Credentials Procedure Manual

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Section 1 Credentials Committee

1.1 Composition: The Credentials Committee shall consist of at least four (4) Active Members appointed by the President. The Credentials Committee must include at least one (1) Member from the Clinical Section of Medicine and one from the Clinical Section of Surgery. Members should be chosen because of their experience as medical leaders or their interest in learning the nuances of credentialing. The President will appoint one (1) Member as the Chair of the Credentials Committee. Members will be appointed for three (3) year terms with the initial terms staggered such that approximately one third (1/3) of the members will be appointed each year. The Chair will be appointed for a three-year (3) term. The Chair and members may be reappointed for additional terms without limit Any member of the Credentials Committee, including the Chair, may be relieved of his/her committee membership by a two-thirds (2/3) vote of the MEC. The Credentials Committee shall also include a member of the Board, who will serve in an ex-officio capacity. The Credentials Committee may also invite, at its discretion, additional ex-officio members, including representatives from Hospital administration and the Board, if it should believe such participation will further its ability to perform its duties.

1.2 Meetings: The Credentials Committee shall meet at the call of its Chair.

1.3 Responsibilities:

(1) To review and recommend action on all applications and reapplications for membership and status on the Medical Staff;

(2) To review and recommend action on all requests for Clinical Privileges;

(3) To interview and investigate the qualifications of Applicants as warranted by the Credentials Committee;

(4) To recommend criteria for the granting of Medical Staff membership and Clinical Privileges for the Hospital;

(5) To develop, recommend, and consistently implement policy and procedures for all credentialing activities at Fishermen's Community Hospital; and

(6) To perform such other functions as requested by the MEC.

1.4 Reporting: The Credentials Committee will make a written report of its findings and recommendations to the MEC. The Chair of the Credentials Committee shall be available to meet with the Board or its committees on all recommendations issued by the Credentials Committee.

1.5 Confidentiality:

(1) The Credentials Committee shall function as a peer review committee consistent with federal and state law. All members of the Credentials Committee shall, consistent with the Medical Staff and Hospital confidentiality policies, keep in strict confidence all papers, reports, and information obtained by virtue of membership on the committee. All professional review activity and recommendations will be strictly confidential. Members of the Medical Staff who have access to credentialing, privileging, or peer review information agree to maintain the confidentiality of this information. No disclosures of any such information (discussions or documentation) may be made outside of the meetings of the peer review committees, except:

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a) To another authorized individual and for the purpose of conducting professional review activity;

b) As authorized by Hospital or Medical Staff policy; or

c) As authorized, in writing, by legal counsel to the Hospital.

(2) Any breach of confidentiality may result in appropriate sanctions.

(3) A Practitioner may review his or her credentials file only upon written request approved by the President, the Chair of the Credentials Committee or the CEO. Review of such files will be conducted in the presence of the Medical Staff Services professional, Medical Staff Officer or a designee of Hospital administration. Confidential letters of reference may not be reviewed by Practitioners and will be sequestered in a separate file and removed from the official credentials file prior to review by the Practitioner. No item may be removed or copied from the file. The Practitioner may make notes for inclusion in the file. A written or electronic record will be made and placed in the file confirming the dates and circumstances of the review.

(4) All minutes, reports, recommendations, communications, and actions made or taken by the Credentials Committee or any committee or individuals pursuant to the provisions of this Manual are considered peer review work product and entitled to the protections of the federal Health Care Quality Improvement Act of 1986 ("HCQIA"), Florida Statute Sections 395.0193 and 766.101 and the provisions of any other state or federal statute or regulations providing protection to peer review, credentialing, quality assurance, patient safety or other related activities. All individuals, committees and bodies acting under the provisions of this manual shall be considered "professional review bodies" as defined in the HCQIA, as may be amended from time to time.

Section 2 Qualifications for Medical Staff Membership

2.1 No Entitlement to Membership: No Practitioner shall be entitled to membership on the Medical Staff or to Clinical Privileges merely by virtue of licensure, membership in any professional organization, or clinical privileges at any other healthcare organization.

2.2 Minimum Criteria for Appointment to Medical Staff: The following qualifications must be met before an application will be processed:

(1) Demonstrate that he/she has successfully graduated from an accredited school of medicine, osteopathy, or podiatry;

(2) Have a current unrestricted license as a physician, dentist, podiatrist or psychologist required for the practice of his/her profession within the State of Florida. If the Applicant is in the last six (6) months to one (1) year of residency training, the Applicant will be eligible to apply;

(3) Possess a current, valid, unrestricted Drug Enforcement Administration (DEA) number if applicable; a copy of the DEA application for those recently completing their residency will be accepted for processing. An official copy of the application is required until final approval of the DEA certificate;

(4) Demonstrate recent clinical performance and competence within the last twelve (12) months with an active clinical practice in the clinical specialty area in which Clinical Privileges are sought, for purposes of ascertaining current clinical competence;

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(5) Provide evidence of skills to provide a type of service that the Board has determined to be appropriate for the performance within the Hospital and for which a need exists;

(6) Complete "Certificate of Financial Responsibility" form to show compliance with state law;

(7) Have a record that is free from current Medicare/Medicaid/CHAMPUS (Tricare) sanctions or felony convictions (within the last three (3) years), or occurrences that would raise questions of undesirable conduct which could injure the reputation of the Medical Staff or Hospital;

(8) A Physician Applicant (MD or DO) must have successfully completed an allopathic or osteopathic residency program of at least three (3) years, approved by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA) and be currently board certified or must become certified within five (5) years of initial Medical Staff appointment by an approved board of the American Board of Medical Specialties or the AOA in the specialty of application. Board certified Physician Members of the Medical Staff must continuously maintain their board certification in the manner established by the applicable specialty board. Failure to become board certified within five (5) years of the date of initial appointment shall be deemed a voluntary relinquishment of membership and Clinical Privileges;

(9) A podiatric physician (DPM) must have successfully completed a two-year (2) residency program in surgical, orthopedic, or podiatric medicine approved by the Council on Podiatric Medical Education of the American Podiatric Medical Association (APMA), and be board certified by the American Board of Podiatric Surgery or the American Board of Podiatric Orthopedic and Primary Podiatric Medicine within five (5) years of initial Medical Staff appointment. Failure to become board certified within five (5) years of the date of initial appointment shall be deemed a voluntary relinquishment of the Practitioner's membership and Clinical Privileges; and

(10) Demonstrate compliance with any MEC and Board approved residency requirements.

For purposes of this Manual, a Practitioner is "able to become board certified" if the Practitioner is board eligible, board admissible, board qualified or an active candidate for board certification, as such terms are used by the applicable specialty.

2.3 Minimum Criteria for Allied Health Professionals: Allied Health Professionals ("AHPs") include Clinical Psychologists, Physician Assistants, Advanced Registered Nurse Practitioners, and Certified Registered Nurse Anesthetists. The following qualifications must be met before an application will be processed:

(1) Demonstrate that he/she has successfully graduated from an accredited school in his/her allied health profession;

(2) Have a current unrestricted license to practice as required for the practice of his/her profession within the State of Florida;

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(3) Demonstrate recent clinical performance and competence within the last twelve (12) months with an active clinical practice in the clinical specialty area in which Clinical Privileges are sought, for purposes of ascertaining current clinical competence;

(4) Provide evidence of skills to provide a type of service that the Board has determined to be appropriate for the performance within the Hospital and for which a need exists;

(5) Have a record that is free from current Medicare/Medicaid/CHAMPUS (Tricare) sanctions or felony convictions (within the last three (3) years), or occurrences that would raise questions of undesirable conduct which could injure the reputation of the Medical Staff or Hospital;

(6) A psychologist must have an earned a doctorate degree, (PhD or Psy.D, in psychology) from an educational institution accredited by the American Psychological Association and have completed at least two (2) years of clinical experience in an organized healthcare setting, supervised by a licensed psychologist, one (1) year of which must have been post doctorate, and have completed an internship endorsed by the American Psychological Association (APA), and board certification as appropriate to area of clinical practice within five (5) years of initial Medical Staff appointment. Note: in order to be licensed as a psychologist by the State of Florida a clinical internship or practicum must be completed.

2.4 Exceptions: The Board may make exceptions to the above Sections 2.2 or 2.3 only under the following circumstances:

(1) After discussion by the Joint Conference Committee; and

(2) Upon presentation of information conclusively demonstrating that the Applicant possesses a level of clinical judgment, skill, and overall performance equal to or greater than that possessed by other Applicants to the Medical Staff, who meet the qualifications stated in Section 2.2 or 2.3, as applicable. Such information could consist of any of the following:

a) A statement to the above signed by each member of the MEC.

b) A report documenting direct review by a board-certified physician of like specialty selected by the Credentials Committee at the Applicant's expense of an acceptable number of patient records reflecting treatment by the Applicant that indicates the Applicant practices at a level commensurate to that of a board-certified physician in such specialty. Such report must be signed by two (2) individuals acceptable to the Hospital, both of whom are board-certified in the Applicant's specialty.

2.5 Continuing Criteria: Members must continuously meet the following criteria:

(1) Fulfill the criteria as identified in Sections 2.2 and 2.3 above, as applicable;

(2) Demonstrate his/her background, experience and training, current competence, knowledge, judgment, ability to perform and technique in his/her specialty for all Clinical Privileges requested;

(3) Maintain his/her board certification within the parameters of the specialty in which such board certification was initially granted;

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(4) Upon request, provide evidence of both the physical and mental health necessary and appropriate to exercise the Clinical Privileges granted or requested and to fulfill all the obligations of Medical Staff membership. The CEO, President, or Clinical Section Chief of the Clinical Section to which the Member is assigned may require the Member to undergo an appropriate medical or psychological examination in order to provide this evidence;

(5) Maintain appropriate personal qualifications, including Member's consistent observance of ethical and professional standards of care and conduct. These standards include, at a minimum:

a) Compliance with all local, state or federal laws;

b) Abstinence from any participation in fee splitting or other illegal payment, receipt, or remuneration with respect to any impermissible referrals or patient service opportunities; and

c) A history of consistently acting in a professional, appropriate and collegial manner with others in previous clinical and professional settings; and

(6) Possess appropriate written and verbal communication skills. Note: When two (2) Practitioners cannot read a Member's documentation or understand the Member's verbal communication at the time such documentation or communication needs to be understood or implemented, it is determined to be illegible for written documentation and inappropriate for verbal communication.

2.6 In assessing experience, ability and current competence, a review of the following general competencies, as described by the Joint Commission, shall be incorporated in the credentialing and privileging process: patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice.

Section 3 Application Request Procedure

All requests for applications for appointment to the Medical Staff and requests for Clinical Privileges must be made to the CEO or his or her designee. Individuals requesting medical staff membership must demonstrate compliance with the administrative criteria established by the Board. These Board criteria, as established and modified from time to time by the Board, will be enumerated in the application, which will be provided to the potential Applicant by the Baptist Health South Florida, Inc. ("BHSF") Credentialing Verification Services Office ("CVO"). In the event the Board's administrative criteria are not met, the potential Applicant will be notified that he/she is ineligible to apply for membership on the Medical Staff and the application will not be processed. Denial of a potential Applicant's request for membership due to his/her failure to comply with such Board criteria will not entitle such potential Applicant to a Fair Hearing or any of the rights and due process provided under the Bylaws and supporting Manuals.

Section 4 Initial Appointment Procedure

4.1 Application: Upon receipt by the CVO of a request forwarded by the CEO or designee, the CVO will provide to appropriate prospective Applicants an application package that includes a blank application faun, a list of required supporting information, and a list of expectations applicable to individuals granted Medical Staff membership and/or Privileges if such a list of expectations has been formally adopted by the Medical Staff

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4.2 Applicant Agreement: The Applicant must sign the application fowl_ This signature will signify the Applicant's agreement to all of the following:

(1) Attestation to the accuracy and completeness of all information in the application and accompanying documents, and agreement that any inaccuracy, omission, or misrepresentation, whether intentional or not, may be grounds for telmination of the application process without the right to a fair hearing or appeal. If the inaccuracy, omission or misstatement is discovered after an individual has been granted appointment and/or Clinical Privileges, the individual's appointment and Privileges shall lapse effective immediately upon notification of the individual without the right to a fair hearing or appeal.

(2) Consent to appear for any requested interviews in regard to his/her application.

(3) Authorization of Hospital and Medical Staff representatives to consult with prior and current associates and others who may have information bearing on Applicant's professional competence, character, ability to perform the Clinical Privileges requested, ethical qualifications, ability to work cooperatively with others, and other qualifications for membership and the Clinical Privileges requested.

(4) Consent for Hospital and Medical Staff representatives' inspection of all records and documents that may be material to an evaluation of his/her professional qualifications and competence to carry out the Clinical Privileges requested, of his/her physical and mental health status to the extent relevant to the requested Clinical Privileges, and of his/her professional and ethical qualifications.

(5) Release from liability, promises not to sue and grants immunity to the Hospital, its Medical Staff, and its representatives for acts performed and statements made in connection with evaluation of the application, his/her credentials and qualifications to the fullest extent permitted by the law.

(6) Release from liability and promises not to sue, any and all individuals and organizations who provide information to the Hospital or the Medical Staff, including, but not limited to, otherwise privileged or confidential information to Fishermen's Community Hospital representatives concerning his/her background, experience, competence, professional ethics, character, and physical and mental health to the extent relevant to the requested Clinical Privileges, emotional stability, utilization practice patterns, and other qualifications for appointment and Clinical Privileges.

(7) Authorization of Medical Staff and administrative representatives of the Hospital to release to other hospitals, medical associations, licensing boards and other organizations concerned with Applicant's performance and the quality and efficiency of Applicant's patient care any information relevant to such matters that Hospital may have concerning him/her and release of Hospital representatives from liability for so doing. For the purposes of this provision, the temi "Hospital representatives" includes the Board, its directors and committees, the CEO or his/her designee, registered nurses and other employees of the Hospital, the Medical Staff, and its agents, successors and assigns, and all Medical Staff appointees, clinical units and committees that have responsibility for collecting and evaluating the Applicant's credentials or acting upon his/her application and any authorized representative of any of the foregoing.

(8) Agreement to abide by the Medical Staff Bylaws, Manuals, and all Rules and Regulations, policies and procedures of the Medical Staff. Applicant has been oriented to the

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current Medical Staff Bylaws, Manuals and all rules, regulations, policies and procedures of the Medical Staff Such orientation will include at least one of the following: receiving a copy of the Medical Staff Bylaws and associated Manuals and Rules and Regulations, or receiving a summary of the expectations of Medical Staff members and having the Bylaws, Manuals, Rules and Regulations, policies and procedures of the Medical Staff made available to the Applicant.

(9) Provision of accurate answers to the following questions, and agreement to immediately notify the Hospital in writing should any of the information regarding these items change during the period of their Medical Staff membership or Clinical Privileges. If the Applicant answers any of the following questions affirmatively/provides information identifying a problem with any of the following items, the Applicant will be required to submit a written explanation of the circumstances involved.

a. Have any disciplinary actions ever been initiated or are any pending against you by any state licensure board?

b. Has your license to practice in any state ever been relinquished, denied, limited, suspended, or revoked, whether voluntarily or involuntarily?

c. Have you ever been asked to surrender your license?

d. Have you ever been suspended, sanctioned, excluded, debarred or otherwise restricted from participating in any private, federal, or state health insurance program (for example, Medicare, CHAMPUS, or Medicaid)?

e. Have you ever been the subject of an investigation by any private, federal, or state agency concerning your participation in any private, federal, or state health insurance program?

f. Has your DEA certificate ever been relinquished, limited, denied, suspended, or revoked?

g. Is your DEA certificate currently being challenged?

h. Have you ever been named as a defendant in any criminal proceeding or been arrested or charged with a crime within the past ten (10) years?

i. Have you ever entered into an agreement with the federal or state government as a result of violations of state or federal regulations or law, e.g. a corporate integrity agreement?

j• Has your employment, medical staff appointment, or clinical privileges ever been suspended, diminished, revoked, refused, or limited at any hospital or other health care facility, whether voluntarily or involuntarily?

k. Have you ever withdrawn your application for appointment, reappointment, or clinical privileges or resigned from any medical staff before a hospital's or health facility's governing board made a decision regarding you?

1. Have you ever been the subject of focused individual monitoring at any hospital or health care facility?

m. Have you ever been examined by any specialty board, but failed to pass the examination? Please provide details.

n. If not certified, have you applied for the certification exam?

o. If no, do you intend to apply for the certification exam?

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13- Have you ever been accepted to take the certification exam?

cl. If yes, what dates are you scheduled to take the certification exam?

r. What are the date(s) of the next recertification examination (if applicable)?

s. Have any professional liability claims or suits ever been filed against you? Are any liability claims presently pending? Have you been provided notice of intent to file a professional liability claim?

t. Have any judgments or settlements been made against you in any professional liability case?

(10) Agreement to provide evidence of current enrollment (in either the Ordering and Referring Report or the Pending Review File) as either (i) a participating provider,(ii) non-participating provider, or (iii) opt-ed out provider in the Provider Enrollment, Chain and Ownership System (PECOS) of the Centers for Medicare and Medicaid (CMS).

4.3 Procedure for Processing Applicants for Initial Appointment:

(1) Initial processing of an Applicant's application shall be conducted by the CVO and shall follow the procedures outlined in BHSF Policy No. 247.49 Initial Appointment and Verification Guidelines for Baptist Health South Florida's Credentialing Verification Services (as may be amended from time to time) with respect to determining whether an application is complete, the processing thereof and the verifying of credentials.

(2) A completed application includes, at a minimum the items set forth in Section 1(a) through (t) of Policy 247.49. With respect to professional references, peers references must have known the Applicant for a minimum of 12 months and be knowledgeable about the Applicant's ability, experience and current competence specific to the Clinical Privileges requested. A peer is defined as a practitioner in the same professional discipline as the Applicant. To be considered complete, the application shall also include:

a) relevant practitioner-specific data as compared to aggregate data, when available;

b) morbidity and mortality data, when available; and

c) consent to the release of information from all insurance carriers that have insured the Applicant during the past ten (10) years.

(3) An application shall be deemed incomplete if any of the above items are missing or if the need arises for new, additional, or clarifying information in the course of reviewing an application. An incomplete application will not be processed. The burden is on the Applicant to provide all required information. It is the Applicant's responsibility to ensure that the Hospital receives all required supporting documents verifying information on the application and providing sufficient evidence, as required in the sole discretion of the Hospital that the Applicant meets the requirements for Medical Staff membership and the Clinical Privileges requested. If information is missing from the application, or new, additional, or clarifying infotmation is required, a letter requesting such infolmation will be sent to the Applicant. If the requested infolmation is not returned to the Hospital within forty-five (45) calendar days, the application will be deemed both incomplete and a voluntary withdrawal of the application.

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(4) Upon receipt of a completed application, the Medical Staff Office Professional or designee, with input from the Chair of the Credentials Committee or designee, will determine if the requirements of Section 2.2 are met. In the event the requirements of Section 2.2 are not met, the potential Applicant will be notified that he/she is ineligible to apply for membership on the Medical Staff and the application will not be processed. If the requirements of Section 2.2 are met, the application will be accepted for further processing.

(5) If the application is complete, the Applicant will be sent a letter of acknowledgment by the CVO/Hospital. Individuals seeking appointment and reappointment have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, character, ethics and other qualifications and of resolving any doubts.

Any Applicant not meeting the minimum objective requirements for membership to the Medical Staff as outlined in the application or elsewhere in this Credentials Manual will not have his/her application processed and will not be entitled to a fair hearing (see Section 3 above).

(6) Upon receipt of a completed application, the CVO and Hospital, through its Medical Staff Office Professional, will verify its contents from acceptable sources and collect additional information as follows:

a. Information from all prior and current liability insurance carriers concerning claims, suits, settlements and judgments, if any.

b. Documentation of the Applicant's past clinical work experience;

c. Evidence of licensure status in all current or past states of licensure;

d. Information from the AMA or AOA Physician Profile, Federation of State Medical Board, HHS/OIG list of excluded individuals, FACIS (Fraud and Abuse Control Infotmation System), or other such data banks;

e. Information resulting from criminal background checks;

E Documentation concerning the completion of professional training programs including residency and fellowship programs;

g• Information from the National Practitioner Data Bank;

h. Other information about adverse credentialing and privileging decisions;

i. Two (2) or more peer recommendations addressing the Applicant's current clinical competence, ethical character and ability to work with others. A peer is defined as a practitioner in the same professional discipline as the Applicant;

J • Additional information as may be requested to ensure Applicant meets the criteria for Medical Staff membership;

k. Valid Photo ID of the Applicant to verify identity; and

1. If available, the results of any drug testing and/or other health testing required by a health care institution or licensing board.

Note: In the event there is undue delay in obtaining required information, the Hospital will request assistance from the Applicant. During this time period, the "time periods for processing" the application will be appropriately modified. Failure of an Applicant to

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adequately respond to a request for assistance after forty-five calendar days (45) will be deemed a voluntary withdrawal of the application.

(7) When the items identified in Section 4.3(6) above have been received from the CVO or from the primary source, the file will be initially reviewed by the Medical Staff Office Professional (or designee) and then forwarded to the Credentials Committee Chair, who will categorize the application as a Category One or Category Two as follows:

Category One: A complete and verified application' that does not raise the concerns identified in the criteria for Category Two. Applicants in Category One will be granted Medical Staff membership and Clinical Privileges following input from the Clinical Section Chief and upon approval by (i) the Chair of the Credentials Committee acting on behalf of the Credentials Committee, (ii) the MEC and (iii) the Board.

Category Two: If one or more of the following criteria are identified in the course of review of a completed file, the application will be treated as Category Two. The Clinical Section Chief, if applicable, the Credentials Committee, the MEC and the Board shall review all Category Two applications. The Credentials Committee may request that an appropriate subject matter expert2 assess selected applications. At all stages in this review process, the burden is upon the Applicant to provide evidence that he/she meets the criteria for membership on the Medical Staff and for the granting of requested Clinical Privileges. Criteria for Category Two applications include but are not necessarily limited to the following:

a. The application is deemed to be incomplete;

b. The final recommendation of the MEC is adverse or with limitation;

c. The Applicant is found to have experienced an involuntary termination of medical staff membership or involuntary limitation, reduction, denial, or loss of clinical privileges at another organization;

d. Applicant is, or has been, under investigation by a state medical board or has prior disciplinary actions or legal sanctions;

e. Applicant graduated from a medical school which is not accredited by the Liaison Committee for Medical Education (LCME);

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g. Applicant changed medical schools or residency programs or has gaps in training or practice;

h. Applicant has changed practice locations more than three times in the past ten (10) years;

I "Verified application" indicates that the primary source verification has been completed and all items listed under section 4.3 (6) have been received and verified.

2 Subject matter expert is an individual chosen by the Credentials Committee or MEC to assist and advise them in evaluation of recommendations for clinical Privileges for their peers.

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i. Applicant has practiced or been licensed in three (3) or more states;

J. Applicant has one or more reference responses that raise concerns or questions;

k. Discrepancy found between information received from the Applicant and references or verified information;

1. Applicant has an adverse National Practitioner Data Bank report;

m. The request for Clinical Privileges is not reasonable based upon Applicant's experience, training, and competence, and/or is not in compliance with applicable criteria;

n. Applicant has been removed from a managed care panel for reasons of professional conduct or quality;

o. Applicant has potentially relevant physical or mental health problems; or

p. Other issues as determined by the Clinical Section Chief or other representative of the Hospital.

4.4 Applicant Interview:

(1) Applicants may be required to participate in an interview as part of the application process for appointment to the Medical Staff at the discretion of the Credentials Committee. The interview is to be conducted by the Clinical Section Chief, if applicable, or an appropriate subject matter expert as selected by the Credentials Committee. The interview may be used to solicit information required to complete Applicant's application or to clarify information previously provided, e.g., malpractice history, reasons for leaving past healthcare organizations, or other matters bearing on the Applicant's ability to render care at the generally recognized level for the community.

(2) The Applicant will be notified when the verification process is complete and that he/she should contact the responsible individual to schedule an interview. It is the responsibility of the Applicant to contact this individual to arrange the interview. Failure of the Applicant to schedule an interview with the designated Medical Staff leader within thirty (30) calendar days will be deemed a withdrawal of the application.

4.5 Credentials Committee Action:

An application designated Category One based on the criteria set forth in Section 4.3(7) shall be reviewed by the Credentials Committee and will be recommended to the MEC. To clarify information previously provided, phone calls to an Applicant's professional peer references may be made as part of the application process for appointment to the Medical Staff at the discretion of the Credentials Committee if such Applicant, in the exercise of his/her Clinical Privileges, will practice on the Hospital's premises. Based on its review, the Credentials Committee may change a Category One Applicant's designation to Category Two.

An application designated Category Two based on the criteria set forth in Section 4.3(7) shall be reviewed by the Credentials Committee. To clarify information previously provided, phone calls to an Applicant's professional peer references may be made as part of the application process for appointment to the Medical Staff at the discretion of the Credentials Committee if such Applicant, in the exercise of his/her Clinical Privileges, will practice on the Hospital's premises. The Credentials Committee will vote for one of the following actions:

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(1) Deferral: The Credentials Committee may act to defer the application for further consideration or to gather information from the Applicant. The burden is on the Applicant to provide all requested information. If the information requested is not provided to the Credentials Committee within thirty (30) days of the receipt of a letter requesting additional information, the application will be deemed voluntarily withdrawn unless the MEC otherwise determines that the Applicant has made a good faith effort to provide the information in a timely manner. After consideration the Credentials Committee will make recommendations as to approval or denial of, or any special limitations to, Medical Staff appointment, category of Medical Staff, Clinical Section affiliations and scope of Clinical Privileges.

(2) Favorable recommendation: When the Credentials Committee's recommendation is favorable to the Applicant in all respects, the application shall be promptly forwarded, together with all supporting documentation, to the MEC. The Credentials Committee may recommend the imposition of specific conditions. These conditions may relate to behavior or to clinical issues. The Credentials Committee may also recommend that appointment be granted for a period of less than two (2) years in order to permit closer monitoring of the Applicant's compliance with any conditions.

(3) Adverse recommendation: If the Credentials Committee recommends denial of membership or denial or restriction of any requested Clinical Privileges, it will forward its recommendation to the MEC along with an explanation for its recommendation(s).

4.6 Medical Executive Committee Action: If the application is designated Category One application, it is presented to the MEC, where the application shall be reviewed to ensure that it fulfills the established standards for membership and Clinical Privileges. If the application was forwarded to the MEC as a Category One, the MEC shall recommend that the application be presented to the Board for approval. If designated as a Category Two, the MEC shall review the application and vote for one of the following actions:

(1) Deferral: The MEC may act to defer the application for further consideration or to gather information from the Applicant. The burden is on the Applicant to provide all requested information. If the information requested is not provided to the MEC within thirty (30) days of the receipt of a letter requesting additional information, the application will be deemed voluntarily withdrawn unless the MEC determines that the Applicant has made a good faith effort to provide the information in a timely manner. After consideration the MEC will make recommendations to the Board as to approval or denial of, or any special limitations to, Medical Staff appointment, category of Medical Staff, Clinical Section affiliations, and scope of Clinical Privileges.

(2) Favorable recommendation: When the MEC' s recommendation is favorable to the Applicant in all respects, the application shall be forwarded, together with all supporting documentation, to the Board.

(3) Adverse recommendation: When the MEC's recommendation is adverse to the Applicant, a special notice shall be sent to the Applicant. No such adverse recommendation will be acted upon by the Board until after the Applicant has exercised or has waived his/her right to a hearing as provided in the Investigations Manual. A recommendation shall not be considered adverse to the Applicant if Clinical Privileges not central and directly related to the Applicant's prior training and practice are deferred until such time as the Hospital has had sufficient

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opportunity (after initial appointment) to observe the Applicant's practice and qualifications to exercise the deferred Clinical Privileges.

4.7 Board Action:

If the application is designated as Category One, it shall be presented to the Board, which will review the application to ensure that it fulfills the established standards for membership and Clinical Privileges. If forwarded to the Board as a Category Two, the Board shall review the application and vote for one of the following actions:

(1) Favorable recommendation: The Board may adopt or reject in whole or in part a favorable recommendation of the MEC or refer the recommendation to the MEC for further consideration stating the reasons for such referral back and setting a time limit within which a subsequent recommendation must be made. Favorable action by the Board is effective as its final decision.

(2) Adverse recommendation: If the Board acts to deny the Applicant membership on the Medical Staff or to deny or to restrict requested Clinical Privileges, a special notice will be sent to the Applicant, and the Applicant shall then be entitled to the procedural rights provided in the Investigations Manual.

(3) After procedural rights: In the case of an adverse MEC recommendation, the Board shall take final action in the matter as provided in the Investigations Manual.

(4) Notice of final decision: Notice of Board's final decision shall be given, through the CEO to the MEC and to the Chair of each Clinical Section concerned. The Applicant shall receive written notice of appointment and special notice of any adverse final decisions, which require a Fair Hearing under the Medical Staff Bylaws and the Investigations Manual. A decision and notice of appointment includes the staff category to which the Applicant is appointed, the department to which he/she is assigned, the Clinical Privileges he/she may exercise, and any special conditions attached to the appointment.

4.8 Period of Appointment: All appointments to Medical Staff membership and the granting of Clinical Privileges are for a period not to exceed twenty-four (24) months and may be granted for periods less than twenty-four (24) months.

4.9 Basis for Recommendation and Action: The report of each individual or group required to act on an application, including the Board, must state in writing the reasons for each recommendation or action taken with specific reference to the completed application and all other documented information.

4.10 Time Periods for Processing: All individual and groups required to act on an application for Medical Staff appointment must do so in a timely and good faith manner, and, except for good cause, each application will be processed within a six month period. This time period is deemed a guideline and does not create any right to have an application processed within this precise period. If the provisions of the Investigations Manual are activated, the time requirements provided therein shall govern the continued processing of the application. All offers of Medical Staff appointment will expire if the Applicant does not respond in thirty (30) calendar days.

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Section 5 Reappointment

5.1 General Procedures: It is the policy of the Hospital to approve for reappointment only those individuals who meet the criteria for initial appointment as identified in Section 2 and who have been determined by the MEC to be providers of effective care consistent with the Hospital standards of ongoing quality as determined by the MEC and the Hospital performance improvement program. The procedures for granting new Clinical Privileges to existing Medical Staff members will follow the steps described in Section 4 above concerning the initial granting of Clinical Privileges. A suitable peer shall substitute for the Clinical Section Chief in the evaluation of current competency of the Clinical Section Chief and shall provide the required input to the Credentials Committee. Members approved for reappointment shall be appointed to the category of the Medical Staff reflective of such Member's number of Patient Contacts during the prior twenty-four (24) month period. All reappointments and renewals of Clinical Privileges are for a period not to exceed twenty-four (24) months. Reappointment may be granted by the Board for periods less than twenty-four (24) months.

5.2 Reappointment Application:

(1) On or before four (4) months prior to the date of expiration of a Medical Staff appointment, a representative from the Medical Staff Office shall notify the Member of the date of expiration and provide him/her with an application for reappointment. At least ninety (90) calendar days prior to the expiration date, the Member shall furnish the following information:

a) A completed reappointment application form, which includes complete information to update his/her file on items listed in his/her original appointment application, any required new, additional, or clarifying information, and any required fees or dues. By signing the reappointment application form, the Member agrees to the same terms as identified in the above Section 4.2;

b) Attestation of continuing training and education internal and external to the Hospital during the preceding appointment period;

c) Specific requests for Clinical Privileges sought on reappointment, with any basis for changes; and

d) An update on all questions found under Section 4.2(9) of this Manual (including information on any corrective actions taken against the Member at any health care institution).

(2) Failure, without good cause, to provide any requested information, at least thirty (30) calendar days prior to the expiration of appointment will result in a cessation of processing of the application and automatic expiration of appointment. Additional information will be accepted by the Hospital for a sixty (60) day calendar period after the expiration of appointment. Once the information is received, the Hospital shall verify this additional information and notifies the Member of any information inadequacies and resolves any doubts about this data. In this circumstance, the Applicant will not need to file a new application for reappointment.

(3) As part of the reappointment process, the Hospital shall collect information regarding each Member's professional and collegial activities to include, without limitation, those items listed in Section 4.2(9) and the items listed below in (a) through (j):

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a) Summarized description of clinical activity at the Hospital for each Member seeking reappointment, including number of Patient Contacts during the prior twenty-four (24) month period;

b) Infonnation regarding performance and conduct at the Hospital and other healthcare organizations where the Member has provided substantial clinical care since the last reappointment, including, without limitation, patterns of care as demonstrated in findings of quality assessment/performance improvement activities, his/her clinical judgment and skills in the treatment of patients, and his/her behavior and cooperation with Hospital personnel, patients, and visitors;

c) Information regarding Member's service on Medical Staff, department, and Hospital committees;

d) Compliance with requirements for timely and accurate completion of medical records;

e) Compliance with all applicable Bylaws, Manuals, Rules and Regulations, policies and procedures of the Hospital and Medical Staff;

f) Any gaps in employment or practice since the previous appointment or reappointment;

g) National Practitioner Data Bank query;

h) A peer recommendation when insufficient peer review data are available to evaluate current competence, ethical character, and ability to work with others. Such a peer is defined as a Practitioner in the same professional discipline as the Member seeking reappointment, who has known the Member for a minimum of twelve (12) months; is knowledgeable about the Member's ability, experience and current competence specific to the Clinical Privileges requested; and who does not have a financial conflict of interest with such Member;

i) Malpractice history for the past two (2) years which is primary source verified by the malpractice carrier(s), where the Applicant has utilized such carriers for coverage; and

j) Compliance with local, state, and federal laws applicable to Member.

(4) The Member applying for reappointment agrees to allow the Hospital to share infoimation regarding Member's perfomfance with other licensed healthcare facilities of Baptist Health South Florida, including the items listed above.

5.3 Procedure for Processing Applications for Reappointment: When the items identified in 5.2(1), 5.2(3), and 5.2(4) above have been obtained, the file will then be reviewed by the Medical Staff Office Professional (or designee) and then forwarded to the Credentials Committee Chair, who will categorize the application as a Category One or Category Two as follows:

Category One: A complete and verified reappointment application that does not raise the concerns identified in the criteria for Category Two and lacks new adverse information. Category One Members seeking reappointment will be reviewed following the same process as Category One initial Applicants as described in Section 4.3(6), with the exception of making phone calls to

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professional references when reappointment Applicant will be practicing on the Hospital's premises.

Category Two: If one or more of the following criteria are identified in the course of review of a completed file, the reappointment application will be treated as Category Two. Category Two Members seeking reappointment will be reviewed follow same process as Category Two initial applications with the exception of making phone calls to professional references when reappointment Applicant will be practicing on the Hospital's premises. Criteria for Category Two reappointment applications include but are not necessarily limited to the following:

a. The application is deemed to be incomplete;

b. The final recommendation of the MEC is adverse or with limitation;

c. The Member is found to have experienced an involuntary termination of medical staff membership or involuntary limitation, reduction, denial, or loss of clinical privileges at another organization;

d. Member is, or has been, under investigation by a state medical board or has had prior disciplinary actions or legal sanctions;

e. Member has had two (2) or more malpractice cases filed within the past five (5) years or one final adverse judgment in a professional liability action in excess of $500,000;

f. Member has gaps in practice since the most recent re-credentialing;

g. Member has one or more reference responses that raise concern or questions;

h. Discrepancy found between information received from the Member and references or verified infoimation;

i. Member has a National Practitioner Data Bank report with adverse information entered since the time of the Member's previous appointment or reappointment;

j. The request for Clinical Privileges is not reasonable based upon Member's experience, training, and competence, and/or is not in compliance with applicable criteria;

k. Potentially relevant physical or mental health problems that may impede the Member's ability to perform safely and competently the Clinical Privileges requested;

1. A history of criminal or civil violations of local, state or federal laws or exclusions, or sanctions from any government insurance programs; and

m. Information from the quality monitoring and improvement program at the Hospital that raises possible concerns with the Member's quality of care, professional conduct, or capacity to fulfill the responsibilities of Medical Staff membership and the requested Clinical Privileges.

5.4 Input and Actions: In addition, as part of the assessment of the Member's performance, the Clinical Section Chief, if applicable, or one or more subject matter experts may be asked to provide relevant information concerning the Member's clinical and professional qualifications for reappointment category and Clinical Privileges and to evaluate the reappointment application. The Clinical Section Chief may be asked to provide information as to whether or not he/she

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knows of, or has observed or been informed of any conduct which indicates significant present or potential physical or behavioral problems affecting the Member's ability to perform professional and Medical Staff duties appropriately, as well as relevant information concerning the Member's clinical and professional qualifications for reappointment and Clinical Privileges. Such requests for further evaluation may be made by the Credentials Committee, MEC or Board. For the purpose of reappointment an "adverse recommendation" by the Board as used in Section 4 means a recommendation or action to deny reappointment, or to deny or restrict requested Clinical Privileges or any action which would entitle the Member seeking reappointment to a Fair Hearing as outlined in the Investigations Manual.

Section 6 Clinical Privileges

6.1 Exercise of Clinical Privileges: A Practitioner providing clinical services at the Hospital may exercise only those Clinical Privileges granted to him/her by the Board or granted as Emergency or Disaster Privileges as described herein.

6.2 Requests: Each application for appointment or reappointment to the Medical Staff must contain a request for setting-specific Clinical Privileges desired by the Applicant or Member, respectively. Setting-specific requests must also be submitted for Temporary Privileges and for modifications of Clinical Privileges in the interim between reappraisals. "Setting-specific" refers to Clinical Privileges that may be exercised on an identified Hospital campus unless otherwise specified in the Delineation of Privileges form.

6.3 Authorized Privileges: Requests for Privileges will only be evaluated when the Clinical Privilege is for a procedure or clinical activity that has been authorized by the Board to be performed at the Hospital. If a request is made to exercise a Clinical Privilege that is not currently permitted at the Hospital, the Board may, in its discretion, evaluate whether the relevant procedure or clinical activity should be permitted at the Hospital.

6.4 Privileges Lacking Board Criteria: The Board may have determined that a clinical activity or procedure is appropriate for performance at the Hospital but may not have approved privileging criteria for such procedure or activity. In such circumstances, Section 6.4(1) below applies.

(1) In the event a request for Clinical Privileges is submitted for which no criteria have been established, the request will be tabled for a reasonable period of time, usually not to exceed one hundred and twenty (120) calendar days, during which the MEC will, upon recommendation from the Credentials Committee and appropriate subject matter experts, formulate the necessary criteria and recommend these to the Board. Once objective criteria have been establish, the original request will be processed as described herein.

(2) For the development of criteria, the Hospital will compile information relevant to the Clinical Privileges requested, which may include, but need not be limited to, position and opinion papers from specialty organizations and other appropriate sources, position and opinion statements from interested individuals or groups, and documentation from other appropriate hospitals.

(3) Criteria to be established for the Clinical Privilege(s) in question shall include education, training, board status, or certification (if applicable), experience, and evidence of current competence. Proctoring requirements, if any, will be addressed including who may serve

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as proctor and how many proctored cases will be required. Hospital-related issues such as equipment and management will be referred to the appropriate Hospital Director.

(4) If the Clinical Privileges requested overlap two or more specialty disciplines, an ad hoc committee will be appointed by the Credentials Committee Chair to recommend criteria for the Clinical Privilege(s) in question. This committee will consist of at least one, but not more than two, Members from each involved discipline. The chair of the ad hoc committee will be a member of the Credentials Committee who does not economically compete with any of the specialties involved and has no conflict of interest with regard to the issues under discussion.

6.5 Basis for Privileges Determination:

(1) Requests for Clinical Privileges will be considered only when accompanied by evidence of education, training, experience and demonstrated current competence as specified by the Hospital in its Board-approved criteria for Clinical Privileges.

(2) Requests for Clinical Privileges will be evaluated on the basis of prior and continuing education, training, experience, utilization practice patterns, current ability to perfolin the Clinical Privileges requested, and demonstrated current competence, ability, and judgment. Additional factors that may be used in determining Clinical Privileges are patient care needs for, and the Hospital's capability to support, the type of Clinical Privileges being requested and the availability of qualified coverage in the requestor's absence. The basis for Clinical Privileges detelinination in connection with periodic reappointment or a requested change in Clinical Privileges must include documented clinical performance and results of the Member's perfoimance improvement program activities. Clinical Privilege deteuninations will also be based on pertinent information from other sources, especially other institutions and health care settings where the requestor exercises clinical privileges.

(3) The procedure by which requests for Clinical Privileges are processed is outlined in Section 4 of this Manual.

(4) Any Practitioner applying for Clinical Privileges in Emergency Medicine shall be board certified in either emergency medicine, family medicine, internal medicine or surgery, or must become so certified within the time frame required in Section 2.3 of this Manual.

6.6 Telemedicine Privileges: Practitioners providing telemedicine services will be credentialed and privileged through committee processes outlined in this Manual. Practitioners must be currently credentialed and privileged through a Joint Commission-accredited organization and the distant site (i.e., the site where the Practitioner providing the professional service is located) will provide necessary documentation in support of the Practitioner and request for privileges.

6.7 Fellows / Physicians in Training: Fellows who provide care at the Hospital must be Members of the Medical Staff and complete the same credentialing and privileging process as any other Applicant.

6.8 Temporary Privileges: Temporary Privileges may be granted by the CEO (or authorized designee), upon written recommendation of the President (or authorized designee). Temporary Privileges may be granted only in two (2) circumstances: 1) to fulfill an important patient care, treatment and service need; or 2) when an initial Applicant has a complete, clean, application approved by the Credentials Committee Chair yet is awaiting review and approval of the MEC and the Board. The Board will review all grants of Temporary Privileges at its

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regularly scheduled meeting. Temporary Privileges may be granted for a period not to exceed sixty (60) calendar days.

(1) Important Patient Care Need: Temporary Privileges may be granted on a case by case basis when an important patient care, treatment or service need exists that mandates an immediate authorization to practice, for a limited period of time, while the full credentials information is verified and approved, provided there is verification by the President of current licensure and current competence. For the purposes of granting Temporary Privileges, "an important patient care, treatment or service need" is defined as including the following:

a) A circumstance in which one or more individual patients will experience care that does not adequately meet their clinical needs if the Temporary Privileges under consideration are not granted, (i.e., a patient scheduled for urgent surgery who would not be able to undergo the surgery in a timely manner);

b) A circumstance in which the institution will be placed at risk of not adequately meeting the needs of patients who seek care, treatment or service from the institution if the Temporary Privileges under consideration are not granted (i.e., the institution will not be able to provide adequate emergency room coverage in the provider's specialty, or the Board has granted Clinical Privileges involving new technology to a physician on the staff provided the physician is precepted for a specific number of initial cases and the precepting physician, who is not seeking Medical Staff membership, requires Temporary Privileges to serve as a preceptor.

(2) Clean Application Awaiting Approval: Temporary Privileges may be granted for up to sixty (60) days when the new Applicant for Medical Staff membership or Clinical Privileges is waiting for review and recommendation by the MEC and approval by the Board. Criteria for granting Temporary Privileges in these circumstances include the Applicant providing evidence of the following, which has been verified by the Hospital: current licensure; education; training and experience; current competence; current DEA (if applicable); current professional liability insurance or equivalents in the amount required; malpractice history; one favorable reference specific to the Applicant's competence from an appropriate medical peer; and ability to perform the Clinical Privileges requested; and results from a query to the National Practitioner Data Bank. Additionally, the application must meet the criteria for Category One, as noted in Section 4 of this Manual.

(3) Temporary Privileges at Reappointment: Temporary Privileges may not be used to extend a Member's appointment to the Medical Staff beyond the maximum twenty-four (24) month period of appointment.

(4) Special requirements of consultation and reporting may be imposed as part of the granting of Temporary Privileges. Except in unusual circumstances, Temporary Privileges will not be granted unless the Applicant has agreed in writing to abide by the Bylaws, Manuals, Rules and Regulations and policies of the Medical Staff and the Hospital in all matters relating to his/her Temporary Privileges. Whether or not such written agreement is obtained, these Bylaws, Manuals, Rules and Regulations, and policies control all matters relating to the exercise of Clinical Privileges.

(5) Termination of Temporary Privileges: The CEO (or authorized designee), after consultation with the President of the Medical Staff, may terminate any or all of the Practitioner's Temporary Privileges based upon the discovery of any information, or the

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occurrence of any event, of a nature which raises questions about a Practitioner's Clinical Privileges. Where the life or well being of a patient is detennined to be endangered, any person entitled to impose summary suspension under the Bylaws may effect the termination. In the event of any such tennination, the Practitioner's patients then will be assigned to another Practitioner by the CEO or his/her designee. The wishes of the patient shall be considered, when feasible, in choosing a substitute Practitioner.

(6) Rights of the Practitioner with Temporary Privileges: A Practitioner with Temporary Privileges is not entitled to a Fair Hearing, or any of the procedural rights afforded under the Investigations Manual, because his/her request for Temporary Privileges is refused or because all or any part of his/her Temporary Privileges are terminated or suspended.

6.9 Emergency Privileges: In the case of a medical emergency, any Medical Staff appointee is authorized to do everything possible to save the patient's life or to save the patient from serious harm, to the degree pennitted by the appointee's license, but regardless of clinical service affiliation, staff category, or level of Privileges. A Practitioner exercising emergency Privileges is obligated to summon all consultative assistance deemed necessary and to arrange appropriate follow-up as soon as possible.

6.10 Locum Tenens Privileges:

(1) The CEO and the President of the Medical Staff may permit a Practitioner to serve as a locum tenens on the Medical Staff to attend patients for a period of not more than thirty (30) consecutive days within a twelve-month period or not more than sixty (60) total days within a twelve-month period without applying for membership on the Medical Staff in accordance with the requirements of the Medical Staff Bylaws and Manuals.

(2) To obtain Clinical Privileges as a locum tenens Practitioner, such Practitioner must: (i) complete a Request for Clinical Privileges fonn; (ii) be licensed to practice medicine in the state of Florida;(iii) have a DEA registration where applicable; (iv) be in compliance with the statutes of Florida regarding professional liability insurance; (v) provide at least two (2) professional peer recommendations addressing the locum tenens Practitioner's current clinical competence, ethical character and ability to work with others. A peer is defined as a practitioner in the same professional discipline who has known the locum tenens Practitioner for a minimum of twelve (12) months; and (vi) provide relevant information on his/her education and training.

(3) Prior to permitting the locum tenens Practitioner to attend patients, the Practitioner's credentials must be reviewed and approved by the applicable Clinical Section Chief or designee, the Credentials Committee Chair or designee, the President or designee, and the CEO. All professional peer recommendations shall be verified by the Hospital or Clinical Section Chief The Practitioner shall be supervised by the Clinical Section Chief or designees, who shall be a member of the Clinical Section. The CEO shall obtain the Practitioner's signed acknowledgment that he or she has received copies of the Medical Staff Bylaws, Manuals, policies, Rules and Regulations, and agrees to be bound by the terms thereof

6.11 Disaster/Emergency Privileges:

(1) If the Hospital's Emergency Management Plan has been activated, the CEO and such other individuals as identified in the Hospital's Emergency Management Plan with such authority, may, on a case by case basis consistent with medical licensing and other relevant state statutes, grant Disaster Privileges to provide patient care to selected Practitioners in accordance

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with the procedures set forth under BHSF Policy No. 247.52, as may be amended from time to time. In order to grant Disaster Privileges, the Practitioner must present a valid photo identification issued by a State, Federal or Regulatory Agency in addition to one of the following:

a) Presentation of a current hospital photo identification (ID) card;

b) Presentation of a current, clear, unrestrictive, active medical license with photo identification (ID) card issued by any State, District of Columbia or any territory in the United States;

c) Presentation of a photo identification (ID) card that certifies the Practitioner is a Licensed Independent Practitioner (LIP) indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT);

d) Presentation of an (ID) card that certifies the Practitioner is an (LIP) who has been granted authority by a federal, state, or municipal entity to administer patient care, treatment and services in emergencies; or

e) Identification by a current hospital or Medical Staff member (s) who possesses personal knowledge regarding the volunteer Practitioner's ability to act as a licensed independent provider during a disaster.

(2) Practitioners granted Disaster Privileges must adhere to management directives issued by Medical Staff leaders or their designees.

(3) As soon as feasible while a Practitioner is practicing under Disaster Privileges, the Hospital will seek to verify the Practitioner's current license and current competency in the same manner as for individuals granted Temporary Privileges. Primary source verification shall be undertaken in accordance with BHSF Policy No. 247.52.

(4) Once the immediate situation has passed and such determination has been made consistent with the Emergency Management Plan, the Practitioner's Disaster Privileges will terminate immediately.

(5) Any individual identified in the Emergency Management Plan with the authority to grant Disaster Privileges shall also have the authority to terminate Disaster Privileges. Such authority may be exercised in the sole discretion of the Hospital and will not give rise to a right to a fair hearing or an appeal.

(6) The Medical Staff shall oversee the professional performance of volunteer Practitioners who have been granted Disaster Privileges through direct observation, mentoring, or clinical record review. The organization shall make a decision (based on infottnation obtained regarding professional practice of the volunteer) within 72 hours related to the continuation of the Disaster Privileges initially granted.

6.12 Privileges for Allied Health Professionals: Requests for Clinical Privileges from Allied Health Professionals are processed in the same manner as requests for Clinical Privileges by Applicants eligible for Medical Staff membership, with the exception that AHPs are not eligible for membership on the Medical Staff and do not have the rights and privileges of such membership. Only those categories of AHPs approved by the Board for providing services at the Hospital are eligible to apply for Clinical Privileges. AHPs in this category may, subject to any licensure requirements or other limitations, exercise independent judgment only within the areas

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of their professional competence and participate directly in the medical management of patients under the supervision of a physician who has been accorded Clinical Privileges to provide such care. Clinical Privileges to AHPs will be granted only in accordance with the supervision requirements of Florida state law. All individuals applying for Clinical Privileges to provide nursing/patient care will be reviewed by the Vice President of Nursing Services.

Section 7 Reapplication and Modifications of Membership Status or Privileges and Exhaustion of Remedies

7.1 Reapplication after adverse credentials decision: Except as otherwise determined by the MEC or Board in light of exceptional circumstances, a Practitioner who has received a final adverse decision or withdrawn an application for appointment or reappointment or Clinical Privileges is not eligible to reapply to the Medical Staff for a period of two (2) years from the date of the notice of the final adverse decision or the effective date of the resignation of application withdrawal. Any such application is processed in accordance with the procedures then in force. As part of the reapplication, the Practitioner must submit such additional information as the Medical Staff and/or Board requires demonstrating that the basis of the earlier adverse action no longer exists. If such information is not provided, the reapplication will be considered incomplete and voluntarily withdrawn and will not be processed any further.

7.2 Reapplication after administrative revocation: A Practitioner who has had his/her Medical Staff membership or Clinical Privileges administratively revoked for failure to maintain current professional liability insurance in the specified amount, or failure to maintain and complete medical records, will be reinstated to membership with appropriate Clinical Privileges upon submission of documentation that he/she has resolved the reason for the revocation.

7.3 Request for modification of appointment: A Member, either in connection with reappointment or at any other time, may request modification of Medical Staff category, department assignment or Clinical Privileges by submitting a written request to the Medical Staff Services office. A modification request must be on the prescribed form and must contain all pertinent information supportive of the request, as well as any additional information requested. All requests for additional Clinical Privileges must be accompanied by infonuation demonstrating additional education, training, and current clinical competence in the specific Clinical Privileges requested. A modification application is processed in the same manner as a reappointment, which is outlined in Section 5 and 6 of this Manual. A Practitioner who determines that he/she no longer exercises, or wishes to restrict or limit the exercise of, particular Clinical Privileges that he/she has been granted shall send written notice, through Medical Staff Services, to the Credentials Committee and MEC. A copy of this notice shall be included in the Practitioner's credentials file.

7.4 Resignation of Medical Staff appointment: A Practitioner may resign his/her Medical Staff appointment and/or Clinical Privileges by providing written notice to the Credentials Committee. The resignation shall specify the reason for the resignation and the effective date. A Practitioner who resigns his/her Medical Staff appointment and/or Clinical Privileges is obligated to fully and accurately complete all portions of all medical records for which he/she is responsible and appropriately transfer the continuing care of all inpatients prior to the effective date of resignation. Failure to do so shall result in an entry in the Practitioner's credentials file acknowledging the resignation and indicating that it became effective under unfavorable circumstances.

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7.5 Exhaustion of administrative remedies: Every Practitioner agrees that he/she will exhaust all the administrative remedies afforded in the various sections of this Manual, the Bylaws and the Investigations Manual before initiating legal action against the Hospital or its agents.

7.6 Reporting requirements: The CEO or his/her designee shall be responsible for assuring that the Hospital satisfies its obligations under state and federal laws. Actions that must be reported include any negative professional review action against a physician related to clinical incompetence or misconduct that leads to a reduction in Clinical Privileges of greater than thirty (30) days, resignation, surrender of Clinical Privileges, or acceptance of Clinical Privilege reduction either during investigation or to avoid investigation.

Section 8 Leave of Absence

8.1 Leave request: A Member may obtain a voluntary leave of absence for a period of up to one year by providing written notice to the Credentials Committee. The notice must state the reasons for the leave and approximate period of time of the leave, which may not exceed one year except for military service. During the period of time of the leave, the Member may not exercise Clinical Privileges or prerogatives and has no obligation to fulfill Medical Staff responsibilities. Leave requests must be brought to the attention of the MEC and the Board.

8.2 Termination of leave: At least thirty (30) days prior to the termination of the leave, or at any earlier time, the Member may request reinstatement by sending a written notice to the Credentials Committee. The Member must submit a written summary of relevant activities during the leave if the MEC or Board so requests. The Credentials Committee and MEC shall make a recommendation to the Board concerning reinstatement, and the applicable procedures concerning the granting of Clinical Privileges are followed.

Section 9 Practitioners Providing Contracted Services

9.1 When the Hospital contracts for patient care services with Practitioners who provide official readings of images, tracings or specimens through a telemedicine mechanism, and these Practitioner's services are under the control of a Joint Commission-accredited organization, one of the following mechanisms will be implemented:

The Hospital will specify in a contract that the entity providing these services by contract (the contracting entity) will ensure that all services provided under this contract by individuals who are LIPs will be within the scope of those individual's Privileges at the contracting entity; or

The Hospital will verify that all individuals who are LIPs and providing services under the contract have Privileges that include the services provided under the contract.

9.2 When the Hospital contracts for care services with Practitioners who provide official readings of images, tracings or specimens through a telemedicine mechanism, and these Practitioner's services are not under the control of a Joint Commission-accredited organization, all LIPs who will be providing services under this contract will be permitted to do so only after being granted Privileges at the Hospital through the mechanisms established in this manual.

9.3 Exclusivity policy: Whenever Hospital policy specifies that certain Hospital facilities or services may be provided on a an exclusive basis in accordance with contracts or letters of agreement between Fishermen's Community Hospital and qualified Practitioners, then other staff appointees must, except in an emergency or life threatening situation, adhere to the exclusivity policy in arranging for or providing care. Application for initial appointment or for Clinical

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Privileges related to Fishermen's Community Hospital facilities or services covered by exclusive agreements will not be accepted or processed unless submitted in accordance with the existing contract or agreement with the Hospital.

9.4 Qualifications: A Practitioner who is or will be providing specified professional services pursuant to a contract or a letter of agreement with the Hospital must meet the same qualifications, must be processed in the same manner, and must fulfill all the obligations of his/her appointment category as any other Applicant or staff appointee.

9.5 Effect of disciplinary or corrective action recommended by the MEC: The terms of the Medical Staff Bylaws will govern disciplinary action taken or recommended by the MEC.

9.6 Effect of contract or employment expiration or terniination: The effect of expiration or other termination of a contract upon a Practitioner's staff appointment and Clinical Privileges will be governed solely by the terms of the Practitioner's contract with Fishermen's Community Hospital. If the contract or the employment agreement is silent on the matter, then contract expiration or other termination alone will not affect the Practitioner's staff appointment status or Clinical Privileges.

Section 10 Definitions

1. "Active Member" shall mean a Member appointed to the Active Category of the Medical Staff as described in Article II, Section 1 of the Bylaws.

2. "Admitting Privileges" shall mean authority issued to admit individuals to the Hospital as described in the Delineation of Privileges/ Clinical Privileges Form.

3. "Affiliate Member" shall mean a Member appointed to the Affiliate Category of the Medical Staff as described in Article II, Section 3 of the Bylaws.

4. "AHPs" or "Allied Health Professionals" shall mean the individuals who are trained and qualified in allied health disciplines as described in Article II, Section 5 of the Bylaws and the Rules and Regulations.

5. "Applicant" shall mean an individual who has submitted an application to become a Member of the Medical Staff.

6. "Associate Member" shall mean a Member appointed to the Associate Category of the Medical Staff as described in Article II, Section 2 of the Bylaws.

7. "Board" shall mean the Board of Directors of Fishemien's Health, Inc.

8. "Bylaws" shall mean the Medical Staff Bylaws.

9. "Category One" shall have the meaning ascribed in the Credentials Manual.

10. "Category Two" shall have the meaning ascribed in the Credentials Manual.

11. "Clinical Privileges" shall mean the authorization granted by the Board to a Member, Practitioner or AHP to provide specific care, treatment and services in the Hospital or in its facilities in accordance with the process set forth in the Credentials Manual.

12. "Clinical Section Chief(s)" shall mean the elected chief(s) of the Clinical Section of Medicine and/or the Clinical Section of Surgery and any other Clinical Section created by the MEC in accordance with the Organization Manual.

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13. "Clinical Sections" shall mean the Clinical Section of Medicine and the Clinical Section of Surgery of the Medical Staff

14. "Credentials Committee" shall refer to the Credentials Committee described in Section 1.1 of the Credentials Manual.

15. "Credentials Manual" shall mean the Credentials Procedure Manual of the Medical Staff

16. "Department" shall mean a department of the Hospital.

17. "Honorary Member" shall mean a Member appointed to the Honorary Category of the Medical Staff as described in Article II, Section 4 of the Bylaws.

18. "Hospital" shall mean Fishermen's Health, Inc. d/b/a Fishermen's Community Hospital"

19. "Investigations Manual" shall mean the Investigations/ Corrections/ Hearings/ Appeal Manual of the Medical Staff

20. "Joint Conference Committee" shall refer to the Joint Conference Committee described in Section Article VII of the Bylaws, which is comprised of the Chairperson, Vice Chairperson, Treasurer and Secretary of the Board of Directors of the Hospital and the Officers of the Medical Staff

21. "Manuals" shall mean the Credentials Manual, the Investigations Manual and the Organization Manual of the Medical Staff

22. "MEC" shall mean the Medical Executive Committee of the Medical Staff

23. "Medical Staff' shall mean the body of all physicians who are credentialed and privileged to provide care, treatment and services through the processes described in the Credentials Manual and includes both voting and nonvoting members of the organized medical staff

24. "Member" shall mean an individual admitted to the Medical Staff of the Hospital.

25. "Nominating Committee" shall mean the Nominating Committee described in Article III, Section 3 of the Bylaws.

26. "Officers" shall mean the elected officers of the Medical Staff, including the President, Vice President, Immediate Past President and the Member-At-Large.

27. "Organization Manual" shall mean the Organization and Functions Manual of the Medical Staff

28. "PAC" shall refer to the Practice Analysis Committee described in Section 2.4 of the Organization Manual.

29. "Patient Contact" shall mean an inpatient admission, observation, consultation, inpatient or outpatient surgical procedure, or consults to the Emergency Department for admission and/or surgery.

30. "Physician" shall mean a doctor of medicine, osteopathy, or podiatry who is licensed to practice medicine.

31. "Practitioners" shall mean a licensed independent practitioner and other practitioners who are permitted by law to provide care, treatment and services to patients within the scope of their respective practices.

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32. "Reappointment Applicant" shall mean an individual who has submitted a application for reappointment to the Medical Staff

33. "Rules and Regulations" shall mean the Rules and Regulations of the Medical Staff.