies/Absentee Ballots by Medical Staff Members A. Any proxy given by a Medical Staff Member pursuant to these Bylaws for purposes of voting for or against proposed amendments to these Bylaws, shall be in writing, signed by the Medical Staff Member and submitted by the Medical Staff Member to the Medical Staff Services Office. An executed proxy shall be valid only as to the specific matter referenced therein. Subject to any express limitation on the proxy's authority appearing on the face of the proxy form, the vote of the proxy shall be accepted as that of the Medical Staff Member who issued the proxy. B. Any Active Staff Member may vote on a Bylaw amendment brought before the Medical Staff by requesting, at least ten calendar days prior to the date of a Medical Staff Meeting at which the Bylaw amendment is being considered, an absentee ballot which specifically describes the action voted on by such Medical Staff Member. Notwithstanding any provision herein to the contrary, votes cast by Medical Staff Members, either pursuant to an absentee ballot or by a proxy, shall be The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStar"), and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of WellStar is explicitly prohibited. WellStar Kennestone Hospital Medical Staff Bylaws Page 33 counted for purposes of determining whether a quorum existed at any Medical Staff meeting and whether the Medical Staff approved any proposed Bylaw. Section 2. Conflicts Notwithstanding any provision herein to the contrary, (i) in the event of any conflict between these Bylaws and the Medical Staff Rules, Regulations and Policies herein, the terms of these Bylaws shall control; (ii) in the event of any conflict between these Bylaws and the Medical Staff Rules, Regulations and Policies and either the WellStar Appointment Policy, the WellStar Fair Hearing Policy or a WellStar Health System Policy, the terms and provisions of the WellStar Appointment Policy, WellStar Fair Hearing Policy or a WellStar Health System Policy, as the case may be, shall control; and (Iii) in the event of any conflict between either these Bylaws, the Medical Staff Rules, Regulations and Policies, the WellStar Appointment Policy, the WellStar Fair Hearing Policy or a WellStar Health System Policy and the Hospital Bylaws or the Governing Body Bylaws, the Governing Body Bylaws shall control. Section 3. Actions by a Professional Review Body Any action taken by a Professional Review Body pursuant to these Bylaws, the WellStar Appointment Policy, the WellStar Fair Hearing Policy, or any other WellStar Health System or Medical Staff Policy, or the Governing Body Bylaws shall be in the reasonable belief that it is in furtherance of quality healthcare (including the provision of care in a manner that is not disruptive to the delivery of quality medical care at the Hospital) only after a reasonable effort has been made to obtain the true facts of the matter, after adequate notice and hearing procedures are afforded to any Applicant or Medical Staff Member, and only in the reasonable belief that the action is warranted by the facts known after a reasonable effort has been made to obtain the facts. Section 4. Severability The invalidity of any part of these Bylaws shall not impair or effect in any manner the validity, enforceability or effect of the balance of these Bylaws. Section 5. Time Limits In computing any period of time prescribed or allowed herein, the date of the act or the event shall not be included. The day following the act or event is Day 1 for purposes of computation. The last day of the period so computed shall be included. Saturdays, Sundays, and Federal or State holidays are to be included in the calculation of time periods. If the end date, however, falls on a Saturday, Sunday, or Federal or State holiday, the end ate is the next Federal or State workday, as the case may be. Revised/Approved: Medical Executive Committee General Staff WellStar Governing Body 08/09/2005 09/12/2005 10/06/2005 The information contained herein is confidential and proprietary to WellStar Health System, Inc. and its affiliates ('WeIlStan, and is protected by applicable copyright and other laws and regulations. Any reuse, recopying, redistribution, republication or dissemination of this information without the express prior written consent of Well5tar is explicitly prohibited WellStar Kennestone Hospital Medical Staff Bylaws Page 34 Appendix J 2006 Hospital Financial Survey Annual Hospital Financial Survey: Parts A-F WellStar Kennestone Hospital HOSP615 2006 Cobb Part A: General Information Facility UIO: Hc)S~_6ij:::::J Facility Name: WellStar Kennestone Hospital Georgia Department of Community Health Year: 2006 UIO: HOSP615 County: Cobb Street Address: ~_Church Street IMarietta, Ga Mailing Address: 1677 Church Street I IMarietta, Ga "I 130060 I 130060 Report Period: Please report data for the hospital fiscal year ending during calender year 2006 only. Please indicate your hospital fiscal year. 17/1/2005 lthrough I 6/30/20061 Please indicate your cost report year. [771!2OO5-lthrough 16130720061 Check the box to the right if your facility was not operational for the entire year If your facility was not operational for the entire year, provide the dates the facility was operational below: I Part B: Contact Information Fax: I 1770-792-5272 Tille: Contact Person: ITim Beatty Telephone: [770-792-5039 IDirector of Reimbursement E-mail: !tim.beatty@wellstar.org Part C: Financial Data and Indigent and Charity Care Please report the following data elements. Data reported here must balance in other parts of the HFS. Revenue or Expense Amount 1 a. Inpatient Gross Patient Revenue 719,211,866 lb. Total Inpatient Admissions accounting for 37,204 Inpatient Revenue 2a. Outpatient Gross Patient Revenue 2b. Total Outpatient Visits accounting for Outpatient Revenue 3. Medicare Contractual Adjustments: 4. Medicaid Contractual Adjustments: I Revenue or Expense Amount 5. Other Contractual Adjustments: 288,892,010 6. Hill Burton Obligations: 0 7. Bad debt: 44,451,690 8. Uncompensated Indigent Care (net): 34,924,767 9. Uncompensated Charity Care (net ): 18,602,115 10. Other Free Care: 1,752,470 11. Other Revenue/Gains: 17,038,839 12. Total Expenses: 411,047,924 Part 0: Indigent/Charity Care Policies and Agreements 1. Did the hospital have a formal written policy or written policies concerning the provision of indigent and/or charity care during 2006 ? ~ 2. What was the effective date of the policy or poliCies in effect during 2006 ? 17/01/2005 J 3. Please indicate the title or position held by the person most responsible for adherence to or interpretation of the policy or policies you will provide the department. IVice President of Revenue Cycle l 4. Did the policy or policies include provisions for the care that is defined as charity pursuant to HFMA guidelines and the definitions contained in the Glossary that accompanies this survey (i.e., a sliding fee scale or the accomodation to provide care without the expectation of compensation for patients whose individual or family Income exceeds 125% of federal poverty level guidelines)? I~ 5. If you had a provision for charity care in your policy, as reflected by responding yes to item 4, what was the maximum income level, expressed as a percentage of the federal poverty guidelines, for a patient to be considered for charity care (e.g., 185%,200%,235%, etc.)? [200% i Did the hospital have an agreement or agreements with any city or coun~rning the receipt of government funds for Indigent and/or charity care during 2006 ? ~ 6. Tuesday Apnl 15, 2008 2006 Hospital Financial Survey, Page 1 of 3 HOSP615 WellStar Kennestone Hospital Part E: Indigent And Charity Care Please Indicate the totals for indgent and charity care for the categories provided below. If the hospital used a sliding fee scale for certain charity patients, only the net charges to charity should be reported (i.e., gross patient charges less any payments received from or billed to the patient.) Total Uncompensated IIC Care must balance to totals reported in Part C. Indigent/Charity ,Indigent Care Charity Care Care Provided , ,21,~88,558 [I _~_~1 0.872,3281 32,060,886 13,736,209 7.729,7871 21,465,996 34,924,767 18,602,115 Gross VC 1. Inpatient 2. Outpatient I Source of funding Amount 3. Home County 0 4. Other Counties 0 5. City Or Cities 0 6. Hospital Authority I 0 i Source of funding 8. Federal Government 9. Non-Government Sources 10. Charitable Contributions 11. Trust Fund From Saie Of Pu o I 12. All Other Total Compensation for IIC Care Uncompensated VC Care 7. State Programs And Any Other State Funds (Do Not Include Indigent Care Trust Funds) 53,526,882 t- Amount 0 , 0 I 0 blic Hospital 0 0 o 53,526,882 Part F: Total Indigent/Charity Care By County Inp Ad-I = Inpatient Admissions (Indigent Care) Inp Ch.1 = Inpatient Charges (Indigent Care) Out Vis-I = Outpatient Visits (Indigent Care) Out Ch-I = Outpatient Charges (Indigent Care) County oweta Iynn JGilmer IFulton IForsyth. IFloyd' IFayette Fannin IDoug.las. : Dougherty IDeKalb - jAppling IDade IHabersham Foffee Fobb Flay ton Fherokee Fhattooga Fhatham Fatoosa Farroll /Butts IBartow IDawson IMurray tNashington tN alton IUnion Inp Ad.C = Inpatient Admissions (Charity Care) Inp Ch-C = Inpatient Charges (Charity Care) Out Vis-C = Outpatient Visits (Charity Care) Out Ch.C = Outpatient Charges (Charity Care) Tuesday, April 15, 2008 12,537 o 10,469,437 2,155 1,223,845 o o o .9,299 878 366,376 1,259 1,226 607 1,606 1,832 HOSP615 WellS tar Kennestane Hospital 2006 Hospital Financial Survey, Page 2 of 3 County Rockdale IRichmond IPulaski Ipolk IPickens IPaulding jother Out of Stat pordon IMuscogee pwinnett IMeriweth'er Irea:on ~ackson IHenry IHeard IHart IHarris . IHaralson ~~:tlield JNewton Total Inpatient Admissions (Indigent Care) Total Inpatient Charges (Indigent Care) Total Outpatient Visits (Indigent Care) Total Outpatient Charges (Indigent Care) 1,630 Total Inpatient Admissions (Charity Care) 21,188,558 Total Inpatient Charges (Charity Care) 9,204 Total Outpatient Visits (Charity Care) 13,736,209 Total Outpatient Charges (Charity Care) 1,528 10,872,328 7,038 7,729,787 Tuesda~Apnl 15,2008 2006 Hospital Financial Survey, Page 3 of 3 HOSP615 WellStar Kennestone Hospital 2006 Hospital Financial Survey Signature Form WellStar Kennestone Hospital Georgia Department of Community Health Electronic Signature(s) I state, certify and attest that to the best of my knowledge upon conducting due diligence to assure the accuracy and completeness of all data, and based upon my affirmative review of the entire completed survey, this completed survey contains no untrue statement, or inaccurate data, nor omits requested material information or data. I further state, certify and attest that I have reviewed the entire contents of the completed survey with all appropriate staff of the facility. I understand that inaccurate, incomplete or omited data could lead to sanctions against me or this facility. I further understand that a typed version of my name is being accepted as my original signature pursuant to the Georgia Electronic Records and Signature Act. Signature of Chief Executive: IGregory L. Simone, M.D. Title: !President and Chief Executive Officer Date: 3/11/2008 I hereby certify that I am the financial officer authorized to sign this form and that the information is true and accurate. I further understand that a typed version of my name is being accepted as my original signature pursuant to the Georgia Electronic Records and Signature Act. Signature of Financial I Officer: Marsha Title: IChlef Financial Officer Date: 3/11/2008 Burke C.mm,"" I Calculated Totals: The following totais are calculated from the reported information in the 2006 HFS. You may click on the category name in blue for a definition of the term. ~--- Financial Statistics Gross Patient Revenue: 1,238,394,616 Total Deductions from Patient Revenues: 799.448.247 INet Patient Revenue: 438,946.369 ,Total Revenues: 1,255.433.455 ITotal Net Revenues: 455,985,208 Total Expenses: 411,047,924 jMargin: 44,937,284 IMargin Percent: 9.9% ICost to Charge Ratio: 33.2% Indi ent and Charit Care Statistics Reported Uncomp Indigent/Charity Care: Adjusted Gross Revenue: Reported Indigent/Charity Care as % of AGR: 53,526,882 800.156,570 6.7'4 I I HOSP615 Appendix J Charity Care Policy WEl~STAR Health Syslem Standard Policy and Procedure Subject: I UNCOMPENSA TED OR CHARITY CARE Function: Leadership I spp#: LD-24 I Policy Replaces: New Reference - Standards: AMHCN LD.1.4 AMH / AMAC LD.1.6 AMHC LD.5.2 AML TC LD.2.4 Key Words: Charity, Un-Insured, Effective Date Reviewed/Revised Under Insured March I, 1999 January 2004 PURPOSE: To provide guidelines for offering uncompensated or charity medical care DEFINITION(S): None POLICY: It is the policy of WellStar Health System to provide uncompensated medical care to patients who qualitY for uncompensated or charity care. For further information related to uncompensated or charity care, refer to Patient Financial Services' departmental policies. SITE SPECIFIC VARIA TION(S): Note: If there is no variation of this policy at the site, indicate none. If the policy does not apply at the site, indicate N/ A. For variation of the system policy at a site, list the variation(s). Cobb Hospital: None Home Care: None Douglas Hospital: None Hospice: None Kennestone Hospital: None Long Term Care: None Paulding Hospital: None Physician Group: None Windy Hill Hospital: None Policy JHaintenance: The WellS tar Administrative Office is responsible for the interpretation and maintenance of this policy. Approved by: Robert A. Lipson. M.D. President and CEO WellStar Health System Pursuant to SPP LD-O 1 this policy has been authorized and approved as a Standard Policy and Procedure throughout WellStar Health System. Authorizing signatures are maintained in the System Accreditation Office. Attachments: 0 Page I of 1 LD-24 SPP APPROVAL RECORD FUNCTION TEAM: :-i/A FUNCTION TEAM LEADER :-i/A FUNCTION COMMITTEE: N'A STANDARD POLICY NAME/NUMBER: Uncompensated or Charity Care LD-24 DATE OF DEVELOPMENT/REVISION: DATE TO STAKEHOLDERS: DATE OF COMMITTEE APPROVAL: N/A ARE ALL STAKEHOLDER SIGNATURES ATTACHED OR SIGNED OFF BELOW: YES ELECTRONIC COPY OF POLICY EMAILED TO ACCREDITATION: YES IF IT IS IMPERATIVE THIS POLICY BE DISTRIBUTED IMMEDIATELY PLEASE INDICATE. IF NOT INDICATED THIS POLICY WILL BE DISTRIBUTED WITH THE NEXT QUARTER'S REVISION: Distribute with Next Quarter's Revision _Please Distribute Immediately SYNOPSIS OF POLICY/REVISION: KEY STAKEHOLDER SIGN-OFF By signing-off on this policy, through actual signature, em ail or verbal approval to the Policy Owner or Accreditation Department, I am h' , , T 0 /P r 0 affirm in!! my approval to t IS oolicy as written or have prOVided my variations to the FunctIOn earn wner o ICY woe-r. TITLE NAME SiGNATURE DATE (all stakeholders of this policy (there must be a signature on this line or must be listed below) documentation showing how this policy was approved if accomplished throll~h email communication) Function Team Leader Committee Chair Owner Linda Caldwell Accreditation Medical Director CEO Signature on Policy? All policies must have the review of the identified Key-Stakeholders. These individuals will have I \....'eek from the date of receipt to revIew and respond to the owner of the policy. Other mdividuals may be rcqllcsl~d to r~view the policy for applicJtion 10 their individual department but not be identified as a Key-Stakeholder. It is the responsibility oftht' Key-Stakeholders to rCvicw the policy ba,:>cJ upon their Jrc3 of responsIbility for WellStar Health System. Stah:holdcrs ar~ provideJ with a I week deadline for n:view orrolicic.-; A lack of response by th~ deadline date implIes the stJkcholder has no recomlllended chJngcs to the policy. ACCREDITA TlO:-i: Date Received: Distribution Date: Rc\'ision #: