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Successful applicants for Medical Staff appointment must provide evidence of:

•     Current license to practice Medicine or Dentistry in the Commonwealth of Kentucky;

•     Current valid federal drug enforcement registration certificate (if applicable to his/her practice   and privileges requested);

•     Successful completion of an ACGME, AOA or ADA accredited residency program. Dentists and oral surgeons must have graduated from an approved school of dentistry and satisfactorily completed an approved postgraduate training program of at least one year;

•     Effective March 18, 1981, ABMS, American Board of Oral and Maxillofacial Surgery or AOA  board certification or qualification in the specialty area appropriate to the privileges requested.  Board qualified specialists must achieve board certification within five (5) years of eligibility/qualification.  All members of the Baptist Health Lexington Medical Staff must maintain active board certification or pursue active board certification as specified.

•    All members whose board specialties require recertification will be required to maintain certification.  If a certification is expired you will have three (3) years to achieve certification from January 28, 2005.

•    Effective January 28, 2005, members who have expired certifications in their specialty and who are still eligible for recertification, must achieve board certification within three years of January 28, 2005.

•    If the medical board certification of the medical staff member expires, it is the medical staff member’s responsibility to notify the Medical Staff Office.   

•    Failure of a staff member to meet recertification requirements will be reevaluated by the Medical Executive Committee upon the recommendation of the Credentials Committee.

•    Failure of a medical staff member to meet recertification requirements may result in loss of staff privilege.

•    Prior and current clinical practice experience and competence to perform privileges requested, clinical results and utilization practice patterns documenting continuing ability to provide patient care services at an acceptable level of quality and efficiency;

•     Good reputation and character, mental, physical, and emotional stability, and ability to work with and relate well to others, to the extent required by the provisions of these bylaws;

•     Ability to read, write and understand the English language and to prepare medical record entries and other documentation in a legible manner;

•     Professional liability insurance of a type and in an amount established by the Governing Body; and

•     Lack of any sanctions for misuse of Medicare/Medicaid funds.



Regardless of staff category, all staff members with Clinical Privileges must:

A.        Provide timely and continuous care to their patients.

B.         Complete patients' medical records as specified in rules governing patient records, including factors of timeliness, legibility and accurate content.

C.         Be subject to the rules and regulations of the Clinical Service Department(s) in which privileges are held, and to the authority of the MEC and Governing Body, through the chair of the service department to which the individual is assigned with relevant input of other service department chairs.

D.        Participate in development of physician-specific non-economic performance data, including quality practice, accessibility, and attitude, and shall respond to reasonable suggestions, if properly presented by individuals with authority in the organized medical staff or their designees.

E.        Respond to reasonable requests to perform necessary Medical Staff organizational  functions, such as serve as physician analyst.

F.         Cooperate with procedures for renewing Clinical Privileges every two years.

G.        Follow bylaws, rules, and procedural guidelines.

H.        Participate in the on-call coverage of the emergency services and other coverage programs as requested or determined by the specific service department chair or the Medical Executive Committee.

I.          Observe and comply with Baptist Healthcare System's standards of conduct as set forth in the Corporate Responsibility Program.

In case of an emergency, any staff member, to the degree permitted by his license and regardless of staff status or Clinical Privileges, shall be permitted, but not required to assist in the care of the patient.

For the purposes of this provision, "emergency" refers to a condition in which serious or permanent harm might result to a patient, or in which the life of a patient might be in immediate danger, in the event of delay in administering treatment.