MEDICAL STAFF BYLAWS YUMA REGIONAL MEDICAL CENTER YUMA, ARIZONA DEFINITIONS 1. The “Medical Staff" is that group of medical professionals who have been granted appointment by the Board of Directors. 2. The "Board of Directors" (Board) is the group responsible for conducting the ordinary business affairs of Yuma Regional Medical Center (YRMC), and unless otherwise stated, shall be deemed to act through the authorized actions of the officers of the corporation and the President/Chief Executive Officer of YRMC. 3. The “President/Chief Executive Officer" (CEO) is the individual appointed by the Board to act on its behalf in the overall management of YRMC and includes a duly appointed Acting Administrator serving in the absence of the CEO. The Medical Staff may rely upon all actions of the CEO as being the actions of the Board. 4. The “Vice President of Medical Affairs/Chief Medical Officer” (VPMA/CMO) is the individual appointed by the CEO and acts principally as liaison between the medical staff and administration. 5. The "Member" is any professional appointed to, and maintaining membership in any category of the Medical Staff in accordance with these bylaws. 6. The "Patient" is any person undergoing diagnostic evaluation or receiving medical treatment under the auspices of YRMC. 7. The "Allied Health Professional" is an individual, not a member of the Medical Staff or a hospital employee, who is trained in some aspect of the evaluation or treatment of patients and who is allowed, after Board approval, to perform specified services at YRMC. 8. The "Joint Conference" is a meeting between three (3) representatives of the Board appointed by the Chairperson of the Board of Directors and three (3) Medical Staff members appointed by the Chief of Staff who will submit their recommendations to the Board. ARTICLE I. PURPOSE The purpose of the YRMC Medical Staff is to bring its members together into an organized body to promote high quality patient care. To this end, among other activities, it will assist in screening applicants for staff membership, review privileges of members, evaluate and assist in improving the quality of care, in providing education, and in offering advice to the CEO and Board. These Bylaws with the accompanying policies, rules and regulations establish the framework for self-governance of the Medical Staff activities and accountability to the Board. ARTICLE II. MISSION The mission of the Medical Staff is to continually improve the medical care provided at YRMC while assisting the CEO and Board in improving the health care services available to the community.

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ARTICLE III. MEDICAL STAFF MEMBERSHIP SECTION 1. MEDICAL STAFF MEMBERSHIP Appointment to the Medical Staff of YRMC shall be extended to those individuals who continuously meet the qualifications, standards and requirements set forth in these bylaws and associated policies of the Medical Staff and YRMC. SECTION 2.

QUALIFICATIONS FOR MEMBERSHIP

A. In order to qualify for membership, an individual must hold a license to practice in the State of Arizona, and be a Doctor of Medicine, Doctor of Osteopathy, Doctor of Dental Surgery, Doctor of Medical Dentistry, or Doctor of Podiatric Medicine. In addition, applicants must fulfill the requirements set forth in the associated policies on credentialing and privileging as well as maintain compliance with state and federal regulations. B. No individual may be entitled to membership on the Medical Staff or to exercise particular clinical privileges at YRMC merely by virtue of licensure to practice in this or any other state, membership in any professional organization, or privileges at another hospital. C. Exceptions to the above may be made at the discretion of the Board with the concurrence of the Medical Executive Committee (MEC). SECTION 3.

NONDISCRIMINATION

YRMC will not discriminate in granting staff appointment and/or clinical privileges on the basis of age, sex, race, creed, national origin, or affiliation with other medical institutions. SECTION 4.

CONDITIONS AND DURATION OF APPOINTMENT

A. Initial appointments and reappointments to the Medical Staff shall be made by the Board. The Board shall take such action only after there has been a recommendation from the Department Chair, Medical Staff Credentials Committee and the MEC in accordance with the provisions of these bylaws. B. Appointments to the staff will be for no more than two years. SECTION 5.

STAFF DUES

Medical Staff dues shall be governed by the most recent action recommended by the MEC and adopted by the Medical Staff. SECTION 6.

RESPONSIBILITIES OF MEMBERSHIP

Each staff member shall: A. Direct the care of his/her patients and will supervise the work of any Allied Health Professional under his/her direction. B. Assist the Medical Staff in maintaining compliance with state and federal laws as well as other regulatory agencies.

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C. Act in an ethical, professional manner and treat employees, patients, visitors, and other staff members in a dignified and courteous manner. SECTION 7.

CONFLICT RESOLUTION

Resolution of conflict between members of the Medical Staff or between members of the Medical Staff and hospital personnel shall be handled in a professional and nonthreatening manner. Details of formal conflict resolution are addressed in detail in the Medical Staff Organization Procedures and Policies Manual (MSOPP). ARTICLE IV. CATEGORIES/STATUSES OF THE MEDICAL STAFF SECTION 1. THE ACTIVE CATEGORY Qualifications: Appointees to this category shall live within the Yuma area and meet such criteria deemed appropriate by the MEC after giving consideration to a particular appointee’s real or intended activities. Prerogatives: Appointees to this category may: A. Exercise such clinical privileges as are granted by the Board. B. Vote on all matters presented by the Medical Staff or any Department or committee of which he or she is a member. C. Hold office as a Medical Staff leader, unless otherwise specified elsewhere in these Bylaws. Responsibilities: Appointees to this category must: A. Participate in the organization and administrative affairs of the Medical Staff as assigned by the Chief of Staff, MEC, other Medical Staff Officers, or Department Chairs. B. Participate in fulfilling requirements of the Medical Staff with respect to quality improvement, risk management, monitoring activities, and discharging other responsibilities as may be required. C. Assist the hospital in meeting its obligation to provide emergency medical services in accordance with federal and state laws. SECTION 2. THE AFFILIATE CATEGORY Qualifications: Appointees to this category either live outside the Yuma area or do not practice at YRMC in a manner which requires such appointees to assume responsibilities as a member of the Active staff, but they may possess skills and knowledge the MEC identifies as critical for the hospital to achieve its mission. Appointees to this category must meet such criteria deemed appropriate by the MEC after giving consideration to a particular appointee’s real or intended activities. An appointee to this category may not hold office. Prerogatives: Appointees to this category may: A. Exercise such clinical privileges as approved by the Board. B. Attend meetings of the Medical Staff without vote.

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C. Attend Medical Staff or hospital education programs. Responsibilities: Appointees to this category must: A. Participate in committees or task forces consistent with their expertise as requested by the Department Chair, MEC or Chief of Staff. B. Assist the hospital in its obligation to provide emergency medical services in accordance with federal and state law unless exempted by the MEC. SECTION 3. THE EMERITUS CATEGORY Qualifications: Any member of the Medical Staff who has served as a full active member for equal to or greater than 20 years. Others may qualify by recommendation of the department and approval of MEC. Prerogatives: Appointees to this category may: A. Exercise such clinical privileges as are granted by the Board. B. Vote on all matters presented by the Medical Staff or any Department or committee of which he or she is a member. C. Hold office as a Medical Staff leader, unless otherwise specified elsewhere in these Bylaws. Responsibilities: Appointees to this category must: A. Participate in the organization and administrative affairs of the Medical Staff as assigned by the Chief of Staff, MEC, other Medical Staff Officers, or Department Chairs. B. Participate in fulfilling requirements of the Medical Staff with respect to quality improvement, risk management, monitoring activities, and discharging other responsibilities as may be required. SECTION 4.

THE HONORARY STATUS

This status is restricted to those individuals the Medical Staff and Board wish to honor for their prior services to the hospital and community, and appointment to this status is entirely discretionary. Appointees to this status are no longer eligible for clinical privileges, and a reappointment process is not necessary. Physicians with Honorary status are not required to maintain licensure, malpractice, TB attestation or other requirements imposed by medical staff membership. They may attend Medical Staff Meetings, continuing medical educational activities, but they shall not be able to vote or hold office. SECTION 5. LEAVE OF ABSENCE STATUS Members of the Medical Staff may apply for a leave of absence and their privileges will be held in abeyance for a period not to exceed one year, renewable under appropriate conditions for one additional year. Reinstatement of staff privileges may be requested through the Chief of Staff without formal reapplication, if the period of leave has not exceeded four months, and the member’s regular period of appointment has not been exceeded. Leave of absence in excess of four months must be requested with concurrence of the MEC and Credentials Committees. Leave of absence status may not be used to bypass the normal reappointment process as outlined. Other stipulations regarding a leave of absence are detailed in the policies for

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Credentialing and Privileging. Minimum leave of absence period is 45 days unless waived by Chief of Staff for short-term emergencies. Reinstatement must be requested in writing. SECTION 6. TEMPORARY ADMINISTRATIVE LEAVE OF ABSENCE STATUS The Chief of Staff may offer a temporary administrative leave of absence not to exceed 72 hours to any Medical Staff member as outlined in the MSOPP. SECTION 7. GRADUATE MEDICAL EDUCATION/HOUSESTAFF PHYSICIAN STATUS A. Definition – A Housestaff Physician is an intern, resident, or fellow who is enrolled in an accredited ACGME or AOA training program. Housestaff physicians are not members of the YRMC Medical Staff. B. Qualifications – The Housestaff Physician must meet the qualifications for eligibility outlined in the Essentials of Accredited Residencies in Graduate Medical Education, of the American Medical Association Graduate Medical Education Directory, or the AOA Directory of Approved Internships and Residencies and have a training permit as described in A.R.S. 32-1432.03 or a valid Arizona License to practice medicine. C. Competence and Supervision – The competence of the Housestaff Physician shall be evaluated on a regular basis through their accredited training program, which is responsible for maintaining a record of the status and competence of each housestaff physician. The Housestaff Physician must have all activities supervised by an appropriately credentialed Attending Physician in accordance with the Medical Staff Bylaws as outlined in the POLICY ON HOUSESTAFF AND ATTENDINGS: PATIENT CARE ACTIVITIES AND SUPERVISION RESPONSIBILITIES. Supervision must meet the standards described in the ACGME or AOA institutional and program requirements. D. Graduate Medical Education Office Registration – All Housestaff seeing patients at YRMC must register with the Graduate Medical Education Office, receive and wear an identification badge, receive mandatory in-service education and meet requirements as deemed necessary for the orderly functioning of the Hospital and safe patient care. ARTICLE V. OFFICERS SECTION 1.

OFFICERS OF THE MEDICAL STAFF

The elected Officers of the Medical Staff shall be: A. Chief of Staff B. Vice Chief of Staff C. Officer of Physician Relations SECTION 2.

QUALIFICATIONS OF OFFICERS

Officers must be members of the Active or Emeritus Medical Staff at the time of nomination and election, and must remain members in good standing during their terms of office. No officer will serve more than two terms consecutively. SECTION 3.

ELECTION OF OFFICERS

A. Officers shall be elected at a meeting of the general Medical Staff held during the last quarter of the calendar year. Notice of officer elections will be given at least 30 days before the meeting. A letter shall be sent to every staff member, announcing the meeting, the

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nominees, and advising each member that he/she may vote either during the upcoming election meeting, or before the meeting in Medical Staff Services. Voting by mail or fax is permitted so long as the written ballot is authenticated by the signature of the member casting the vote. The signature of the voting member shall be removed from the ballot before it is delivered for counting under subsection (C). To be valid, a ballot must be received by Medical Staff Services no later than noon on the date set for the meeting. All ballots submitted by mail or fax are final and may not be changed or withdrawn after receipt by Medical Staff Services. Only members of the Active or Emeritus Staff shall be eligible to vote. B. A Nominating Committee, consisting of at least five people, three of whom are not members of the MEC, shall be appointed by the MEC. This committee shall offer one or more nominations for each office. A member of the Active or Emeritus Medical Staff may nominate him/herself 35 days prior to election, by notification to the Nominating Committee. C. During the meeting for election of officers, the vote will be taken by secret, written ballot. Ballots will be counted by a designee of the Chief of Staff or the Officer of Physician Relations and Medical Staff Services personnel in an area selected by the Chief of Staff. The counting of the ballots shall be overseen by the Vice Chief of Staff or his/her designee. All ballots, including those cast by mail or fax before the meeting, shall be counted at the end of the meeting. Any member may cast a ballot anytime before the meeting is adjourned. Once cast, a ballot is final and may not be changed or withdrawn. D. The votes will not be counted and registered until the meeting is adjourned. The candidate who receives the most votes for his/her nominated position will be the winner. In the event of a tie, a revote will be taken; and members will have until noon 14 calendar days later to register their vote with Medical Staff Services. The votes will again be counted by a designee of the Chief of Staff or by the Officer of Physician Relations and Medical Staff Services personnel. The Vice Chief of Staff or his/her designee will oversee the count. In the event of a further tie, the winner will be determined by lot. SECTION 4.

TERM OF OFFICE

All officers shall take office on the first day of the calendar year, unless that date is within 30 days of the election, in which case he/she shall assume office 30 days from the date of election. The term of office shall be two years, and may be extended for 30 day intervals under extenuating circumstances. SECTION 5.

VACANCIES IN OFFICE

If there is a vacancy in the office of the Chief of Staff, the Vice Chief of Staff shall serve the remainder of the term and shall be eligible to serve another two terms as Chief of Staff if the vacated term does not exceed one year. A vacancy in the office of Vice Chief of Staff or Officer of Physician Relations shall be filled by a vote of the MEC. SECTION 6.

DUTIES OF OFFICERS

A. The Chief of Staff shall call, preside at, and be responsible for the agenda of all meetings of the general Medical Staff, and meetings of the MEC. He/she shall serve as a voting member of the Board. All other duties are delineated in the MSOPP. B. The Vice Chief of Staff shall be a voting member of the Medical Staff Credentials Committee, a voting member of the MEC, and serve as an ex-officio member of the Board. In the

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temporary absence of the Chief of Staff, he/she shall assume all the duties and have the authority of the Chief of Staff. All other duties are delineated in the MSOPP. C. The Officer of Physician Relations will serve as a liaison to the general Medical Staff and shall be a voting member of the MEC, and an ex-officio member without vote of all other staff committees. In the absence of the Chief of Staff and Vice Chief of Staff, the Officer of Physician Relations shall assume all the duties and have the authority of the Chief of Staff. All other duties are delineated in the MSOPP. SECTION 7. INITIATION OF RECALL ELECTION AND REMOVAL OF OFFICERS Any member of the Active or Emeritus Medical Staff has the right to initiate a recall election of a Medical Staff Officer. Petition for such recall must be presented and signed by at least 25% of the members of the Active and Emeritus Staff. Upon presentation of such valid petition to Medical Staff Services, the MEC will schedule a Special Meeting (see Article VIII, Section 2, B) for the purposes of discussing the issue within 20 days, and if appropriate, vote for removal by ballot at such meeting. Approval for removal requires a two thirds vote. If the removal vote is approved, a general election shall be carried out. Written nominations must be received in Medical Staff Services within seven days, and election within 30 days from that date. SECTION 8. RECALL ELECTION OF A DEPARTMENT CHAIR Any member of a department has the right to initiate a recall election of a department chair. A petition of such recall must be presented and signed by at least 25% of the members of that department. Upon presentation of such valid petition to Medical Staff Services, the department will schedule a staff meeting of the department for the purpose of discussing the issue; and, if appropriate, obtain a no confidence vote. ARTICLE VI. DEPARTMENTS SECTION 1. ORGANIZATION OF DEPARTMENTS The Medical Staff shall be organized into departments. Each department shall have an elected chair with overall responsibility for the supervision and satisfactory discharge of assigned functions of the department. Each Department Chair, or designee, has voting rights and representation on the MEC. Optional Sections Any group of physicians may organize itself into a section. Any section, if organized, will not be required to hold any number of regularly scheduled meetings. Activities of sections are outlined in the MSOPP. SECTION 2.

QUALIFICATIONS, SELECTION AND TENURE OF DEPARTMENT CHAIRS

Each department shall elect a Chair. Each member holding a Department Chair shall: A. Be a member of the Active or Emeritus Medical Staff who practices a specialty that is relevant to the overall services provided by that department, and this is to be determined by the MEC. B. Unless otherwise delineated in the Department’s Rules and Regulations, Chairs and Vice Chairs serve for a two-year term and may serve more than one term.

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C. Be board certified or determined to possess equivalent qualifications by the MEC. SECTION 3.

FUNCTIONS OF DEPARTMENT CHAIRS

The functions of department chairs are delineated in the MSOPP. SECTION 4. FUNCTIONS OF DEPARTMENTS Functions of departments are delineated in the MSOPP. ARTICLE VII. COMMITTEES SECTION 1. MEDICAL EXECUTIVE COMMITTEE (MEC) A. Composition, Removal and Voting: The MEC shall consist of the Medical Staff Officers, the Department Chairs, the Chairs of the Credentials Committee, the Quality Monitoring Committee, the CEO, and the VPMA/CMO. Members of the MEC shall serve for so long as they hold the position qualifying them for membership. A member of the MEC may only be removed if the member is removed from the position qualifying the member for membership. Only the Medical Staff Officers and the Department Chairs may vote on matters coming before the MEC. The Chief of Staff shall serve as Chair of the MEC, shall preside at all meetings, and set the agenda. B. Duties: The duties of the MEC are delineated in the MSOPP. C. Meetings: The MEC shall meet as often as necessary to conduct business and maintain a permanent record of its proceedings and actions. SECTION 2. STAFF FUNCTIONS Provision shall be made by the MEC, approved by the Board, either through assignment to the departments, to staff committees, to staff officers or officials or to multidisciplinary hospital committees, for the effective performance of the staff functions specified in the MSOPP. ARTICLE VIII. MEDICAL STAFF MEETINGS SECTION 1. REGULAR MEDICAL STAFF MEETING A. A general meeting of the Medical Staff will be held at least once during the last quarter of each calendar year. Election of officers will occur at this meeting according to the process delineated elsewhere. Written notice of the meeting shall be sent to all Medical Staff members and conspicuously posted at least 30 days in advance. B. The primary objective of the meeting shall be to report on the activities of the staff and to conduct other business as may be on the agenda. The Chief of Staff, or designee, prepares the agenda. Written minutes of the meeting shall be prepared and recorded. SECTION 2. SPECIAL MEETINGS A. The Chief of Staff may call a special meeting of the Medical Staff at any time. B. The Chief of Staff must call a special meeting within 20 days after receipt of a written request for such a meeting signed by no less than 20% of the Active and Emeritus Medical Staff. Such a request shall state the purpose of the meeting

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C. The Chief of Staff must call a special meeting upon a resolution by the MEC. resolution shall state the purpose of the meeting.

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D. Written notice stating the time, place, and purpose of any special meeting of the Medical Staff shall be sent to all members of the Medical Staff and conspicuously posted at least seven days before the meeting. E. At any special meeting, no business shall be transacted except that stated in the notice of the meeting. SECTION 3. DEPARTMENT AND COMMITTEE MEETINGS A. Committees, departments, members of specialties or subspecialties shall meet as often as deemed necessary to conduct their business. Notice of meetings shall be sent to each department/committee member. B. A meeting of a committee or department may be called by the Committee Chair, Department Chair or the Chief of Staff. C. A meeting must be called if requested by 25% of the committee or department members. Business will be conducted at the discretion of the Chair. SECTION 4. QUORUM The quorum requirements for the following meetings shall be: A. Medical Staff Meetings: Those present and voting. B. MEC: Three voting members present, except for Bylaws and procedure changes, which require a 50% quorum. C. Medical Staff Credentials Committee: Two voting members present. D. Committee/Department Meetings: Those present and voting. SECTION 5. MEETING ATTENDANCE A. Members of the Medical Staff are encouraged to attend the general Medical Staff meetings as well as the meetings of departments and committees to which they are assigned. The action of the majority of the members in attendance shall be the action of the Medical Staff, the department, or the committee, respectively, unless otherwise specified in these Bylaws. B. Members of the MEC and other Medical Staff standing committees or their respective designees are expected to attend at least 50% of the meetings held. Except for Department Chairs, committee members serve at the pleasure of the Chief of Staff. C. A member of the Medical Staff may have his/her presence requested at a department, committee, or MEC meeting, and this process is detailed in the MSOPP. SECTION 6.

ROBERT'S RULES OF ORDER

The latest edition of Robert Rules of Order shall prevail at all meetings of the general Medical Staff, MEC, and departmental meetings unless waived by vote of those present at the request of

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the Chair. In the event of employment of the Robert’s Rules of Order at a general Medical Staff Meeting, or MEC, the Officer of Physician Relations will serve as parliamentarian. SECTION 7. MINUTES Minutes will be prepared of all regular and special meetings of the general Medical Staff, the Departments, or the committees, and those minutes maintained for 10 years. The minutes shall include a record of attendance and action taken on each matter. The minutes shall be signed by the presiding officer of each meeting. ARTICLE IX. PRACTITIONER RIGHTS SECTION 1.

REPRESENTATION ON MEC

In the event a practitioner is unable to resolve a difficulty working with his/her respective department chair, that physician may, upon presentation of a written notice, meet with the MEC to discuss the issue. Any physician may, upon presentation of a written notice, request an audience with the MEC to discuss any issue he/she feels is of vital importance to the Medical Staff and does not warrant discussion at a general Medical Staff meeting. SECTION 2.

PHYSICIAN RIGHTS UNDER FAIR HEARING PLAN

Any physician has a right to a hearing/appeal pursuant to the Medical Staff's Fair Hearing Plan in the event any of the following actions are taken or recommended: A. Denial of initial staff appointment; B. Denial of reappointment; C. Revocation of staff appointment; D. Denial or restriction of requested clinical privileges; E. Reduction in clinical privileges; F. Revocation of clinical privileges; G. Individual application of, or individual changes in, mandatory consultation requirement; and H. Suspension of staff appointment or clinical privileges. ARTICLE X. CONFIDENTIALITY, IMMUNITY, RELEASES Medical Staff policy on confidentiality, immunity, and releases is included in the MSOPP. ARTICLE XI. REVIEW, REVISION, ADOPTION, AND AMENDMENT OF THE BYLAWS SECTION 1.

MEDICAL STAFF RESPONSIBILITY

The Medical Staff as represented by the MEC shall have the responsibility of formulating, reviewing every two years, adopting and recommending amendments to these Bylaws of the

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Medical Staff, which shall be effective when approved by the Board. This also applies to the review, adoption and amendment of related rules, policies, and protocols developed to implement various sections of these bylaws. SECTION 2.

METHODS OF ADOPTION AND AMENDMENT

A. All proposed amendments and changes to these Bylaws, whether originated in the MEC, a department, or other committee, shall be approved by the MEC prior to distribution, and distributed to the members of the Active and Emeritus Medical Staff as soon as possible. B. All proposed amendments to these Bylaws that have been approved by a vote of the general Medical Staff will be reviewed and endorsed by a vote of the MEC and submitted to the Board for adoption. Such amendments shall be effective when approved by the Board. C. The MEC shall have the authority to adopt changes to these Bylaws which are technical or legal modifications, clarifications, errors of grammar or spelling, or structural changes in form. Such amendments shall be effective when approved by the Board. SECTION 3.

RELATED PROTOCOLS AND MANUALS

Administrative procedures associated with processes described in these bylaws for corrective actions, fair hearing and appeal, credentialing, privileging, and appointment are described in manuals, policies, and rules and regulations incorporated by reference and made a part of these bylaws or the MSOPP. All changes to such documents shall be proposed by the MEC to the Board and shall only become effective after Board approval. SECTION 4.

JOINT CONFERENCE AMENDMENT

If the Board of Directors has determined not to accept a recommendation submitted to it by the Medical Executive Committee, other than a proposed amendment to the Medical Staff Bylaws, the Medical Executive Committee is entitled to a Joint Conference. The Joint Conference shall be for purposes of further communicating the Board's rationale for its contemplated action, and to permit the Medical Staff conferees to fully articulate the rationale for the Medical Executive Committee's recommendation. Such a Joint Conference will be scheduled by the Chief Executive Officer within two weeks after receipt of a request of same submitted by the Chief of Staff of the Medical Staff. ARTICLE XII. FINAL AUTHORITY The final authority in all matters of the Medical Staff is the general Medical Staff subject to Board approval. Reviewed by Credentials Committee: 6/15/10, 7/20/10 Reviewed by Medical Executive Committee: 7/26/10 Reviewed by Medical Staff: 8/18/10 Recommendation to Forward to the Board by MEC: 8/23/10 Approved by Quality of Services: 8/30/10 Ratified by Board of Directors: 9/2/10