( b) as authorized by a Medical Staff or Hospital policy; or( c) as authorized by the CEO, CMO / VPMA, or by legal counsel to the Hospital.
Any breach of confidentiality may result in appropriate sanctions, including but not limited to a professional review action, termination of Medical Staff membership and / or privileges, or legal action. Breaches of confidentiality will not constitute a waiver of any privilege. Any member of the Medical Staff or Advanced Practice Provider Staff who becomes aware of a breach of confidentiality is encouraged to inform the CEO, CMO / VPMA, or Chief of Staff.
1. D. 2. Peer Review Protection:
Credentialing, professional practice evaluation, and peer review activities pursuant to this Manual and related policies will be performed by peer review committees in accordance with state law. These committees include, but are not limited to:
( a) all standing and ad hoc Medical Staff and Hospital committees;( b) all departments and sections( as applicable);( c) hearing and appellate review panels;( d) the Board and its committees; and
( e) any individual or body acting for or on behalf of a peer review committee, Medical Staff Leaders, and experts or consultants retained to assist in credentialing, professional practice evaluation, and peer review activities.
The protections offered under peer review are only in place when the individual( s) is acting on behalf of the Medical Staff and / or its committees within the scope of the charge as requested.
All oral and written communications, reports, recommendations, actions, and minutes made or taken by peer review committees are confidential and covered by the provisions of applicable law and are deemed to be“ professional review bodies” as that term is defined in the Health Care Quality Improvement Act of 1986(“ HCQIA”), 42 U. S. C. § 11101 et seq.
1. E. SUBSTANTIAL COMPLIANCE
While efforts will be made to comply with the provisions of this Manual, substantial compliance is all that is required. Technical or minor deviations from the procedures in this Manual do not invalidate any recommendation that is made or any review or action that is taken. The procedures in this Manual may be expanded to provide greater process or protections for an individual member.
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