BY-LAWS

OF

THE MEDICAL STAFF OF THE

GWINNETT HOSPITAL SYSTEM

Revised: October 14, 2014

Approved By MEC: October 14, 2014
Approved by the Board: October 27, 2014
 TABLE OF CONTENTS

DEFINITIONS ...............................................................................................................................4

ARTICLE I - PURPOSE ...............................................................................................................4

ARTICLE II - BASIC STEPS FOR APPOINTMENT, REAPPOINTMENT, AND THE

GRANTING OF CLINICAL PRIVILEGES ..................................................................5
Qualifications for Appointment ........................................................................................5
Process for Appointment, Reappointment, and the Granting of Clinical Privileges ...5

ARTICLE III - CLASSIFICATIONS..........................................................................................5

The Medical Staff ...............................................................................................................5
Honorary Staff ...................................................................................................................5
Consulting Staff..................................................................................................................5
Active Staff .........................................................................................................................6
Courtesy Staff .....................................................................................................................7
Provisional Staff .................................................................................................................7
Administrative Staff ..........................................................................................................7
Non-Admitting Staff ..........................................................................................................8

ARTICLE IV - DEPARTMENTS ................................................................................................8

Clinical Departments .........................................................................................................8
Administrative Departments .............................................................................................8
Organization of Departments ...........................................................................................8
Services................................................................................................................................9

ARTICLE V - OFFICERS AND COMMITTEES .....................................................................9

Officers ................................................................................................................................9
Executive Committee .......................................................................................................10
Other Committees ............................................................................................................12

ARTICLE VI - MEETINGS .......................................................................................................13

General Meetings .............................................................................................................13
Department Meetings ......................................................................................................13
Special Meetings ...............................................................................................................13
Attendance Requirements ...............................................................................................13
Quorum .............................................................................................................................13

ARTICLE VII - PRACTITIONER RIGHTS ...........................................................................14

ARTICLE VIII - ADOPTION AND AMENDMENT OF BYLAWS .....................................16

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ARTICLE IX - OTHER RECOGNIZED PRACTITIONERS ...............................................17

ARTICLE X - HISTORY AND PHYSICAL EXAMINATION..18

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 MEDICAL STAFF OF THE
GWINNETT HOSPITAL SYSTEM

DEFINITIONS

1. The Term "Medical Staff" shall mean the organized Medical Staff of the Gwinnett Hospital
System, consisting of all physicians, podiatrists, and dentists who have current appointments
to membership on the medical staff of Gwinnett Hospital System in accordance with Article
II.

2. The term "Governing Body" shall mean the Board of Directors of the Gwinnett Hospital
System.

3. The term "Hospitals" shall mean the licensed facilities comprising the Gwinnett Hospital
System.

4. The term "member" shall mean any individual having a current appointment to the Medical
Staff.

5. The term "Executive Committee" shall mean the Executive Committee of the Medical Staff.

7. The term Medical Staff Year shall refer to a Calendar Year starting January 1 and ending
on December 31.

ARTICLE I
PURPOSE

The purpose of this organization shall be:

1. To provide all patients of the Gwinnett Hospital System with quality care;

2. To provide a means by which problems of governance may be discussed by the Medical Staff
with the Administration and Governing Body of the Hospital;

3. To provide a framework to initiate and maintain rules and regulations and policies related to
the Medical Staff;

4. To provide for continuing education.

5. To act in the furtherance of the goals of the Gwinnett Hospital System and to meet the
necessary requirements of licensing and accreditation agencies.

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 ARTICLE II
BASIC STEPS FOR APPOINTMENT, REAPPOINTMENT AND PRIVILEGING

The details associated with the following Basic Steps are contained in the Credentialing
Policy.

Section 1. Qualifications for appointment

To be eligible to apply for initial appointment or reappointment to the Medical Staff or
for the grant of clinical privileges, an applicant must demonstrate current active Georgia
License and appropriate education, training, experience, current clinical competence,
professional conduct and ability to safely and competently perform the clinical privileges
requested as set forth in the Credentialing Policy.

Section 2. Process for appointment, reappointment, and the granting of clinical privileges
Application forms that meet the criteria and requirements of the Credentialing Policy are
transmitted to the applicable department chief, who prepares a written report to the
Credentials Committee, which then prepares a recommendation and forwards it along
with the department chiefs report to the Executive Committee for review and
recommendation and to the Board for final action.

ARTICLE III
CLASSIFICATIONS

Section 1. The Medical Staff

The Medical Staff shall be divided into Honorary, Consulting, Active, Courtesy, Provisional,
Administrative, and Non-Admitting classifications.

Section 2. The Honorary Medical Staff

The Honorary Medical Staff shall be appointed directly by the Governing Body upon
recommendation of the Executive Committee and shall consist of outstanding physicians and
dentists who by their past performance in the Gwinnett Hospital System are considered
worthy of an emeritus position on its Medical Staff. The Honorary members are not eligible
to vote or hold office and shall not admit or consult on any patients. They shall have no
clinical privileges and shall be exempt from maintaining professional liability insurance.
They shall have no assigned duties relating to the educational program or care of staff
patients. They may request transfer to the Consulting Staff, but must first provide evidence
of meeting the requirements as established by the credentialing policies of the Medical Staff.

Section 3. The Consulting Medical Staff

The Consulting Medical Staff shall consist of those physicians and dentists of recognized
professional ability who have rendered outstanding service to the Gwinnett Hospital System.
They shall have either: (1) served on the Active Staff for a period of twenty-five (25) years;
or (2) served on the Active Staff at least ten (10) years and shall have reached the age of sixty
(60) years; or (3) can no longer fulfill Active Staff Responsibilities due to physical

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 limitations.

The Consulting Staff members, when requested, shall give consultation. They may also be
requested to make special contributions to the educational program, when appropriate, but
will have no regular assignments on rotation in the care of inpatients or outpatients.
Consulting Staff members shall not be eligible to vote or hold office. Membership on the
Consulting Medical Staff does not preclude membership on the Active Staff. Those
physicians and dentists eligible to transfer to the Consulting Staff may, at their request,
remain on the Active Staff on a year to year basis, but may at their pleasure, request transfer
to the Consulting Staff.

Section 4. Active Staff

Subsection 1.
The Active Medical Staff shall consist of those qualified physicians and dentists having
private patients in the Hospital and who assume the responsibility for the educational
program, care of staff cases, and the administrative affairs of the Medical Staff. Physicians
and dentists shall be eligible to request Active Medical Staff privileges following satisfactory
completion of the initial provisional appointment period. Members of the Active Staff shall
be eligible to vote and to hold office.

Subsection 2.
The Active Staff shall assume the following duties and Responsibilities:
a. They shall be responsible for the medical care of inpatients, outpatients, or emergency
patients as assigned to them by the Chief of their department.

b. They shall be encouraged to attend and participate in departmental and general Medical
Staff meetings; the frequency and attendance requirements of departmental meetings shall be
determined at the discretion of each department.

c. They shall participate in peer review, performance improvement, and committees of the
Medical Staff as requested by the Chief of the department or the President of the Medical
Staff.

d. Active Staff physicians and dentists who admit or consult on from one to eleven (11)
inpatient/outpatient admissions per medical staff year shall be automatically transferred to
the Courtesy Staff. Exceptions may be made for illness or other reasons and for non-
admitting members of the Medical Staff as approved by the Executive Committee.

e. They shall be required to accept responsibility for emergency room calls and inpatient care
at the hospitals of the Gwinnett Hospital System in which they practice for the entire
specialty which they actively practice in this or any other community or hospital, and for
which they have professional liability insurance.

Section 5. Courtesy Staff

The Courtesy Staff shall consist of those physicians and dentists who qualify for other staff
categories and who wish only to occasionally attend private patients in the Hospital. Their
department shall be assigned at the time of appointment. They shall have no Responsibilities

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 relating to the educational program. A Courtesy Staff member shall not be required to attend
meetings in accordance with Article VI. He shall be required to fulfill assignments as given
by the Chief of his department, and shall have privileges commensurate with his
qualifications. Courtesy Staff members must admit or consult on from one (1) to eleven (11)
inpatient/outpatient admissions in one (1) medical staff year. To exceed this threshold, they
must request and be advanced to the Active Staff. Courtesy Staff members who do not admit
or consult on any patients in a medical staff year shall be automatically transferred to the
Non-Admitting Staff. Courtesy Staff members shall not be eligible to vote or hold office.
Physicians and dentists shall be eligible to request Courtesy Medical Staff privileges upon
satisfactory completion of the initial provisional appointment period.

Section 6. Provisional Staff

Subsection 1.
All initial appointments to the Medical Staff shall be to the Provisional Staff for a period of
one (1) year. Following an appropriate release from established monitoring requirements, the
provisional member must assume responsibility on the Emergency Department Call Roster as
assigned by the Department Chief if their admission volume exceeds eleven (11) in a medical
staff year. Provisional members who do not meet this volume may request placement on the
Emergency Department Call Roster following release from departmental monitoring
requirements. Provisional Staff shall be eligible to vote if in attendance at a medical staff
meeting. Provisional Staff shall not be eligible to hold office.

Subsection 2.
Provisional staff members shall be assigned to a department where their performance shall be
observed by the Chief of the Department or his appointed representative to determine the
eligibility of such provisional members for advancement and for exercising the clinical
privileges provisionally granted to them. Forty-five days prior to the end of the provisional
appointment period, the member shall submit an application for reappointment, indicating an
advancement request to either the Active or Courtesy Staff, or Non-admitting Staff. The
application shall be as outlined in Article II, Section 2. At the end of the provisional period,
the Chief of the Department shall forward a recommendation for advancement to regular
staff or termination of staff appointment to the Executive Committee. A provisional
appointee whose membership is so terminated shall have the rights accorded by these Bylaws
to a member who has failed to be reappointed.

Section 7. Administrative Staff

The Administrative Medical Staff shall consist of those physicians and dentists who meet the
basic qualifications for medical staff membership set forth in Article II, and whose
professional activities consist solely of performing administrative duties for Gwinnett
Hospital System and for its affiliates. The Administrative Staff members are not eligible to
vote or hold office and shall not admit or consult on any patients. They shall have no
clinical privileges and shall have no assigned duties relating to the care of patients.

Section 8. Non-Admitting Staff

Non-Admitting Staff shall consist of those physicians and dentists who wish to refer patients
to the Gwinnett Hospital System, but who do not have admitting privileges. Once their
patients have been admitted by a practitioner with admitting privileges, the Non-Admitting

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 staff member may follow that patient and consult with the attending. The non-admitting staff
member does not retain responsibility or authority for the independent treatment of these
patients. At no time shall the Non-admitting staff member take full responsibility for the
comprehensive care of a patient. All orders written by a Non-admitting staff member must
be co-signed by the admitting physician within 24 hours. A Non-admitting staff member
may give outpatient orders pursuant to Medical Staff Policies: Provider Orders and Non-
Staff Referring Physicians. They cannot write admission orders from the Emergency Room.
They shall have no responsibilities relating to the educational program. A Non-Admitting
Staff member shall not be required to attend meetings in accordance with Article VI. Non-
Admitting Staff members shall be limited to consult on up to five (5) inpatient/outpatient
admissions in one (1) medical staff year. To exceed this threshold, they would automatically
be advanced to the Courtesy Staff. Non-Admitting Staff members shall not be eligible to
vote or hold office except for members of the Department of Family Medicine. Non-
Admitting Staff Members of the Department of Family Medicine may vote on matters that
pertain only to the Department of Family Medicine, including the officers of the Department.
If the Chief of the Department of Family Medicine is a member of the Non-Admitting staff,
he/she shall be a full member of the Medical Executive Committee and may vote on all
matters before the MEC and Medical Staff. Physicians and dentists shall be eligible to
request Non-Admitting Staff privileges upon satisfactory completion of the initial provisional
appointment period.

Section 9. The Resident Physician Staff

The Resident Physician Staff is composed of those physicians participating in a Graduate
Medical Education Program (GME Program) at the Hospital. Resident Physician Staff
members may apply for Active/Active Provisional Staff membership in their final year of
residency in anticipation of meeting all requirements for application pursuant to the Medical
Staff Credentialing Policy, Article 2.A.1. Members of the Resident Physician staff may not
vote or hold office. Resident Physicians shall be selected and credentialed pursuant to GME
Program and Medical Staff Policies and shall be authorized to carry out those duties and
responsibilities pursuant to policies of the GME Program under the supervision of designated
GME Program faculty who are members of the Medical Staff. Resident Physicians may
write orders to include admission status orders but will be required to be under supervision as
required by accrediting body requirements and GME policies on resident physician
supervision. Resident Physicians may admit patients to hospital services but will do so under
the name of a responsible faculty member. Resident Physicians may participate in Medical
Staff meetings, but not as voting members. They may be assigned to be active medical staff
committee members however.

ARTICLE IV
DEPARTMENTS

Section 1. Clinical Departments

Clinical Departments of the Medical Staff shall be as follows: Medicine, Surgery, OB-GYN,
Orthopaedic Surgery, Pathology, Radiology, Pediatrics, Emergency Medicine, Family
Medicine, and Anesthesia.

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Section 2. Administrative Departments
Subsection 1.
Oral/Maxillofacial Surgery and Dentistry. The Department of Oral/Maxillofacial Surgery
and Dentistry shall be an organized segment of the Active Medical Staff. The members of
this department shall be accorded privileges and responsibilities in the various clinical
departments which shall be assigned in accordance with their experience and training on
recommendation of the Executive Committee. In any service in which a dentist shall have
privileges, he shall be subject to the jurisdiction of its Chief and also the Chief of the
Department of Oral/Maxillofacial Surgery and Dentistry.

Section 3. Organization of Departments

Subsection 1.
Each department shall have a Chief appointed by the Governing Body after considering
recommendations from the members of the Department. The Chief of each clinical
department shall be a member of the Active Staff of that department. In the Department of
Family Medicine, the Chief of the Department may be a member of the Non-Admitting Staff.
If the Chief of the Department of Family Medicine is a member of the Non-Admitting staff,
he/she shall be a full member of the Medical Executive Committee and may vote on all
matters before the MEC and Medical Staff. All Department Chiefs shall be certified through
their respective American specialty board or shall have established comparable competence
as board certification within their specialty. Department officers shall serve a two year term
and shall be eligible for re-election, but department chiefs in those departments having
sufficient members, shall not serve more than two (2) consecutive terms. A change in Chief
may be recommended by the Executive Committee to the Governing Body at any time such
change is deemed necessary for more efficient management of the Department.

The following departmental officers shall be elected in odd-numbered years: Medicine,

OB/GYN, Pathology, Pediatrics, and Anesthesia. The following departmental officers shall
be elected in even-numbered years: Orthopaedic Surgery, Surgery, Radiology, Emergency
Medicine, , and Oral/Maxillofacial Surgery. Each department shall elect their new officers
approximately six months prior to the expiration of the term of office of the current officers
in order that the newly elected officers may begin to orient themselves and participate in
formal educational opportunities regarding their medical staff leadership responsibilities.
Newly elected officers shall take office beginning January 1; officers-elect may assume
partial responsibilities of their office prior to January 1 at the discretion of the current
department chief and only following an adequate training period.

Succession of departmental officers unable to fulfill their term shall be as outlined in the
Medical Staff Leadership Plan.

Subsection 2.
Duties of Chief of Clinical and Administrative Departments. Each chief of a clinical
department shall have the Responsibilities as outlined in the Medical Staff Leadership Plan.

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Section 3. Services
Particular services and/or departments may have an appointed leader such as a Medical
Director or Physician Service Line Coordinator who shall serve upon appointment.
Administration, in consultation with the Medical Staff President, shall make such
appointments with specific responsibilities to be defined in written agreements as established
in accordance with regulatory and accreditation standards as well as operational needs of the
organization.

ARTICLE V
OFFICERS AND COMMITTEES

Section 2. Executive Committee

Subsection 1.
The Executive Committee shall consist of the officers of the Medical Staff, the immediate
past President of the Medical Staff, the chief of each department, the Chairman of the
Credentials Committee, and the Chairman of the Ethics Committee, the Director of Graduate
Medical Education, the Medical Director of the Critical Care Service, the Medical Director
of the Trauma Service, and the Medical Director of the Hospital-employed Hospitalist Group
(or, with the approval of the Medical Staff President, the Medical Directors delegate). If the
Medical Director of the hospitalist group is a member of the Executive Committee by virtue
of another appointed or elected position, the associate Medical Director of the Program shall
represent the Hospitalist program as a voting member. If the Chief of the department is
elected an officer of the Medical Staff, the Vice Chief of the department shall represent the
department as a voting member of the Executive Committee. At the discretion of the
Executive Committee, representatives from other corporations comprising the Gwinnett
Health System may attend the committee meetings without vote. The President and CEO
and the Chief Nurse Executive of the Hospital System or their designee shall be ex-officio,
non-voting members of the Executive Committee.

Subsection 2.
The President of the Medical Staff shall call and preside at all meetings of the Medical Staff.
He shall be the Chairman of the Executive Committee of the Medical Staff, and shall be an
ex-officio member of all committees unless provisions to the contrary are made. He shall
consult with the Chiefs of each department and the President of the Hospital as often as
necessary to effect a maximum correlation of professional work and administrative programs
of the Hospital.

Subsection 3.
The Vice President of the Medical Staff shall preside at all meetings of the Medical Staff in
the absence of the President. He shall be the Vice Chairman of the Executive Committee of
the Medical Staff, and in the Chairman's absence shall preside at meetings of the Executive
Committee. If for any reason the President of the Medical Staff is unable to complete his
term of office, the Vice President shall succeed the President for the remainder of that term
with the approval of the Governing Body. The Vice President shall also serve as the
Chairman of the Medical Performance Improvement Committee.

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 Subsection 4.
The Secretary of the Medical Staff shall be Secretary of the Executive Committee. In the
absence of the President and Vice President, the Secretary shall preside at all meetings. The
Secretary shall also serve as the Chairman of the Continuing Medical Education Committee.

Subsection 5.
The Governing body may remove any officer after receiving such a recommendation by
majority vote of the Executive Committee. The Medical Staff may remove any officer by
petition of 25% of the Active Medical Staff and a subsequent majority vote by ballot of the
Active Staff present and voting at a general staff meeting called for such a purpose. Removal
from office shall be for failure to conduct those responsibilities assigned within these bylaws
or other policies and procedures of the Medical Staff.

Subsection 6.
Succession of officers unable to fulfill their term shall be as outlined in the Medical Staff
Leadership Plan.

Section 2. Executive Committee

Subsection 1.
The Executive Committee shall consist of the officers of the Medical Staff, the immediate
past President of the Medical Staff, the chief of each department, the Chairman of the
Credentials Committee, and the Chairman of the Ethics Committee, and the Medical Director
of the Hospital-employed Hospitalist Group (or, with the approval of the Medical Staff
President, the Medical Directors delegate). If the Medical Director of the hospitalist group
is a member of the Executive Committee by virtue of another appointed or elected position,
the associate Medical Director of the Program shall represent the Hospitalist program as a
voting member. If the Chief of the department is elected an officer of the Medical Staff, the
Vice Chief of the department shall represent the department as a voting member of the
Executive Committee. At the discretion of the Executive Committee, representatives from
other corporations comprising the Gwinnett Health System may attend the committee
meetings without vote. The President and CEO and the Chief Nurse Executive of the
Hospital System or their designee shall be ex-officio, non-voting members of the Executive
Committee.

Subsection 2.
The Executive Committee shall receive and act on reports and recommendations from
medical staff departments, medical staff committees, and Administration and shall approve
and bi-annually review medical staff policies and medical staff leadership documents not
otherwise reviewed by a standing committee of the medical staff. The Executive Committee
is empowered to act for the Medical Staff in the intervals between medical staff meetings.
The Executive Committee shall serve as a liaison for communication among the medical
staff, hospital administration, and the governing body.

The Executive Committee is also responsible for making recommendations directly to the
Governing Body for its approval; such recommendations shall include:
a. The structure of the Medical Staff;

Board Approved October 2014 11

 b. The mechanism used to review credentials for appointment and reappointment and
to delineate individual clinical privileges;
c. Recommendations of individuals for Medical Staff membership;
d. Recommendations for delineated clinical privileges for each eligible individual;
e. The participation of the Medical Staff in organizational PI activities of the Medical
Staff as well as the mechanism used to conduct, evaluate, and revise such activities;
f. The mechanism by which membership or privileges on the Medical Staff may be
restricted or terminated;
g. The mechanism for fair hearing procedures;
h. Recommendations on all matters concerning patient care services within the
Hospitals.

Whenever a decision of the Governing Body is contrary to a recommendation of the

Executive Committee, the Executive Committee may request that the matter be referred to a
special committee (the "Joint Committee") comprised of the officers of the Governing Body,
the officers of the Medical Staff, and the President and Chief Executive Officer of Gwinnett
Hospital System, Inc. for further review and recommendation within thirty (30) days. The
request shall be in writing, signed by an officer of the Medical Staff, and delivered to the
Chairman or the President and Chief Executive Officer within five days of the Governing
Body's decision. If the Executive Committee requests further review and recommendation by
the Joint Committee as provided herein, the matter shall be reconsidered by the Governing
Body and a final decision by the Governing Body shall not be made until the Joint
Committee's recommendation has been received. At its next meeting following receipt of the
Joint Committee's recommendation, the Governing Body shall make its final decision.

Subsection 3.
The Executive Committee shall meet monthly. Meetings may be called by the President of
the Medical Staff or on request of no less than three (3) members of the Executive
Committee and only in extreme emergencies should less than forty-eight (48) hours notice be
given to each member of the Committee. A quorum shall be one-half of the number of
members of the Committee, and the majority of the members present shall be required to take
a recommended action on any matter.

Section 3. Other Committees

Subsection 1.
The President of the Medical Staff shall, in consultation with the Executive Committee and
the President of the Hospital, appoint annually from the roster of the Active Staff, those
committees and committee members that are required by licensing and accrediting bodies
and as he deems in the best interest of the Hospital. Where necessary, the President of the
Medical Staff may designate a Vice Chairman of the committee.

Subsection 2.
Standing committees of the Medical Staff shall include the following:

a. Credentials Committee
The Credentials Committee shall review and make recommendations to the Executive
Committee on completed applications for appointment and reappointment to the Medical
Staff in accordance with established credentialing policies. Applications shall be submitted
to the Office of Medical Staff Services. The Office of Medical Staff Services shall ascertain
that the application is complete and is processed in accordance with established policies.

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 The Credentials Committee shall meet monthly.

b. Medical Performance Improvement Committee

The Medical Performance Improvement (PI) Committee shall conduct or coordinate quality,
appropriateness, and improvement activities of the Medical Staff and of multidisciplinary
functions of the Hospitals. The committee shall be chaired by the Vice President of the
Medical Staff and shall be composed of the Vice Chief of each Medical Staff department and
representatives from designated medical staff functions. The committee shall meet at least
eight times annually, preferably two months of every three, and shall govern their activities
in accordance with established PI plans and policies and procedures of the Hospitals and
Medical Staff.

c. Ethics Committee
The Ethics Committee Board shall provide an optional forum to anyone involved with, or
impacted by, the care rendered to a patient and shall review all research projects involving
human subjects to ensure that the rights, health, and welfare of human subjects are protected.
The activities of the committee shall include education regarding ethical issues, dilemmas,
and clinical investigations, consultation to those who request assistance, and development
and maintenance of policies related to the committee's responsibilities. The committee shall
meet as often as necessary and shall be comprised of representatives of the medical staff, the
hospital staff, and the community. Medical Staff membership determinations shall be made
by the Medical Staff President. Other members shall be appointed by the committee
chairman in coordination with the President of the Hospitals.

d. Continuing Medical Education Committee

The Continuing Medical Education (CME) Committee shall provide education regarding
activities, new developments or technology, and other perceived needs and shall oversee the
Hospital's professional library services. The committee shall be chaired by the Secretary of
the Medical Staff and shall meet as often as necessary to conduct its required functions as
established by medical staff policy.

e. Cancer Committee
The Cancer Committee shall plan, initiate, stimulate, and assess the results of the cancer
activities at Gwinnett Medical Center. The committee shall meet at least quarterly with a
tumor conference to be held at least weekly. The chairman of the committee shall be
appointed by the President of the Medical Staff; the appointed chairman of the committee
shall appoint its members. Membership shall include representation from the following
disciplines: surgery, medical oncology, radiation oncology, radiology, pathology, physician
cancer liaison, administration, nursing, social services, cancer registry, quality assurance,
pain control/palliative care physician or specialist, clinical research representative, and
genetic professional/counselor. The Cancer Committee is responsible for the breast Program
Leadership Committee.

f. Other Committees
The President of the Medical Staff may appoint medical staff liaisons for multidisciplinary
functions to interface with standing committees of the medical staff and to convene
multidisciplinary meetings and/or committees, as necessary. The President may also
establish other committees as may, from time to time, be necessary to accomplish the
functions of the Hospitals and the Medical Staff. Physician membership determinations shall
be made by the Medical Staff President. Other members shall be appointed by the appointed

Board Approved October 2014 13

 medical staff liaison in coordination with the President of the Hospitals.

ARTICLE VI
MEETINGS

Section 1. General Medical Staff Meetings

The Annual Meeting of the Medical Staff shall be in October of each calendar year. At this
meeting, the retiring officers and committee chairmen shall make such reports as may be
desirable. Medical Staff officers shall be elected at a general staff meeting to be held in April
of the year in which the officers' terms expire.

Section 2. Department Meetings

Each clinical department is encouraged to hold meetings at least on a quarterly basis. A
quorum for department meetings shall be considered from those members present and voting.
Minutes of the departmental meetings are to be maintained and forwarded regularly to the
Executive Committee.

Each clinical department shall establish a PI Committee which shall meet monthly, unless
otherwise determined by the Department Chief and Vice Chief, and forward their reports
regularly to the Medical Staff PI Committee. A quorum for the PI Committee shall be those
members present and voting. The Vice Chief of the department shall serve as the Chairman
of the Department PI Committee. The Chief of the department shall serve as a member and
shall appoint the other members of the committee.

Section 3. Special Meetings

Special meetings of the Medical Staff, Executive Committee, or any standing or special
committee of the Medical Staff may be called at any time by the President of the Medical
Staff or at the request of a majority of the Executive Committee. At a special called meeting,
no business shall be transacted except that stated in the call. Notice of any special meeting
shall be given at least forty-eight (48) hours before the meeting.

Section 4. Attendance Requirements

Members of the Medical Staff are encouraged to attend meetings of the general medical staff,
the departments, and assigned committees. Members of the Credentials Committee and the
Executive Committee are expected to attend at least 50% of the meetings held.

Section 5. Quorum
A quorum at any regular or called meeting of the medical staff, its departments and
committees, except the Executive Committee, shall be defined as those members present and
voting after being given at least one (1) week advance notice of the meeting.

ARTICLE VII
PRACTITIONER RIGHTS

Section 1.
Each member of the Medical Staff has the right to an audience with the Executive
Committee. In the event that a practitioner is unable to resolve a difficulty working through

Board Approved October 2014 14

 his or her department chief, the practitioner may, upon presentation of a written request, meet
with the Executive Committee to discuss the issue.

Section 2.
Any practitioner has the right to initiate a recall election of a medical staff officer and/or
department chief. A petition for such recall must be presented, signed by at least 25% of the
members of the Active Staff for recall of a medical staff officer or at least 25% of the
members of the Active Staff of the respective department for recall of a department chief.
Upon presentation of such valid petition, the Executive Committee will schedule a general
staff meeting or the department will schedule a department meeting for purposes of
discussing the issue and, if appropriate, entertain a no confidence vote.

Section 3.
Any practitioner may call a general staff meeting upon presentation of a petition signed by
25% of the members of the Active Staff. The Executive Committee shall schedule a general
staff meeting for the specific purpose addressed by the petitioners. No business other than
that in the petition may be transacted at such a called meeting.

Section 4.
Any practitioner may raise the challenge or propose an amendment to any rule or policy
established by the Executive Committee. In the event that a rule, regulation, or policy is felt
to be inappropriate, any physician may submit a petition signed by 25% of the members of
the Active Staff. When such a petition has been received by the Executive Committee, the
Executive Committee shall either 1) provide the petitioners with information clarifying the
intent of such a rule, regulation, or policy and/or 2) schedule a meeting with the petitioners to
discuss the issue.

Section 5.
Any group of physicians may establish a specialty section of the department. Any such
section, if established, shall not be required to hold any specified number of regularly
scheduled meetings. Attendance shall not be required.

Section 6.
Details for the following basic steps are contained in the Credentialing Policy. Following
an investigation, the Executive Committee may recommend suspension or revocation of
appointment or clinical privileges based on concerns about exercise of privileges in a
manner detrimental to patient safety or quality of patient care; failure to satisfy
qualifications or fulfill applicable responsibilities; violation of the bylaws, policies, Rules
and Regulations of the Hospital or the Medical Staff; or conduct that is disruptive to the
orderly operation of the Hospital or Medical Staff.

Whenever failure to take action may result in imminent danger to the health and/or safety
of any individual, the President of the Medical Staff, the chief of the relevant clinical
department, the Executive Committee, the CEO, or the CMO is authorized to suspend or
restrict all or any portion of an individuals clinical privileges, or afford the individual an
opportunity to voluntarily refrain from exercising privileges, pending an investigation. A
precautionary suspension or restriction is effective immediately and will remain in effect
unless it is modified by the Executive Committee. The individual shall be provided a
brief written description of the reason(s) for the action within three business days. The
Executive Committee will review the reasons within 14 days. The individual will be

Board Approved October 2014 15

 given an opportunity to meet with the Executive Committee or subgroup.

Medical Staff status and exercise of privileges shall be automatically relinquished if an

individual (a) fails to satisfy medical records requirements as provided in the Rules and
Regulations, or threshold eligibility criteria pursuant to the Credentialing Policy; provide
requested information; or attend a special conference to discuss issues or concerns; (b) is
convicted, or pleads guilty or no contest pertaining to any felony, or to any misdemeanor
involving (i) controlled substances; (ii) illegal drugs; (iii) Medicare, Medicaid, or
insurance or health care fraud or abuse; or (iv) violence; or (c) makes a misstatement or
omission on an application form.

Automatic relinquishment shall take effect immediately and shall continue until the
matter is resolved.

Section 7.
Any physician has the right to a hearing/appeal pursuant to the Gwinnett Hospital System's
Hearing and Appeal Procedures of the Credentialing Policy, in the event that any of the
following actions are taken or recommended:

a. denial of initial appointment to staff status;

b. denial of reappointment;
c. suspension of staff status for more than 30 days (other than precautionary);
d. revocation of staff status;
e. denial of requested clinical privileges;
f. reduction in clinical privileges
g. restriction of clinical privileges, meaning a mandatory concurring consultation
requirement, in which the consultant must approve the course of treatment in
advance;
h. suspension of clinical privileges for more than 30 days (other than precautionary);
i. revocation or termination of clinical privileges;
j. non-reinstatement of staff status or clinical privileges after a leave of absence if the
reasons relate to professional competence or conduct; or
k. revocation of staff status or privileges.

The hearing will begin no sooner than 30 days after the notice of the hearing, unless an
earlier date is agreed upon. The Hearing Panel will consist of at least three members.
The hearing process will be conducted in an informal manner and formal rules of
evidence or procedure will not apply. A stenographic reporter will be present to make a
record of the hearing. Both sides will have the following rights, subject to reasonable
limits: to call and examine witnesses, to the extent they are available and willing to
testify; to introduce exhibits; to cross-examine any witness on any matter relevant to the
issues; to have representation by counsel who may call, examine, and cross-examine
witnesses and present the case; and to submit written memoranda. The personal presence
of the individual who requested the hearing is mandatory. If he or she does not testify, he
or she may be called and questioned. The Hearing Panel may question witnesses, request
the presence of additional witnesses, and/or request documentary evidence. The affected
individual may request an appeal of the recommendations of the Hearing Panel to the
Board. Details associated with these Basic Steps are contained in the hearing and
appellate review plan.

Board Approved October 2014 16

 ARTICLE VIII
REVIEW, REVISION, ADOPTION, AND AMENDMENT OF THE BYLAWS

Section 1. Medical Staff Responsibility

The Medical Staff shall have the responsibility to formulate, review periodically, adopt, and
recommend to the Governing Body a set of medical staff bylaws and amendments thereto
which shall be effective when approved by the Governing Body. Such responsibility shall be
exercised in good faith and in a reasonable, responsible, and timely manner. This applies as
well to the review, adoption, and amendment of the related rules, policies, and protocols
developed to implement various sections of these bylaws.

Section 2. Methods of Adoption and Amendment

All proposed amendments whether originated by the Executive Committee, a standing
committee of the medical staff, or by a member of the Active Staff must be reviewed and
discussed by the Executive Committee prior to any vote.

a. The Executive Committee, after a majority vote, provided that the proposed amendment was
distributed to the members of the Active Staff at least 21 days prior to an Executive Committee
vote, may recommend a proposed amendment to the Board. The Executive Committee's
recommendation may be acted upon by the Board unless more than 10% of the Active Staff
members object by returning a written ballot, noting such objection. If greater than 10% of the
Active Staff members object to a proposed amendment, the President of the Medical Staff or the
Executive Committee shall schedule and hold a general staff meeting, at which time the proposed
amendment shall be presented, discussed, and acted upon. The affirmative vote of a majority of
those Active Staff members present and voting is required for passage.

b. Amendments may also be presented to the members of the Active Staff by petition of 25% of
the members of the Active Staff. The Executive Committee may provide its comments and
recommendations on amendments proposed by petition, along with a written ballot, or the
Executive Committee may convene a general staff meeting.

c. The Executive Committee shall have the power to adopt such amendments to the bylaws as are in
the committee's judgment technical or legal modifications or clarifications, reorganization or
renumbering, or amendments needed because of punctuation, spelling or other errors of grammar
or expression, or amendments needed to comply with regulatory requirements. Such amendment
shall be effective when approved by the Governing Body and shall be communicated to the
medical staff prior to enactment.

d. Such amendment(s) shall be approved by the Governing Body or its authorized agent prior to
becoming effective.

Section 3. Related Protocols and Manuals

The Executive Committee shall recommend for approval by the Governing Body a
credentials policy manual, a fair hearing plan and appellate review manual and a medical
staff leadership plan. Other such policies and manuals that further define general matters
relating to medical staff administrative functions shall be approved by the Executive
Committee subject to the right of challenge by petition by 25% of the members of the Active
Staff. Once approved, these materials will be available to members of the Medical Staff for

Board Approved October 2014 17

 reference.

ARTICLE IX
OTHER RECOGNIZED PRACTITIONERS

Through processes described in separately established credentialing policies and procedures not a
part of these bylaws but approved by the Executive Committee, the Gwinnett Hospital System shall
recognize other categories of practitioners who may be granted clinical privileges to perform limited
functions in the areas of patient care within the Gwinnett Hospital System. These categories of
practitioners may include but are not limited to Independent Mental Health Professionals, Affiliate
Staff members, Non-Physician Practitioners, and Non-Staff Referring physicians. None of these
individuals shall be considered members of the Medical Staff and shall not be afforded the rights and
privileges afforded physicians in these bylaws.

ARTICLE X

The required content and quality of history and physical examinations, as well as the time frames
required for completion, are set forth in the Medical Staff Rules and Regulations.

ADOPTED BY THE BOARD OF DIRECTORS ON AFTER RECEIPT OF A

RECOMMENDATION FROM THE MEDICAL STAFF.

Board Approved October 2014 18