Proposed Sherman Hospital Medical Staff Bylaws

July, '07

ARTICLE I - GENERAL PROVISIONS.
Section 1. Definitions.
Section 2. Delineation of Duties.
Section 3. Fair Assignment of Duties to Members.
Section 4. Delivery of Medical Care.
Section 5. Professional Judgments.
Section 6. Self Government.
Section 7. Construction.
Section 8. Disputes.

ARTICLE II - CATEGORIES OF THE MEDICAL STAFF.
Section 1. Attending Staff.
Section 2. Associate Attending Staff.
Section 3. Associate Staff.
Section 4. General Courtesy Staff.
Section 5. Consulting Staff.
Section 6. Honorary Staff.
Section 7. Part-Time Hospital Based Staff.
Section 8. Distance Staff.

ARTICLE III - ADJUNCT PROFESSIONAL PERSONNEL.
Section 1. Eligibility.
Section 2. Three Categories.
Section 3. Departmental Qualifications.
Section 4. Independent APP.
Section 5. Dependent APP.
Section 6. Hospital APP.
Section 7. Removal Procedures and Status.

ARTICLE IV - APPOINTMENT TO THE MEDICAL STAFF.
Section 1. General Principles for Appointment or Reappointment
Section 2. Specific Criteria for Appointment or Reappointment
Section 3. No Entitlement to Appointment or Reappointment
Section 4. Non-Discrimination Policy.
Section 5. General Obligations Assumed by Members.
Section 6. Agreements and Acknowledgments by All Applicants.
Section 7. Burden of Providing Information.
Section 8. Authorization to Obtain or Disclose Information.
Section 9. Standards for Deliberations on Applications.
Section 10. Reapplication after Adverse Decision.

ARTICLE V - INITIAL APPLICATION.
Section 1. Pre-Application Procedure for Initial Applicants.
Section 2. Application for Initial Appointment and Clinical Privileges.
Section 3. Application Procedure for Initial Applicants.
Section 4. Credentials Committee Review.
Section 5. Consideration of Health Status.
Section 6. Medical Executive Committee Decision.
Section 7. Board of Directors Decision.
Section 8. Provisional Status.
Section 9. Demonstration of Competence.
Section 10. Ineligibility for Continued Medical Staff Membership.
Section 11. Time Requirements for Promotion.

ARTICLE VI - REAPPOINTMENT.
Section 1. Application.
Section 2. Factors to be Considered.
Section 3. Department Chief Verification of Information.
Section 4. Department Chief Collection of Information from Internal Sources.
Section 5. Department Chief Presentation of Completed Application.
Section 6. Departmental Review.
Section 7. Medical Executive Committee Review.
Section 8. Board Action.
Section 9. Time Periods for Processing.

ARTICLE VIII - CONTRACTS FOR CLINICAL SERVICES.
Section 1. Authority to Enter Into Exclusive Contracts.
Section 2. Authority to Enter Into Non-exclusive Contracts.
Section 3. Clinical Competency for Physicians with Hospital Contracts.
Section 4. Expiration or Termination of Privileges and Staff Appointment
Section 5. Contract Terms Controlling.

ARTICLE IX - LEAVE OF ABSENCE OR RESIGNATION.
Section 1. Procedure for Leave of Absence.
Section 2. Conclusion of Leave.
Section 3. Board Action and Right to Hearing and Appeal.
Section 4. Resignation.

ARTICLE X - SUMMARY SUSPENSION.
Section 1. Causes.
Section 2. Effective Upon Imposition.
Section 3. Medical Executive Committee Action.

ARTICLE XI - AUTOMATIC ADMINISTRATIVE SUSPENSION AND REVOCATION.
Section 1. Removal of Privileges.
Section 2. Recidivism.
Section 3. Demotion.
Section 4. Fair Hearing Rights.

ARTICLE XII - CORRECTIVE ACTION.
Section 1. Initiation of Corrective Action.
Section 2. Review of Complaints.
Section 3. Member's Rights During a Review.
Section 4. Actions on Complaints.
Section 5. Exclusive Procedure.

ARTICLE XIII - JOINT CONFERENCE COMMITTEE.
Section 1. Purpose.
Section 2. Composition.
Section 3. Voting.
Section 4. Hearings on Adverse Actions.
Section 5. Hearing Rights and Procedures.

ARTICLE XIV - FAIR HEARING PLAN.
Section 1. Right to Hearing and Appellate Review.
Section 2. Notices.
Section 3. Practitioner Rights.
Section 4. Request for Hearing.
Section 5. Notice of Commencement of Hearing.
Section 6. Hearing Committee.
Section 7. Conduct of Hearing.
Section 8. Appeal to the Board.
Section 9. Final Decision by the Board.
Section 10. One Evidentiary Hearing.
Section 11. Notice Regarding Economic Factors and Reporting.
Section 12. Exclusive Contract Impacting Member's Privileges.

ARTICLE XV - INFORMAL PROCEEDINGS, CONFIDENTIALITY, PEER REVIEW AND RECORD COMPLETION.
Section 1. Informal Proceedings.
Section 2. Confidentiality and Reporting.
Section 3. Peer Review Protection.
Section 4. Incomplete Records.

ARTICLE XVI - INDEMNIFICATION FOR ADMINISTRATIVE DUTIES.
Section 1. Indemnity and Hold Harmless.
Section 2. Exceptions to Indemnification.
Section 3. Professional Liability.
Section 4. Reimbursement Determination.
Section 5. Non-exclusive Right.

ARTICLE XVII - MEDICAL STAFF REPRESENTATIVES.
Section 1. Qualifications of Representatives.
Section 2. President of the Medical Staff.
Section 3. Vice President of the Medical Staff.
Section 4. Secretary-Treasurer.
Section 5. Immediate Past President.
Section 6. Election of Officers.
Section 7. Removal of Officers.
Section 8. Vacancies in Office.
Section 9. Relationship of the Board of Directors and Officers.
Section 10. Compensation for Medical Staff Representatives.
Section 11. Records, Contracts, Loans, Checks and Deposits.

ARTICLE XVIII - MEETINGS OF THE MEDICAL STAFF.
Section 1. Annual Staff Meeting.
Section 2. Regular Staff Meetings.
Section 3. Special Staff Meetings.
Section 4. Balloting by Mail.
Section 5. Record Date.
Section 6. Quorum.
Section 7. Proxies.
Section 8. Agenda.

ARTICLE XIX - DEPARTMENT AND COMMITTEE MEETINGS.
Section 1. Department Meetings.
Section 2. Committee Meetings.
Section 3. Special Department and Committee Meetings.
Section 4. Quorum.

ARTICLE XX - PROVISIONS COMMON TO ALL MEETINGS.
Section 1. Notice of Meetings.
Section 2. Attendance Requirements.
Section 3. Rules of Order.
Section 4. Voting.
Section 5. Conflicts of Interest.
Section 6. Minutes.

ARTICLE XXI - DEPARTMENTS.
Section 1. List of Departments.
Section 2. Establishing Criteria for Granting Privileges and Evaluating Care.
Section 3. Clinical Department Chiefs.
Section 4. Hospital Department Chiefs.
Section 5. Functions of Department Chiefs.

ARTICLE XXII - COMMITTEES AND FUNCTIONS.
Section 1. Medical Staff Committee Functions.
Section 2. Delegation.
Section 3. Committee Appointments, Reporting, Removals, and Vacancies.
Section 4. Medical Executive Committee.
Section 5. Credentials Committee.
Section 6. Nominating Committee.

ARTICLE XXIII - RULES AND REGULATIONS OF THE MEDICAL STAFF.
Section 1. Content.
Section 2. Adoption.
Section 3. Department Rules and Regulations.
Section 4. Policy Manual and Hospital Policies.
Section 5. Forms.

ARTICLE XXIV - ADOPTION AND AMENDMENT OF BYLAWS.
Section 1. Effect Upon Adoption.
Section 2. Review.
Section 3. Amendment.
Section 4. Proposal and Vote.
Section 5. Publication.
Section 6. Balloting.
Section 7. Adoption.
Section 8. Policy Manual Adoption and Amendment.

ARTICLE XXV - MEDICAL STAFF BILL OF RIGHTS.
Section 1. Parties Bound.
Section 2. Right to Practice.
Section 3. Contracts to Practice Medicine.
Section 4. Voluntary Relinquishment and Surrender.
Section 5. Freedom of Information.
Section 6. Right to Question.
Section 7. Freedom of Assembly.
Section 8. Power of the Medical Staff.
Section 9. Power of Departments.
Section 10. Authority of This Article.

ADOPTION

(a) These Medical Staff Bylaws and the subordinate Policy Manual are adopted and made effective upon approval of the Medical Staff and the Board, superseding and replacing any and all previous Medical Staff Bylaws, and henceforth all activities and actions of the Hospital, Medical Staff and of each individual exercising Clinical Privileges at the Hospital shall be taken under and pursuant to the requirements of these Bylaws and the Policy Manual. The provisions of these Bylaws and the Policy Manual shall only apply to actions initiated after their effective date.

(b) The present rules and regulations of the Medical Staff are hereby placed into effect insofar as they are consistent with these Bylaws and Policy Manual, until such time as they are amended and readopted in accordance with the terms of these Bylaws, such time not to exceed two (2) years.

Adopted by the Medical Staff on:

_____________________________

(Date)

Approved by the Board on:

_____________________________

(Date)

PREAMBLE

The Hospital and Medical Staff acknowledge that they must work together to assure that patient care within the Hospital meets all relevant standards and to maintain and improve the quality of medical care delivered in the Hospital. The Hospital acknowledges the special expertise of the Medical Staff in those areas where medical judgment and the evaluation of medical competence are involved. The Medical Staff acknowledges that it bears responsibility for monitoring, evaluating and improving the quality of the clinical services provided by Members and APP (Adjunct Professional Personnel) in the Hospital, which responsibility must be exercised in conjunction with the Board's ultimate responsibility for quality of care in the Hospital and consistent with the Hospital's legal fiduciary obligations to the community it serves. Recognizing that the best interests of their patients are protected by concerted efforts and harmonious relationships between the Medical Staff, its individual Members and the Hospital, the Medical Practitioners practicing at Sherman Hospital hereby organize themselves as the Medical Staff of the Hospital in conformity with these Bylaws.

ARTICLE I

GENERAL PROVISIONS

Section 1. Definitions.

The following definitions shall apply to terms used in these Bylaws and the Policy Manual. Amendments to this Section, which can only be made pursuant to Article XXIV of these Bylaws, shall automatically apply to the Policy Manual.

"Adjunct Professional Personnel (APP)" means those Health Care Professionals who are not Members of the Medical Staff but who provide clinical services (for which Clinical Privileges are granted), clinical management (to extend the Clinical Privileges of a Member) or hospital services (excluding Clinical Services for which Members are privileged) in the Hospital and who may provide independent professional recommendations regarding patient care. Persons granted APP status shall not be considered Medical Staff Members (as that term is defined in this Section). APPs are divided into three (3) categories:
1. "Independent APP". This Category consists of APPs who provide clinical services to patients by expressing independent judgment at the order and under the general supervision of a Member in accordance with the Bylaws and the Adjunct Professional Personnel Policy contained in the Policy Manual attached hereto and incorporated by reference.
2. "Dependent APP". This category consists of those APPs who provide clinical management to patients pursuant to a documented relationship with an employing or sponsoring Member or Members by performing a portion of the Member's or Members' professional responsibilities to patients in the Hospital under the direct supervision of their employing or sponsoring Member or Members, all in accordance with the Bylaws and the Adjunct Professional Personnel Policy contained in the Policy Manual attached hereto and incorporated by reference.
3. "Hospital APP". This category consists of those APPs who provide hospital services to patients in the Hospital pursuant to a contract or employment relationship with the Hospital.
"Adverse Action" shall mean an action limiting, reducing, suspending, restricting, or revoking Medical Staff Membership or Clinical Privileges.
"Adverse Decision" shall mean a decision denying or not renewing Medical Staff Membership or Clinical Privileges.
"All Reasons" shall mean each of the defaults, failures, deficiencies or conditions determined to be present by the Medical Executive Committee, Board or Hearing Committee when an Adverse Action or Adverse Decision is recommended or imposed, and the general grounds or findings of fact relied upon for the conclusions reached, including all reasons based on the quality of medical care or any other basis, including economic factors. The term "All Reasons" shall not be interpreted to require a recitation of each fact relied upon by the decision making body or a detailed exposition of the supporting rationale for the decision but such general detail as may be necessary for the affected Provider or, if applicable, the Medical Executive Committee, to properly evaluate the facts and opinions relied upon by the decision maker and to effectively prosecute a hearing or appeal.
"Associated With" means an applicant who is a bona fide current or prospective employee, independent contractor, partner or co-owner in the medical practice of a current Member for which all medical services to be rendered by the applicant for Hospital patients are billed by the current Member's medical practice.
"Board" or "Board of Directors" means the Local Governing Board of Sherman Hospital, which has responsibility for the operation of the Hospital, or other institution where indicated.
"Chief Executive Officer" means the individual appointed by the Board to act on its behalf in the management of the Hospital or his designee.
"Clinical Privileges" means the permission granted to a Practitioner to render specific diagnostic, therapeutic, medical, surgical, podiatric or dental patient care and treatment services ("Clinical Services") in the Hospital.
"Clinical Services" means specific diagnostic and therapeutic medical, dental or podiatric patient care and treatment services for which Clinical Privileges are normally granted.
"Dentist" means an individual who has a doctor of dental surgery degree who is duly licensed to practice dentistry in the State of Illinois.
"Department" shall mean the Clinical and/or Hospital Departments of the Medical Staff as delineated in Article XXI.
"Department Chiefs" shall mean those parties elected or appointed to preside over a Department as provided in Article XXI.
"Economic Factor" shall mean any information or reasons for Adverse Decisions or Adverse Actions unrelated to quality of care or professional competency.
"Employed Practitioner" means a practitioner who is compensated and issued an applicable W-2 form for Clinical Services to patients by an employer under whom the professional fees for those services are billed.
"Ex Officio" means service as a member of a body by virtue of an office or position held and, unless otherwise expressly provided, means without voting rights.
"Fair Hearing" shall mean the procedural rights of applicants and Members under the Fair Hearing Plan set forth in Article XIV.
"Hospital" means Sherman Hospital and, depending on the context, includes both the physical building and the licensed not-for-profit entity which owns and operates the facility including, without limitation, such entity's administrators, employees, agents and assigns.
"Hospital Affiliate" means any parent, subsidiary or affiliate of the Hospital or any joint venture or other business entity in which the Hospital may have a controlling equity or ownership interest.
"Medical Staff" means the Medical Staff Organization the structure of which is defined by these Bylaws and which includes all Members collectively.
"Medical Staff Representative" means any and all Medical Staff officers, Clinical Department Chiefs and Medical Executive Committee members at large.
"Medical Staff Year" shall mean that period commencing on the first day of July of each year and ending on the thirtieth day of June in the following year.
"Member" means any Practitioner who has been granted Medical Staff membership and Clinical Privileges.
"Non-restrictive Actions" shall mean minor disciplinary measures such as issuing a warning to a Member, imposing a probationary period with retrospective review but without special requirements of prior or concurrent consultation and direct supervision, issuing a formal letter of reprimand or other similar actions which do not restrict a Member's right to exercise Clinical Privileges independently.
"Oral and Maxillofacial Surgeon" means an individual who has a doctor of dental surgery degree, has completed a residency in oral and maxillofacial surgery and is state licensed as a Dental Specialist in Oral and Maxillofacial Surgery.
"Pertinent Information" shall mean all written information utilized or reviewed in the decision making process relating to the initial grant or renewal of a Member's Medical Staff membership or Clinical Privileges or to summary suspensions, administrative suspensions or Adverse Actions, or Adverse Decisions, whether threatened or imposed, except the phrase "pertinent information" shall not include credentialing information on other Practitioners, Hospital or corporate business plans, any information obtained or generated which is privileged or confidential as attorney-client privilege, physician-patient privilege, or which is privileged or confidential under any applicable state or federal law, rule or regulation.
"Physician" shall be interpreted to include doctors of medicine ("M.D.s"), doctors of osteopathy ("D.O.s") and Oral and Maxillofacial Surgeons.
"Podiatrist" shall be interpreted to mean a doctor of podiatric medicine ("D.P.M.").
"Policy Manual" means the manual adopted with these Bylaws and approved by the Medical Executive Committee and Board describing certain Hospital policies affecting the Medical Staff.
"Practitioner" means a duly licensed Physician, Dentist or Podiatrist.
"Prerogatives" means the rights granted, by virtue of Staff category or otherwise, to a Member or APP to perform, manage, supervise, assist or otherwise provide clinical services in the Hospital and to participate in Medical Staff Self-government, which rights are exercisable subject to the conditions imposed by these Bylaws and in other Hospital and Medical Staff policies.
"President" means the Physician elected as President of the Medical Staff pursuant to Article XVII.
"Professional Affairs Committee" is a subcommittee of the Board of Directors. The membership of this committee is determined by the Board and may include Medical Staff Members. The members of this committee are appointed by the Board for terms determined by the Board.
"Proximate Service Area" means the geographical area described as that portion of the Elgin Township north of the Illinois Central railroad tracks and that portion of the Dundee Township south of Illinois Route 72.
"Self-government" means the duty of the Members, officers, committees and Departments of the Medical Staff to initiate and carry out the functions assumed by the Medical Staff, to govern their own representative and organizational affairs, and to fulfill the obligations provided for in these Bylaws and by law.
"VPMA" means the individual appointed as Vice President for Medical Affairs or equivalent position of professional liaison between the Hospital Administration and the Medical Staff, such individual preferred to possess both medical knowledge and administrative ability.

Section 2. Delineation of Duties.

Under these Bylaws and in accordance with applicable state and federal law, the Medical Staff shall be responsible for: i) reviewing, analyzing and evaluating the quality of patient care within the Hospital, ii) determining appropriate standards of care, including, without limitation, appropriate tests required on all admissions and the Hospital formulary, iii) quality improvement activities in the Hospital, iv) Self-government, and v) safeguarding the professional autonomy of all Members. Members and those Practitioners with temporary privileges granted as provided hereunder shall be responsible for: i) providing all medical, podiatric and dental care to patients in the Hospital, ii) assuring the ethical treatment of their patients, and iii) securing continuity of care. The Board shall be responsible for the overall maintenance, operation and administration of the Hospital facilities as well as ultimate responsibility for the quality of care and for providing such allied professionals, technicians and other support staff as appropriate for the effective and ethical delivery of quality medical care to patients in the Hospital. The Hospital shall not furnish nor directly provide Clinical Services, or otherwise exercise professional medical judgment, which duties may only be performed by Members who are duly licensed by the State of Illinois and who are granted credentials in accordance with the procedures established in these Bylaws. Inpatients and outpatients may only be admitted to the Hospital by a Member with admitting privileges and must remain under the professional care of a Member until discharged. Patients admitted by a non-Physician Practitioner shall be under the care of both the Physician Member and the non-Physician Practitioner Member. The non-Physician Practitioner Member shall be responsible for all care within the limits of the privileges granted to them while the Physician Member shall be responsible for all aspects of general medical care. All persons performing clinical services in the Hospital must either be Members or be generally supervised by a Member. The Hospital and Medical Staff shall work cooperatively to evaluate credentials of applicants for Medical Staff membership and clinical privileges.

Section 3. Fair Assignment of Duties to Members.

The assignment of administrative duties, responsibility for the care of unassigned, uninsured or underinsured Hospital patients, emergency call within each Department and other compulsory duties shall be assigned amongst the Members in a reasonable and equitable manner. Emergency call for the Practitioners in each Department may be made compulsory in the rules adopted for each Department; provided, however, emergency call for Members fifty five (55) years of age or older may be declined at the discretion of the Member without penalty or prejudice.

Section 4. Delivery of Medical Care.

Each Member shall be allowed to employ his or her skills as a fiduciary for his or her patients and neither the Hospital nor the Medical Staff shall interfere with or restrict a Member's exercise of independent medical judgment in the diagnosis, treatment or referral of patients unless such independent medical judgment is not consistent with applicable law and regulations, the standards imposed in these Bylaws or the standard of care in the medical community as determined by the Board and the Medical Staff in accordance with these Bylaws.

Section 5. Professional Judgments.

The Medical Staff and the Hospital recognize that the formation of Hospital policy may at times require the expert advice of its Medical Staff. The Medical Executive Committee has the right to participate with the Hospital in policymaking activities related to the delivery of clinical care and professional medical care in the Hospital. Without limiting the scope of the foregoing, the Hospital will specifically provide the Medical Staff with information and solicit feedback from the Medical Staff regarding the Hospital's strategic planning goals, financial goals, and capital and operational budget items which impact patient care. Further, the Hospital shall solicit the reasoned opinion of its Medical Staff before adopting Hospital operational policies which may impact the quality of patient care in the Hospital, or the exercise of Prerogatives under these Bylaws. The Board of Directors shall give great weight to the professional opinions and recommendations of the Medical Executive Committee in matters regarding Self-government or regarding the exercise of professional medical judgment in the evaluation of the medical care provided by Members of the Medical Staff, including matters relating to the quality of care provided and the utilization of facilities, tests, therapies, or medications. If the Board of Directors does not follow the Medical Executive Committee's recommendations regarding matters of general policy such as Self-government, quality of care, or utilization, the Medical Executive Committee may request that the above-specified general policy matters be referred to an individual who is a qualified specialist in the subject under consideration with such individual providing a recommendation to the Professional Affairs Committee. The cost of the qualified specialist, who will be mutually agreed upon by the Medical Executive Committee and the Board, shall be shared equally by the Medical Executive Committee and the Board of Directors. Upon receipt of the recommendation, the Professional Affairs Committee shall make a decision in the matter. The Hospital and Medical Executive Committee shall cooperate regarding the development and implementation of policies related to delivery of clinical care and professional medical care in the Hospital.

Section 6. Self Government.

The Hospital shall not interfere with the Medical Staff's process of Self-government under these Bylaws.

Section 7. Construction.

Time Frames. The time periods specified within these Bylaws are intended to be guidelines for action. An action shall not be invalidated solely because a party did not strictly comply with specified time periods.

Pronouns and Plurals. Words used in these Bylaws shall be read as the masculine or feminine gender, and as the singular or plural, as the content requires.

Captions. The captions and headings supplied in these Bylaws are for convenience only and are not intended to limit or define the scope or effect of any provision of these Bylaws.

Interpretation. If any provision in these Bylaws requires judicial interpretation, the judicial body interpreting or construing such provision shall not apply the assumption that the terms hereof shall be more strictly construed against the one who either itself or through its agents prepares the same. The Hospital, Board, Medical Staff and Members hereby agree that they and their agents have participated in preparation of these Bylaws equally.

Preamble. The Preamble shall be considered an integral part of these Bylaws.

Abide By Bylaws. The Hospital, including its Board of Directors, and the Medical Staff, as an integral part of the Hospital, agree to abide by the provisions contained in these Bylaws when performing activities affected by these Bylaws.

Relationship Created. Nothing contained in these Bylaws shall be deemed or construed to create the relationship of principal and agent or of partnership or of joint venture or of any other business association between the Hospital and the Medical Staff, and neither the Hospital's payment of administrative compensation to the Medical Staff nor any other acts of the Hospital and its Medical Staff shall be deemed to create any relationship between the Hospital and the Medical Staff other than the relationship of independent advisor, the duties of each for providing patient care being separate and distinct.

Exercise of Discretion. Whenever the Hospital, Medical Staff or Medical Staff Member has the right to exercise discretion in the interpretation, performance or administration of these Bylaws, such discretion must be exercised fairly, reasonably and in good faith. Reasonableness shall be determined under a reasonably prudent business person standard.

Severability. If any provision of these Bylaws, or the application of such provision to any person or circumstance, shall be held invalid by any court, governmental agency or regulatory body, the remainder of these Bylaws, or the application of such provisions to persons or circumstances other than those to which it is held invalid, shall not be affected thereby and shall remain in full force and effect. To the extent permitted by applicable law, the parties hereto hereby waive any provision of law that renders any provision hereof prohibitive or unenforceable in any respect.

Successors. The Hospital's and Medical Staffs adoption of these Medical Staff Bylaws, and each Member's acceptance of Clinical Privileges and Prerogatives, shall be binding upon and inure to the benefit of the parties and their legal representatives, successors and assigns.

Waiver. No waiver of any provision of these Bylaws shall be valid except in specific instances when agreed to by each party affected by the waiver, provided, however, notwithstanding the above, a Member may waive or have his rights waived under the Fair Hearing Plan at Article XIV of these Bylaws if the Hospital has granted an exclusive contract to provide a particular service at the Hospital, and an exclusive contract signed either individually or by a representative of the group contains a waiver of rights under the Fair Hearing Plan at Article XIV and/or rights under 210 ILCS 85/10.4(b) 2A-H.

Section 8. Disputes.

A. Dispute Resolution. Disagreements between the Medical Staff and the Hospital involving the proper interpretation of these Bylaws shall be referred to the Joint Conference Committee in accordance with the procedures established in Article XIII.

B. Remedies. After the exhaustion of all administrative procedures set forth herein and upon the failure of all efforts to resolve a matter in a fair, reasonable and amicable manner, the Hospital, Medical Staff or any individual Member may file a suit in equity to enjoin the others, and all persons associated with them, from any breach of these Bylaws as well as any other remedies available in law or equity.

C. Recovery of Costs. If any action at law or equity, including an action for declaratory judgment, is brought to enforce or interpret the terms, covenants or provisions of these Bylaws, the prevailing party in such litigation shall be entitled to recover reasonable attorney fees from the other party, which fees may be set by the Court in the trial or appeal of such action or may be enforced by a separate action brought for that purpose and which fees shall be in addition to any other relief which may be awarded.

ARTICLE II

CATEGORIES OF THE MEDICAL STAFF

All appointments to the Medical Staff shall be as approved by the Board upon recommendation of the Medical Executive Committee and shall be to one of the following categories listed as Sections in this Article. All Members shall be assigned by the Medical Executive Committee to a specific Department, but may be eligible for Clinical Privileges in other Departments as applied for and approved pursuant to these Bylaws. All initial Clinical Privileges for new appointees and existing Members shall be provisional for a period of twelve (12) months from the date of appointment as provided in Article VII Section 1. Continuance of appointment after the provisional period shall be conditioned on an evaluation of the factors set forth in Article IV of these Bylaws.

Section 1. Attending Staff.

Qualifications. The Attending Staff shall consist of Practitioners who regularly provide Clinical Services in attendance to patients at the Hospital. Candidates for the Attending Staff must have served on the Associate Attending Staff for at least one (1) year prior to becoming eligible for advancement to the Attending Staff. The homes and offices of Attending Staff appointees shall be located close enough to the Hospital, as determined in the rules of the Medical Staff, to fulfill their responsibilities to the Hospital and the Medical Staff and to provide, either personally or through another qualified Member, timely and continuous care for their patients in the Hospital.
Prerogatives. Appointees to the Attending Staff shall be entitled to vote on all Medical Staff, assigned Department or assigned committee matters, to hold office, to serve on Medical Staff committees, and to serve as Chiefs of Departments and chairpersons of committees except as may be provided to the contrary in Article XVII and Article XXV of these Bylaws. Voting rights and eligibility to serve as a Medical Staff representative are subject to attendance requirements as provided for in Article XX Section 2. Attending Staff appointees may admit patients without limitation except as may be otherwise provided in the Medical Staff Rules and Regulations and Hospital admission policies, and may exercise such Clinical Privileges as may be granted under Article VII of these Bylaws.
Obligations. Each appointee to the Attending Staff, by accepting appointment, shall agree to assume all of the following functions and responsibilities, where appropriate and when required by these Bylaws or assigned by the Medical Executive Committee: 1) to contribute to the organizational and administrative affairs of the Medical Staff, including service on Medical Staff and Department committees, and to faithfully perform the duties of any office or position to which elected or appointed, 2) to provide care for unassigned patients, 3) to provide specialty emergency coverage, 4) to provide consultation to other Members consistent with delineated Clinical Privileges, 5) to participate in teaching assignments and educational programs offered by the Medical Staff, 6) to participate in performance improvement and monitoring activities, including the evaluation of provisional appointees, 7) to attend Medical Staff and Department meetings as provided in Article XX Section 2, and 8) to fulfill such other Medical Staff functions as may be reasonably required by the Medical Executive Committee and the Board.
Advancement. Appointees to the Attending Staff may submit a written request to their assigned Department Chief for consideration of transfer to any other Staff Category at any time. Denial of the request shall not be considered an Adverse Action or Adverse Decision and shall not entitle the affected Member rights under the Fair Hearing Plan.

Section 2. Associate Attending Staff.

Qualifications. The Associate Attending Staff shall consist of Practitioners who regularly provide Clinical Services in attendance to patients at the Hospital. Associate Attending Staff appointees must have completed at least one (1) year of satisfactory performance on the Associate Staff. The homes and offices of Associate Attending Staff appointees shall be located close enough to the Hospital, as determined in the rules of the Medical Staff, to fulfill their responsibilities to the Hospital and the Medical Staff and to provide, either personally or through another qualified Member, timely and continuous care for their patients in the Hospital.
Prerogatives. Associate Attending Staff appointees may admit patients without limitation except as may be otherwise provided in the Medical Staff Rules and Regulations and Hospital admission policies, may exercise such Clinical Privileges as may be granted under Article VII of these Bylaws, and may vote on all matters presented at meetings of the committees to which they have been appointed. Associate Attending Staff appointees are not eligible to be Medical Staff Representatives and shall not have the right to vote at Department or Medical Staff meetings.
Obligations. Appointees to the Associate Attending Staff, by accepting appointment, shall agree to assume the same functions and responsibilities as appointees to the Attending Staff and may be required to assist in the Medical Executive Committee's evaluation of Associate Staff appointees and shall participate in such peer review activities of their own conduct as the Medical Executive Committee or its designee may require in order to evaluate their performance. Appointees to the Associate Attending Staff shall attend regular and special meetings of the Medical Staff and the Department and committees of which they are a member as provided in Article XX Section 2.
Advancement. Appointees to the Associate Attending Staff may submit a written request to their assigned Department Chief for consideration of advancement to the Attending Staff after serving at least one (1) year on the Associate Attending Staff, or of transfer to any other Staff Category at any time. Failure to change Staff Category shall not be considered an Adverse Action or Adverse Decision and shall not entitle the affected Member rights under the Fair Hearing Plan.

Section 3. Associate Staff.

Qualifications. The Associate Staff shall consist of those Practitioners who have received initial appointment to the Medical Staff pursuant to the provisions of Article V and who have not been initially appointed to another medical staff category. The homes and offices of Associate Staff appointees shall be located close enough to the Hospital, as determined in the rules of the Medical Staff, to fulfill their responsibilities to the Hospital and the Medical Staff and to provide, either personally or through another qualified Member, timely and continuous care for their patients in the Hospital.
Prerogatives. Associate Staff appointees may admit patients without limitation except as may be otherwise provided in the Medical Staff Rules and Regulations and Hospital admission policies, and may exercise such Clinical Privileges as may be granted under Article VII of these Bylaws. Associate Staff appointees shall not be entitled to vote at any Medical Staff or Departmental meetings. They may serve as voting members on Medical Staff committees but shall not be eligible to be a Medical Staff Representative.
Obligations. Appointees to the Associate Staff, by accepting appointment, shall agree to assume the same functions and responsibilities as appointees to the Attending Staff and shall participate in such peer review activities of their own conduct as the Medical Executive Committee or its designee may require in order to evaluate their performance. Appointees to the Associate Staff shall attend regular and special meetings of the Medical Staff and the Department and committees of which they are a member as provided in Article XX Section 2.
Advancement. Appointees to the Associate Staff will be considered for advancement to the Associate Attending Staff or may submit a written request to their assigned Department Chief for consideration of transfer to the General Courtesy Staff after serving not less than one (1) year on the Associate Staff.

Section 4. General Courtesy Staff.

Qualifications. The General Courtesy Staff shall consist of Members who wish to provide Clinical Services in attendance to a limited number of patents in the Hospital. A person shall be eligible for appointment to the General Courtesy Staff only after satisfactorily serving as an Associate Staff appointee for a minimum of one (1) year.
Prerogatives. Members of the General Courtesy Staff shall be permitted to admit or attend only twenty four (24) patients during a calendar year. A group practice of Practitioners with more than one member on the General Courtesy Staff shall be considered as one Member and shall be allowed twenty four (24) admissions/consultations per year for that group. General Courtesy Staff appointees shall not be entitled to vote at Medical Staff, Departmental or committee meetings and may not serve as a Medical Staff Representative. If the General Courtesy Staff appointee wishes to admit or attend more than twenty four (24) patients a year, he must apply through his assigned Department for transfer back to the Staff Category from which he last transferred to the General Courtesy Staff.
Obligations. General Courtesy Staff appointees shall be responsible to provide emergency coverage at the request of their respective Department. Such consultations, when requested, shall not be counted against the twenty four (24) patient restriction imposed by these Bylaws. General Courtesy Staff appointees shall also satisfy the mandatory appearance requirements for peer review meetings set forth in Article XX Section 2.
Advancement. General Courtesy Staff appointees may submit a written request to their assigned Department Chief for consideration of transfer back to the Staff Category from which they last transferred to the General Courtesy Staff at any time. Failure to change Staff Category shall not be considered an Adverse Action or Adverse Decision and shall not entitle the affected Member rights under the Fair Hearing Plan.

Section 5. Consulting Staff.

Qualifications. The Consulting Staff shall consist of certified specialists who have distinguished themselves as authorities in their areas of specialization who can assist on a special project or provide services to the Hospital or Medical Staff which are not otherwise offered by current Members. Appointment may be made directly to the Consulting Staff category without going through Associate and Associate Attending Staff categories.
Prerogatives. Consulting Staff appointees shall have all the rights and privileges of Medical Staff membership insofar as their specialties are concerned except they may not vote on any Medical Staff, Department or committee matter, serve as a Medical Staff Representative or admit patients.
Obligations. Consulting Staff appointees shall not be required to take emergency call, however, they must meet the basic responsibilities of all Members provided in these Bylaws and satisfy the mandatory appearance requirements for peer review meetings set forth in Article XX Section 2.
Advancement. Consulting Staff appointees desiring to change their Medical Staff category must meet the requirements of the new category and must submit an application for change in Medical Staff category for review by the Department, Credentials Committee, Medical Executive Committee and Board of Directors.

Section 6. Honorary Staff.

Qualifications. The Honorary Staff shall consist of Members who have retired from Hospital practice or Practitioners with outstanding professional obtainment.
Prerogatives. Honorary Staff appointees may attend Medical Staff and Department meetings and any Hospital education programs. Honorary Staff appointees may not admit patients or provide clinical services within the Hospital. Honorary Staff appointees are not eligible to vote or serve as a Medical Staff Representative.
Obligations. Honorary Staff appointees have no specific obligations under these Bylaws.
Advancement. Honorary Staff appointees desiring to change their Medical Staff category must meet the requirements of the new category and must submit an application for change in Medical Staff category for review by the Department, Credentials Committee, Medical Executive Committee and Board of Directors.

Section 7. Part-Time Hospital Based Staff.

Qualifications. The Part-Time Hospital Based Staff shall consist of those appointees to Hospital Departments working less than an average of thirty two (32) hours per week at the Hospital. Part-Time Hospital Based Staff may be appointed directly to this category without first being appointed to the Associate Staff category. If an appointee to this category, during a term of appointment, exceeds the aforementioned work hour limit, the individual must apply for transfer to the Associate Staff category to continue Medical Staff membership.
Prerogatives. Appointees to the Part-Time Hospital Based Staff may serve without vote on Medical Staff committees but they are not eligible to serve as a Medical Staff representative or to vote at Departmental or Medical Staff meetings and they may not admit patients.
Obligations. Each appointee to the Part-Time Hospital Based staff Category is encouraged to attend general and special Medical Staff meetings and Departmental meetings but are not required to do so except to satisfy the mandatory appearance requirements for peer review meetings set forth in Article XX Section 2.
Advancement. Part-Time Hospital Based Staff appointees desiring to change their Medical Staff category must meet the requirements of the new category and must submit an application for change in Medical Staff category for review by the Department, Credentials Committee, Medical Executive Committee and Board of Directors.

Section 8. Distance Staff.

A. Qualifications. The Distance Staff shall consist of Practitioners who regularly provide Clinical Services to patients at the Hospital from a distance through a suitable form of interactive communication. Appointment may be made directly to the Distance Staff category without going through Associate and Associate Attending Staff categories.

B. Prerogatives. Appointees to the Distance Staff may serve without vote on Medical Staff committees provided that they may elect to participate in said meetings from a distance through a suitable form of interactive communication. They are not eligible to serve as a Medical Staff representative or to vote at Departmental or Medical Staff meetings, and they may not admit patients.

C. Obligations. Distance Staff appointees shall be responsible to provide emergency coverage at the request of their respective Department and shall satisfy the mandatory appearance requirements for peer review meetings set forth in Article XX Section 2, provided that they may elect to provide said coverage and satisfy said appearance requirements from a distance through a suitable form of interactive communication.

D. Advancement. Distance Staff appointees desiring to change their Medical Staff category must meet the requirements of the new category and must submit an application for change in Medical Staff category for review by the Department, Credentials Committee, Medical Executive Committee and Board of Directors.

ARTICLE III

ADJUNCT PROFESSIONAL PERSONNEL

Section 1. Eligibility.

Only those specialties of APP for whose skills the Board of Directors and the Medical Executive Committee, pursuant to the Adjunct Professional Personnel Policy in the Policy Manual has determined a demonstrated need shall be eligible to provide patient care services in the Hospital. Persons granted APP status shall not be considered Members.

Section 2. Three Categories.

APP shall be divided into three (3) categories: Independent APP, Dependent APP, and Hospital APP.

Section 3. Departmental Qualifications.

Where appropriate, the Medical Executive Committee may establish particular qualifications required for a specific specialty of APP, provided that such qualifications are not arbitrary or contrary to applicable law, and the Department to which the APP is assigned may develop, implement and enforce quality control criteria.

Section 4. Independent APP.

Qualifications. Independent APP shall consist of:
1. Individuals with an advanced degree in Psychology from an accredited college or university who are certified and licensed to practice by the State of Illinois.
Prerogatives. Independent APP may provide patient care services within the limits of their qualifications as provided for in this Section 4 and the clinical privileges granted to them in accordance with the credentialing and privileging process detailed in this Section 4. The Fair Hearing Plan provided for in Article XIV of these Bylaws shall apply to Independent APP as it would to any other applicant or Member. If asked, they may serve on appropriate committees of the Medical Staff with vote if allowed by the terms of their committee appointment.
Obligations. Independent APP shall:
1. Exercise independent judgment in their areas of competence, provided that a Member shall have the ultimate responsibility for patient care;
2. Participate directly in the care of patients under the general supervision or direction of a Member;
3. Record reports and write notes on patient records in accordance with Hospital policy and write orders for treatment to the extent established in the Rules and Regulations of the Medical Staff, provided that such orders are within the scope of licensure, certification or other legal credential;
4. Not admit or discharge patients at the Hospital;
5. Such individuals may be invited to attend certain Medical Staff meetings and may, as a condition of continued privileges, be required to attend meetings involving the clinical review of patient care in which they participated; and
6. Maintain professional liability insurance in accordance with the Member requirements of Article IV of these Bylaws. Certification of coverage must be provided prior to the granting of APP privileges, and coverage must be maintained throughout the Independent APP's tenure at the Hospital.
Supervisor Responsibility. While a Member may supervise the general care being provided a particular patient by an Independent APP, the Independent APP assumes full responsibility and is fully accountable for the clinical services he or she renders.
Application, Credentialing and Privileging. Applications of Independent APP shall be reviewed as any applications for membership and Clinical Privileges are reviewed under Articles IV, V, VI and VII of these Bylaws.
Department Assignment. The Medical Executive Committee shall assign Independent APP to a clinical Department appropriate to their professional training.
Performance Improvement. The quality of clinical services provided by Independent APP shall be reviewed as part of the performance improvement program of the Medical Staff and Hospital.

Section 5. Dependent APP.

Qualifications. Dependent APP shall possess such training, experience and licensure as may be provided by Rule, pursuant to the Adjunct Professional Personnel Policy contained in the Policy Manual, or required by law. Each Dependent APP must be employed by, sponsored by, or have a collaborative agreement with a physician Member of the Medical Staff who assumes full responsibility and is fully accountable for the Clinical Management (described herein) rendered by the Dependent APP. The collaborative agreement shall, at a minimum, contain such terms and conditions as required by law and as the Medical Executive Committee may establish by rule.
Application. The employing, sponsoring or collaborative Member and the Dependent APP shall jointly make application for Dependent APP status, which shall be processed and reviewed in accordance with the procedures and criteria set forth in the Adjunct Professional Personnel Policy in the Policy Manual. While the employing, sponsoring or collaborative Member must hold clinical privileges, the Dependent APP is not granted privileges by the Medical Staff.
Description of Clinical Management. Dependent APP may only serve to extend the existing privileges as an agent of their employer, sponsor, or collaborative physician Member within the scope of their training, experience and licensure, and consistent with and rules established by the Medical Executive Committee upon recommendation of the applicable Departments and Divisions.
Prerogatives. A Dependent APP may:
1. Provide specified clinical management services as an agent and under the direct authority of his or her Medical Staff employer, sponsor or collaborative physician member within the scope of the Dependent APP's license, certificate or other legal credential.
2. Not admit patients; and
3. Exercise such other Prerogatives as shall be accorded any specific of APP as may be approved by the Medical Executive Committee.
Employer, Sponsor, or Collaborative Physician Responsibility. The employer, sponsor, or collaborative physician of the Dependent APP shall assume full responsibility and be fully accountable for the conduct of such individual within the Hospital. It is also the responsibility of the employer, sponsor, or collaborative physician of the Dependent APP to acquaint said individual with these Bylaws and the applicable Rules and Regulations of the Medical Staff and with the Hospital personnel with whom said individual will be working at the Hospital. Said employer, sponsor, or collaborative physician shall furnish evidence of professional liability insurance coverage for such individual in the same manner as described in Article IV Section 5 of these Bylaws.
Department Assignment. The Dependent APP shall be assigned to the Department of which his employer, sponsor, or collaborative physician is a member.
Termination of Duties. The clinical duties and responsibilities and APP status of the Dependent APP within the Hospital shall automatically terminate if: i) the employment, sponsorship or collaborative agreement of the Dependent APP is terminated, or ii) if the Medical Staff membership of the employer, sponsor or collaborative physician Member is terminated for any reason, or iii) if the employer's, sponsor's, or collaborative physician's Clinical Privileges are curtailed to the extent that the professional services of said individual within the Hospital are no longer permissible to assist the employer, sponsor, or collaborative physician. The Dependent APP is not granted privileges by the Medical Staff and no additional hearing or review rights under these Bylaws shall apply. However, the terminated APP shall be granted an audience with the Chief and appropriate subcommittee of his Department if requested.

Section 6. Hospital APP.

Qualifications. To provide specific hospital services, Hospital APP shall be under contract or have an employment relationship with the Hospital for the provision of said hospital services and have such training, experience, licensure, and supervision provided by Rule pursuant to state and federal law and the Adjunct Professional Personnel Policy contained in the Policy Manual. Hospital APP shall not be eligible to provide clinical services for which members are ordinarily privileged.
Specialties of Hospital APP. The permissible specialties of Hospital APP and the patient care functions which may be performed by each specialty of Hospital APP shall be as agreed by the Hospital, the Medical Executive Committee and the applicable Departments and Divisions.
Applications. Applications by individuals for Hospital APP status need not be reviewed or approved by the Medical Staff. The Hospital APP is not granted privileges by the Medical Staff and no additional hearing or review rights under these Bylaws shall apply.
Hospital Responsibility. Hospital APPs act as agents of the Hospital and the Hospital shall assume full responsibility and be fully accountable for the conduct of Hospital APPs within the Hospital. It is also the responsibility of the Hospital to acquaint said individual with any applicable policies, rules and regulations.
Obligations. Hospital APPs shall participate in medical performances improvement activities as may be required by the Medical Executive Committee.

Section 7. Removal Procedures and Status.

The Hospital may, upon recommendation of the Medical Executive Committee, suspend or terminate any or all of the privileges or functions of any APP, without recourse on the part of the APP or others to the review or hearing and appeal process of these Bylaws, except as provided in subparagraphs 7(A), 7(B) and 7(C) below.

Independent APP. Independent APP's are subject to Summary Suspension (Article X), Administrative Suspension (Article XI), Corrective Action (Article XII), Fair Hearing (Article XIV) and Informal Proceedings (Article XV) as would any physician Member.
Dependent APP. The Dependent APP's are not granted privileges by the Medical Staff and only serve to extend the existing privileges of their employer, sponsor, or collaborative physician Member. The employer, sponsor, or collaborative physician Member of a Dependent APP may terminate the relationship with the Dependent APP without involvement of the Hospital or Medical Staff. The Dependent APP shall have no additional rights to hearing or review under these Bylaws. After Informal Proceedings as provided for in Article XV, the Hospital may terminate the status of a Dependent APP. Except for automatic termination as provided for in Section 5 of this Article III, said termination shall be considered a corrective action against the employer, sponsor, or collaborative physician Member.
Hospital APP. The Hospital may at its sole discretion solicit the recommendation of the Medical Executive Committee or the President in the case of a summary suspension before it restricts, suspends or terminates a Hospital APP. Hospital APP are not granted privileges by the Medical Staff and shall have no additional rights to hearing or review under these Bylaws, such rights, if any, exclusively arising under the Hospital's employment manual or policies and any contract the Hospital APP may have with the Hospital.

ARTICLE IV

APPOINTMENT TO THE MEDICAL STAFF

Section 1. General Principles for Appointment or Reappointment.

Qualifications. Appointment and reappointment to the Medical Staff is a privilege which shall be extended only to professionally competent individuals who continuously meet the qualifications, standards and requirements set forth in these Bylaws. All individuals providing Clinical Services in the Hospital, unless excepted by specific provisions of these Bylaws, must first have been appointed to the Medical Staff.
Confidentiality. All processes described in this Article shall be subject to the confidentiality and peer review provisions set forth in Article XV Sections 2 and 3 of these Bylaws.
Economic Criteria. Except for membership or privileges exercised exclusively under a contract or employment relationship with the Hospital, the denial, restriction or termination of Medical Staff Membership or Clinical Privileges based on economic criteria unrelated to clinical qualifications, professional competency, or quality of care is prohibited; provided, however, that such prohibition shall not apply if the Medical Executive Committee recommends and the Board concurs, based upon an objective standard, that the Practitioner has demonstrated a consistent pattern of medically inappropriate utilization of Hospital services and facilities and has failed to appropriately modify his or her utilization pattern following reasonable notice.
Participation in Specific Programs. Except pursuant to a contract with the Hospital, Medical Staff Membership and Clinical Privileges shall not be conditioned on a Practitioner's participation or non-participation in provider contracts with a third party payer or in any Hospital sponsored health care or managed care plans or programs.

Section 2. Specific Criteria for Appointment or Reappointment.

Only Practitioners who satisfy each of the following threshold conditions shall be qualified for appointment or reappointment to the Medical Staff:

License. Are currently licensed to practice in Illinois;
Location. Are or will be located close enough to the Hospital, in accordance with the rules reasonably established and uniformly applied by the appropriate Department to provide timely care for their patients;
Insurance. Possess current, valid professional liability insurance coverage in such form and in amounts as specified in Section 5 of this Article IV;
Board Certification. Members who are granted initial membership on the Medical Staff any time after December 31, 1999 must satisfy the following professional certification criteria to qualify for appointment and/or reappointment. The goal of this Certification requirement is to help insure that specialized privileges are exercised within the Hospital by Members with acceptable specialty training and education (post doctoral residency). To that end, applicants for appointment or reappointment must either have board certification or have recently completed an accredited post doctoral residency that leads to board certification. The scope of practice and body of knowledge represented by a Specialty Board Certificate shall be determined by the Board upon recommendation of the Medical Executive Committee, and shall reflect the Specialty Board's stated training and educational requirements for that Certificate and the highest standard of specialty care that is practical within the community. Pursuant to Article VII Section 1, Applicants may request only those specialized privileges that are reflected by a Board Certificate that they have been issued or for which they have fulfilled the training and educational requirements.
1. Physicians are required to have a current valid and unexpired (or expired for less than three years) General Specialty and/or Subspecialty Certificate issued by one or more of the following Specialty Boards:
  1. a Member Board of the American Board of Medical Specialties;
  2. an Osteopathic Specialty Board approved by the American Osteopathic Association Bureau of Osteopathic Specialists;
  3. the American Board of Oral and Maxillofacial Surgery;
  or are required to have fulfilled within the five (5) years immediately prior to application for appointment or reappointment said Specialty Board's training and educational requirements for said Certificate, unless such time requirement is extended by the Board upon recommendation of the Medical Executive Committee for those applicants who practice in medical specialties where there are specific practice prerequisites for admissibility to board examination or such Certificate requirement is waived by the Board upon recommendation of the Medical Executive Committee after considering the specific competence, training, and experience of the individual in question.
2. Podiatrists are required to have a current valid and unexpired (or expired for less than three years) Certificate issued by the American Board of Podiatric Surgery, or are required to have fulfilled within the five (5) years immediately prior to application for appointment or reappointment said Specialty Board's training and educational requirements for said Certificate, unless such time requirement is extended by the Board upon recommendation of the Medical Executive Committee for those applicants who practice in medical specialties where there are specific practice prerequisites for admissibility to board examination or such Certificate requirement is waived by the Board upon recommendation of the Medical Executive Committee after considering the specific competence, training, and experience of the individual in question.
3. Dentists are encouraged to achieve nationwide certification but are required only to have a current valid and unexpired Dentist License issued by the Illinois Department of Financial and Professional Regulation.
Abilities. Can document and attest to their:
1. background, experience, training and demonstrated competence, and
2. professional conduct including their physical and mental health and emotional stability in accordance with the procedures provided in Article V Section 5, all as may relate to the Clinical Privileges and Medical Staff responsibilities requested;
Absence of Negative Information. For whom no reliable evidence has been discovered which would tend to indicate that they have not:
1. adhered to the ethics of their profession.
2. demonstrated their ability to work harmoniously with others sufficiently to convince the Medical Executive Committee and the Hospital that all patients treated by them at the Hospital will receive quality care and that the Hospital and the Medical Staff will be able to operate in an orderly manner.

Section 3. No Entitlement to Appointment or Reappointment.

No individual shall be entitled to appointment or reappointment to the Medical Staff or to the exercise of particular Clinical Privileges in the Hospital merely by virtue of the fact that such individual:

Meets any of the criteria in Section 2 of this Article IV,
Is licensed to practice a profession in this or any other state,
Is a member of any particular professional organization,
Has had in the past, or currently has, medical staff appointment or privileges at any other hospital or health care facility,
Resides or practices in the geographic service area of the Hospital, or
Is a party to a contract with or is employed by another Member or the Hospital or Hospital Affiliate, or other business entity in which one of the foregoing has an ownership interest or contractual relationship.

Section 4. Non-Discrimination Policy.

No individual shall be denied appointment or reappointment on the basis of race, creed, color, national origin, religion or gender.

Section 5. General Obligations Assumed by Members.

As a condition of appointment, reappointment and the exercise of Clinical Privileges and Prerogatives, each Member shall assume such reasonable duties and responsibilities as may be agreed upon by the Medical Staff and the Board including, without limitation, the following specific obligations:

Continuity of Care. Each Member shall agree to provide appropriate continuous care and supervision to all patients within the Hospital for whom he or she has responsibility.
Committee Assignments and Administrative Duties. Each Member shall agree to accept committee assignments and such other reasonable duties and responsibilities as shall be assigned.
Compliance with Law. Each member shall agree to comply with all applicable federal, state and local laws, rules and regulations.
Delegation of Responsibilities. Each Member shall agree to refrain from delegating responsibility for diagnoses or care of hospitalized patients to any individual who is not credentialed and privileged to undertake this responsibility or who is not adequately supervised.
Patient Disclosure. Each Member shall agree to refrain from deceiving patients as to the identity of an operating surgeon or any other individual providing treatment or services.
Consultation. Each Member shall agree to seek consultation whenever appropriate.
Debarment. Each Member shall agree to promptly notify the Chief Executive Officer, or a designee, and the President, of any change in eligibility for participation in Medicare or Medicaid, including any sanctions imposed by the federal Department of Health and Human Services.
Ethical Precepts. Each Member shall agree to abide by generally recognized ethical principles applicable to the Member's profession.
Bylaws Controlling. Each Member shall agree that these Bylaws contain the sole and exclusive rights and procedures for resolving conflict concerning these Bylaws between and among the Member, the Hospital or the Medical Staff (other than contractual conflicts) including, without limitation, an Adverse Decision or Adverse Action against a Member.
Monitoring and Evaluation Activities. Each Member shall agree to participate in the monitoring and evaluation activities of the Departments.
Validation Data. Each Member shall agree to provide, upon request, reasonable outside information or to use the Hospital and its facilities sufficiently to allow the Medical Executive Committee, through assessment by appropriate Medical Staff committees and Department Chiefs, to evaluate in a continuous manner, the current competence of the Member.
Duty to Update. Should any material information provided in the Member's application for appointment or reappointment change during the term of appointment, the Member shall provide within forty-five days information about such change to the Medical Executive Committee sufficient for the Medical Executive Committee's review and assessment. Notice of professional licensure revocation, federal drug enforcement license revocation, Medicare and Medicaid sanctions, limitation or loss of hospital privileges, any lapse in professional liability coverage required by the Hospital, or conviction of a felony shall be provided within five business days of the Member's notice.
Medical Records. Each Member shall agree to complete in a timely manner the medical and other required records for all patients as required by the Medical Staff Bylaws, Rules and Regulations, and applicable policies in the Policy Manual.
Continuing Medical Education. Each Member shall agree to participate in continuing education programs for the benefit of the Member and for the benefit of other professionals and Hospital personnel.
Congeniality. Members shall be expected to relate in a positive and professional manner to other health care professionals, and to cooperate and work collegially with the Medical Staff leadership and Hospital management and personnel so as to improve and promote, and not to adversely affect, patient care.
Dues. Each Member shall agree to pay to the Medical Staff all Medical Staff dues as may be assessed by the Medical Executive Committee from time to time. Medical Staff dues shall be assessed in a reasonable and equitable fashion and may be based upon Medical Staff category.
Malpractice Insurance.
1. Each Member and any individual granted Clinical Privileges or the right to provide services in the Hospital (collectively, "Provider") shall maintain in force professional liability insurance in an amount not less than the minimum amount as may be determined by the Board of Directors after consultation with the Medical Executive Committee.
2. In the event a Provider procures insurance coverage which is not on an "occurrence basis," the Provider shall at all times, including, without limitation, after the expiration or termination of the Provider's membership for any reason, maintain insurance coverage for any professional liability directly or indirectly resulting from professional acts or omissions arising, in whole or in part, in connection with the Provider's exercise of Prerogatives or otherwise related to his or her rendering of medical services to patients in the Hospital. Such continuing coverage may be maintained by: (a) keeping the claims made policy in full force and effect, (b) procuring a subsequent policy which provides for a retroactive date of coverage equal to the date when the Provider first began providing services at Hospital, (c) procuring an extended reporting endorsement (tail) applicable to the entire period the Provider exercised Prerogatives, or, (d) such other method acceptable to Hospital.
3. Provider shall provide Hospital with a certificate of insurance issued by the insurance carrier or its agent evidencing that all insurance coverage or extended reporting endorsement (tail) required by the Bylaws are in effect. Provider shall provide Hospital ten (10) days prior written notice of cancellation, non-renewal or changes in levels of coverage of such insurance.
4. Provider shall fully indemnify and hold harmless Hospital from any and all liability, loss or damage, including costs of defense and/or settlements, which the Hospital may suffer as a result of claims, demands, costs or judgments against it arising from Provider's failure to maintain professional liability insurance as required in this Subparagraph Q.

Section 6. Agreements and Acknowledgments by All Applicants.

As a condition to consideration of a Practitioner's application, each applicant for Medical Staff appointment or reappointment shall specifically agree and covenant to the Medical Staff and Hospital as follows:

Abide by Bylaws. Each applicant shall agree to abide by these Bylaws as they are in force at the time of application in all matters relating to consideration of the application without regard to whether or not appointment to the Medical Staff and/or Clinical Privileges are granted;
Acknowledgment of Receipt of Bylaws and Other Policies. Each applicant shall acknowledge that he or she has received and had an opportunity to read a copy of the Bylaws of the Hospital, these Bylaws and the Rules and Regulations of the Medical Staff and the Policy Manual as are in force at the time of application and that he or she understands the rights, duties and procedures provided therein;
Duty to Update. Each applicant shall agree to provide to the Credentials Committee, with or without request, and, as it occurs while the application is being considered, new or updated information that is pertinent to any question on the application form (for purposes of this duty to update, "pertinent" shall mean information that is clearly relevant);
Personal Interviews. Each applicant shall agree to appear for personal interviews in regard to the application if requested;
Misrepresentations, Misstatements and Omissions. Each applicant shall acknowledge that he or she understands that any material misrepresentation or misstatement in, or omission from the application, whether intentional or not, may constitute grounds for immediate rejection of the application and denial of Medical Staff appointment and Clinical Privileges or, in the event that an appointment has been granted prior to the discovery of such material misrepresentation, misstatement or omission, such discovery may result in summary dismissal from the Medical Staff.
Release of Information. Each applicant shall agree on forms required by the Hospital to authorize the release of all information necessary for an evaluation of the individual's qualifications for initial appointment, reappointment, and/or Clinical Privileges;
Validation Data. Each applicant shall agree on forms required by the Hospital to provide sufficient outside information to allow the Medical Executive Committee and Hospital, through assessment by appropriate Medical Staff committees and Department Chiefs, to evaluate the current competence of the applicant;
Exclusive Remedy. Each applicant shall agree that the hearing and appeal procedures set forth in the Bylaws shall be the sole and exclusive remedy with respect to any Adverse Decision taken on the application;
Covenant Not to Sue. Each applicant shall agree not to sue the Hospital, its officers or directors, or the Medical Staff, or any individual Member or anyone acting in good faith and without malice by or on behalf of the Hospital and its Medical Staff for any matter relating to or arising out of an application for Medical Staff appointment or reappointment, or for Clinical Privileges, or relating to the evaluation of the applicant's qualifications on any matter related to appointment, reappointment or Clinical Privileges;
Immunity. Each applicant shall agree to extend immunity to the fullest extent allowed by law to the Hospital, the Medical Staff and all individuals acting in good faith and without malice by or for the Hospital and/or its Medical Staff for all matters relating to appointment, reappointment and Clinical Privileges or the individual's qualifications for the same.

Section 7. Burden of Providing Information.

Burden on Applicant. The applicant shall have the burden of producing information deemed adequate by the Hospital and Medical Executive Committee for a proper evaluation of competence, character, ethics and other qualifications, and for resolving any doubts about such qualifications.
Notice of Deficiencies. The Hospital shall advise the applicant of any deficiencies in the application and identify any additional issues which require supplementary information or documentation in order for the Medical Executive Committee and the Hospital to complete their consideration of applicant's application.
Verification. The applicant shall have the burden of providing evidence that all the statements made and information given on the application are true and correct.
Completion of Application. Until the applicant has provided all information requested by the Hospital or the Medical Staff, the application for appointment may be deemed incomplete and may not be processed.

Section 8. Authorization to Obtain or Disclose Information.

The following statements, which shall be included on the application form and which form a part of these Bylaws, are express conditions to appointment and are applicable to all Medical Staff applicants, Members, and others having or seeking Clinical Privileges at the Hospital. By applying for appointment, reappointment or Clinical Privileges, the applicant or Member expressly accepts these conditions, whether or not appointment or Clinical Privileges are granted. This acceptance also applies during the time of any appointment or reappointment.

Immunity. To the fullest extent permitted by law, applicants and Member will release from any and all liability, and extend immunity to the Hospital and other Members participating in the application review process or performance improvement process, their authorized representatives and other participating or contributing third parties, with respect to any acts, communications or documents, recommendations or disclosures involving the applicant or Member and arising out of the following acts if made in good faith and without malice, whether the same occurred at this Hospital or any other health care facility:
1. applications for appointment or Clinical Privileges, including temporary Clinical Privileges;
2. evaluations concerning reappointment or changes in Clinical Privileges;
3. proceedings for suspension or reduction of Clinical Privileges or for revocation of Medical Staff appointment or any other disciplinary sanction;
4. summary suspension;
5. automatic suspension;
6. hearings and appellate reviews;
7. medical care evaluations;
8. utilization reviews;
9. other activities relating to the quality of patient care or professional conduct;
10. matters or inquiries concerning the applicant's or Member's professional qualifications, credentials, clinical competence, character, current mental or emotional stability, physical condition, ethics or behavior related to patient care, the exercise of Clinical Privileges or professional conduct; and/or
11. any other matter that might directly or indirectly relate to the applicant's or Member's competence, to patient care, or to the orderly operation of this or any other hospital or health care facility.
Authorization to Obtain Information. The applicant and Member shall specifically authorize the Hospital, Medical Staff and their authorized representatives to consult with any third party who may have information bearing on the individual's professional qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics, behavior, or any other matter reasonably having a bearing on the applicant's or Member's satisfaction of the criteria for initial and continued appointment to the Medical Staff. This authorization shall further cover the right to inspect or obtain any and all communications, reports, records, statements, documents, recommendations or disclosures of said third parties that may be relevant to such questions. The applicant and Member shall also specifically authorize said third parties to release said information to the Hospital, Medical Staff and their authorized representatives upon request.
Authorization to Disclose Information. The applicant and Member shall specifically authorize the Hospital, Medical Staff and their authorized representatives to release such information to other hospitals, health care facilities and their agents, who solicit such information with the applicant's or Member's consent for the purpose of evaluating the applicant's or Member's professional qualifications pursuant to a request for appointment and/or Clinical Privileges.

Section 9. Standards for Deliberations on Applications.

All actions on applications must be taken in the reasonable belief that the action was in furtherance of quality health care.

Section 10. Reapplication after Adverse Decision.

A Practitioner seeking appointment or reappointment who has received a final Adverse Decision, a Practitioner who has had his/her appointment terminated by virtue of an Adverse Action, and a Member whose Clinical Privileges have been reduced or restricted shall not be eligible to reapply for Medical Staff membership or the denied or reduced Clinical Privileges, whichever is applicable, for a period of three (3) years from the date of the final Adverse Decision or Adverse Action unless the Board, based upon the recommendation by the Medical Executive Committee, provided for a longer period at the time the Adverse Decision was made or the Adverse Action taken. Any such reapplication shall be processed as an initial application, and the applicant shall submit such additional information as the Department, Credentials Committee, Medical Executive Committee or the Board may require to demonstrate that the basis for the earlier Adverse Decision no longer exists.

ARTICLE V

INITIAL APPLICATION

Section 1. Pre-Application Procedure for Initial Applicants.

Request for Application. All requests for initial applications for Medical Staff membership shall be in writing on a form prescribed by the Medical Executive Committee and approved by the Board of Directors (Request for Application). A Request for Application shall be submitted on the specified form. After review, if the Request for Application form deemed complete, the Chief Executive Officer shall determine whether or not an application for appointment shall be provided to the applicant in accordance with Subsection (B) of this Section 1.
Pre-Application Process.
1. All requests for initial application to the Medical Staff shall be forwarded to the Medical Staff Office and then given to the Chief Executive Officer for review.
2. Upon written request from a potential applicant, the Chief Executive Officer shall supply the Request for Application to be completed by the potential applicant.
3. The Request for Application Form shall, at a minimum, request information regarding the name, home address, office address, medical specialty of the potential applicant, medical school attended, year of graduation, post graduate training, board certification, if any. In addition, the form may request information regarding the extent that the Hospital may be utilized by the potential applicant, the reason for selecting the Hospital and the Elgin area as the site for his or her future practice, the current medical staff appointment or institutions in which the applicant holds appointment, copies of current licensure, curriculum vitae, DEA license, proof of professional liability insurance coverage and proof of post-graduate residency training, board certification and current health status.
4. In order to be provided an application for appointment, a potential applicant must meet the minimum requirements provided for in Article IV and not be subject to the "inability to accommodate" provision described in sub-paragraph v of this Subsection B.
5. The Chief Executive Officer or designee may advise a potential applicant desiring to make an application for appointment that the Department, specialty or category of privileges desired by the applicant has been closed by the Board of Directors, that those privileges are the subject of an exclusive contract or the Hospital cannot accommodate the privileges desired by the potential applicant because of lack of facilities or personnel. One or more of these reasons shall be known as the Hospital's "inability to accommodate".
6. Potential applicants who meet the prerequisites described above and for whom there are no "inability to accommodate" concerns may be provided an Application for Appointment.
7. If the potential applicant fails to meet the prerequisites described above or any of the "inability to accommodate" provisions apply, the Chief Executive Officer may advise the potential applicant the Hospital will not provide an application to the individual. Such refusal should not give rise to any right of hearing or appeal under the Fair Hearing Plan.
8. The specific requisites under the Request for Application shall not be related to clinical competency issues. Clinical issues are to be addressed during the credentialing and privileging process by the appropriate medical staff committees.
9. Any material misstatement in or omission from the Request for Application constitutes cause for refusing to send an application for appointment, denial of appointment or summary dismissal from the medical staff.

Section 2. Application for Initial Appointment and Clinical Privileges.

Applications. Applications for initial appointment to the Medical Staff shall be in writing and shall be submitted on forms approved by the Board upon recommendation of the Medical Executive Committee. These forms shall be obtained from the office of the Chief Executive Officer or a designee after the individual has successfully completed the pre-application process.
Required Information. The application shall contain a request for specific Clinical Privileges desired by the applicant and shall require detailed information concerning the applicant's professional qualifications including:
1. the names and complete addresses of at least three (3) Practitioners, as appropriate, who have had extensive and recent experience in observing and working with the applicant and who can provide adequate information pertaining to the applicant's present professional competence and character. These references may not be from individuals associated or about to be associated with the applicant in professional practice or personally related to the applicant. At least two (2) reference shall be from the same specialty area as the applicant;
2. the names and complete addresses of the Chiefs or chairpersons of each Department of any and all hospitals or other institutions at which the applicant has worked or trained. If the number of hospitals the applicant has worked in is great or if a number of years have passed since the applicant worked at a particular hospital, that may be taken into consideration in the appointment process;
3. information as to whether the applicant's medical staff appointment or Clinical Privileges have ever been surrendered voluntarily while his or her professional competence or conduct is under investigation or have otherwise been involuntarily withdrawn, denied, revoked, suspended, subjected to probationary or other conditions, reduced or not renewed at any other hospital or health care facility;
4. information as to whether the applicant has ever withdrawn his/her application for appointment, reappointment or Clinical Privileges, or resigned from a medical staff before final decision by a hospital's or health care facility's governing board;
5. information as to whether the applicant's license to practice any profession in any state, or Drug Enforcement Administration license is or has ever been relinquished voluntarily, suspended, modified, terminated, restricted or is currently being challenged. (The submitted application shall include a list or copy of all the applicant's current licenses to practice, as well as copies of Drug Enforcement Administration license, medical, dental or podiatric school diploma, and certificates from all post graduate training programs completed);
6. information regarding denial, revocation, suspension or probation of membership or fellowship in local, state or national professional organizations, specialty board classification or faculty membership at any medical or other professional school;
7. information as to whether the applicant has currently in force professional liability insurance coverage, the name of the insurance company and the amount and classification of such coverage, and whether said insurance coverage covers the Clinical Privileges the applicant or Member seeks to exercise at the Hospital;
8. a consent to the release of information from the applicant's present and past professional liability insurance carriers;
9. information concerning any litigation against the applicant concerning his or her professional competence, ethics, or actions, specifically setting forth the following information concerning pending claims, final judgments or settlements: (a) the substance of the allegations, (b) the findings, (c) the ultimate disposition, and (d) any additional information concerning such proceedings or actions as the applicant may choose to include or the Department, Credentials Committee, Medical Executive Committee or the Board may deem appropriate and request;
10. information concerning any professional misconduct proceedings and any malpractice actions involving the applicant in Illinois or any other state, whether such proceedings are closed or still pending;
11. information concerning the suspension or termination for any period of time of the applicant's right or privilege to participate in Medicare, Medicaid, any other government sponsored program, and information as to whether there are any investigations or actions pending which could result in such suspension or termination of such rights and privileges;
12. information as to whether the applicant has ever settled with the court, pled nolo contendere, pled guilty, or was convicted of a felony or criminal offense involving moral turpitude or immoral conduct, with details about such instance;
13. a complete chronological listing of the applicant's professional and educational appointments, employment and positions;
14. information on the citizenship and/or visa status of the applicant;
15. two(2) good quality three inch by five inch (3x5) photographs framing the uncovered face, head and neck of the applicant suitable for state or federal photo-identification.
16. the applicant's signature; and
17. such other information related to eligibility criteria for the Medical Staff Category and Clinical Privileges requested as the Department, Credentials Committee, Medical Executive Committee or Board may require.
Evaluation of Malpractice Claims. The history of malpractice verdicts and the settlement of malpractice claims, as well as pending claims, will be evaluated as a criterion for appointment, reappointment and the granting of Clinical Privileges. However, the mere presence of verdicts, settlements or claims shall not, in and of themselves, be sufficient to deny appointment or granting of particular Clinical Privileges. The evaluation shall consider the extent to which verdicts, settlements or claims evidence a pattern of care that raises questions concerning the individual's clinical competence, and whether a particular verdict, settlement or claim in and of itself, represents such deviation from standard medical practice as to raise overall questions regarding the applicant's clinical competence, skill in particular clinical service, or general behavior.

Section 3. Application Procedure for Initial Applicants.

Collection of Information. The application for Medical Staff appointment shall be submitted by the applicant to the Chief Executive Officer or a designee. It must be accompanied by payment of such processing fees as shall be determined from time to time by the Hospital or the Medical Executive Committee. A request for information regarding the applicant shall be submitted to the National Practitioner Data Bank as well as the Illinois Department of Financial and Professional Regulation. The Hospital may also request information regarding any debarment or other sanction relating to Medicare, Medicaid or other government program imposed against the applicant by the Department of Health and Human Services. After reviewing the application to determine that all questions have been answered, and after reviewing all references and other information or materials deemed pertinent, and after verifying the information provided in the application with the primary sources, the Medical Staff Office shall transmit the complete application and all supporting materials to the Credentials Committee. Falsification, withholding or omission of material information may be grounds for disciplinary action, including revocation of Clinical Privileges and Medical Staff membership.
Completion of Application. An application shall be deemed to be complete when all questions on the application form have been answered, all supporting documentation has been supplied and all information verified. An application shall become incomplete if the need arises anytime during the evaluation for new, additional or clarifying information which is relevant and material to consideration of the application. Any application that continues to be incomplete ninety (90) days after the applicant has been notified of the additional information required shall be deemed to be withdrawn. It is the responsibility of the applicant to provide a complete application, including adequate responses from references. An incomplete application may not be processed.
Publication. The Chief Executive Officer or a designee shall post or circulate the name and photograph of the applicant so that each Member may have an opportunity to submit to the Credentials Committee, in writing, information bearing on the applicant's qualifications for Medical Staff appointment or Clinical Privileges. In addition, any current Member shall have the right to appear in person before the Credentials Committee or the applicable Departmental body to discuss in private and in confidence any concerns the Member may have about the applicant.

Section 4. Credentials Committee Review.

Initiation. Upon receipt of the application, the Credentials Committee and the applicable Department shall, as soon as practical, undertake its review.
Function. The applicable Department is to formulate a recommendation for the Credentials Committee as to whether to grant or deny the applicant's privilege requests. The Credentials Committees is to formulate a recommendation for the Medical Executive Committee as to whether to grant or deny the application.
Investigation. The Credentials Committee may request, and the applicant shall provide, further information or documentation considered relevant and material by the Credentials Committee to assess the background and the qualifications of the applicant. All initial applicants must attend an in-person interview and present two forms of identification including a State or Federal photo-identification (such as a driver's license or a passport) satisfactory to the Hospital Administration. The interview and discussion of any aspect of the applicant's application, qualifications, or requested Clinical Privileges shall be conducted by the Credentials Committee and may be attended by the Department Chief and his designees or may be conducted by the Department at the discretion of the Credentials Committee.
Outside Advisors. The Credentials Committee may use the expertise of the Department Chief, or any member of the Department, or an outside consultant if additional information is required to properly evaluate the applicant's qualifications.
Criteria Considered. The Credentials Committee shall examine evidence of the applicant's character, professional competence, qualifications, prior behavior and ethical standing and shall determine, through information contained in references given by the applicant and from other sources available to the committee, whether the applicant has satisfied all of the necessary qualifications for appointment and for the Clinical Privileges requested. The Credentials Committee may take into consideration any and all information coming to its attention in arriving at its determination. The Credentials Committee shall consider any eligibility criteria established or required by the Department and the recommendation of the Department to determine whether the applicant is eligible to apply for and qualified to perform the requested Clinical Privileges with sound judgment and technical skill. The Credentials Committee may not consider privilege requests for which the applicant is ineligible.
Findings and Report. After completion of its review, the Credentials Committee shall submit the recommendation of the Department as well as its own findings as to whether or not the applicant meets the qualifications and standards of eligibility for membership on the Medical Staff and granting of requested Clinical Privileges, as well as any conditions and limitations thereon, to the Medical Executive Committee for its consideration. The report shall be in writing and shall state the specific reasons for the findings and recommendations. Any dissenting views shall also be reduced to writing, be supported by specific reasons, and be attached to the majority report. No adverse finding or recommendation by the Credentials Committee or Department shall in or of itself give rise to any other rights to hearing or appeal set forth in these Bylaws.
Time Frame. If the recommendation of the Credentials Committee is delayed longer than sixty (60) days, the Chairman of the Credentials Committee shall send a letter to the applicant, with a copy to the Medical Executive Committee and Chief Executive Officer, explaining the reasons for the delay.

Section 5. Consideration of Health Status.

Health and Physical Information Questionnaire. If the Credentials Committee's recommendation is to grant Medical Staff membership and Clinical Privileges, before that recommendation is sent to the Medical Executive Committee, the applicant shall complete a health and physical information questionnaire. The form shall be as approved by the Medical Staff and shall be furnished to the applicant by the President or a designee.
Review of Health and Physical Information Questionnaire. The Credentials Committee shall review the completed health and physical information questionnaire and conduct its own investigation if needed to determine if the applicant has any physical or mental condition which would interfere with or impede the safe and competent exercise of requested Clinical Privileges. If, in the opinion of the Credentials Committee, the applicant has such condition, the Credentials Committee together with the Hospital shall consider whether accommodation to the condition is reasonable or possible so as to allow the applicant to safely and competently exercise the requested Clinical Privileges.
Report on Health and Physical Information Questionnaire. The Credentials Committee shall report its findings to the Medical Executive Committee, which report shall include, if appropriate, recommendations as to possible accommodations and as to the terms and conditions under which the applicant may safely and competently exercise the requested Clinical Privileges. No otherwise qualified applicant shall be denied Staff Membership or Clinical Privileges based upon a disability, as defined by law, unless the applicant cannot safely and competently exercise the requested Clinical Privileges after reasonable accommodation.

Section 6. Medical Executive Committee Decision.

Consideration of Reports. At its next regular meeting after receipt of the written findings and recommendation of the Credentials Committee, the Medical Executive Committee shall:
1. Make its decision in the matter, which shall be forwarded to the Board along with the recommendations and reports of all other committees involved; or
2. Refer the matter back to the Credentials Committee and/or Department for further consideration and preparation of responses to specific questions raised by the Medical Executive Committee prior to its final recommendation.
Adverse Finding. No adverse finding or recommendation by the Medical Executive Committee shall in or of itself give rise to any rights to a hearing or appeal set forth in these Bylaws until after the Board has acted on the Application.

Section 7. Board of Directors Decision.

Board Consideration of Medical Executive Committee Recommendation. At its next regular meeting after receipt of the written findings and recommendation of the Medical Executive Committee, the Board shall:
1. Make its decision in the matter; or
2. Refer the matter back to the Medical Executive Committee for further consideration and preparation of responses to specific questions raised by the Board prior to its final decision.
Board Confirmation of Medical Executive Committee Favorable Recommendation. If the Board agrees with the Medical Executive Committee's favorable recommendation notice of the decision shall be given to the applicant and to the Medical Executive Committee.
Board Disagreement with Medical Executive Committee Favorable Recommendation. If the Board rejects a favorable recommendation of the Medical Executive Committee and refuses to appoint, it shall provide written notice to the applicant by certified mail, return receipt requested, explaining All Reasons for its Adverse Decision. The notice shall also advise of the right to request a hearing before the Joint Conference Committee pursuant to Article XIII of these Bylaws. If the applicant does not request a hearing before the Joint Conference Committee in a timely fashion, the Medical Executive Committee shall have the right to request the matter be reviewed by the Joint Conference Committee in a timely fashion providing a recommendation to the Board who shall then make a final decision.
Board Disagreement with Medical Executive Committee Adverse Decision. If the Board rejects an Adverse Decision of the Medical Executive Committee and decides to appoint, the matter shall be referred to the Joint Conference Committee for recommendation.
Board Confirmation of Medical Executive Committee Adverse Decision. If the Medical Executive Committee and Board agree upon an Adverse Decision, the Chief Executive Officer shall promptly notify the applicant in writing by certified mail, return receipt requested, of the Adverse Decision. The notice shall specify all reasons for the Adverse Decision and advise of the right to request a Fair Hearing pursuant to Article XIV of these Bylaws.

Section 8. Provisional Status.

Mandatory Imposition. All initial appointments to the Medical Staff, regardless of the category to which the appointment is made, and all Clinical Privileges granted the initial appointee shall be provisional for a