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RULE 3-14
USE OF RESTRAINTS AND SECLUSION TO PROTECT PATIENTS AND OTHERS..................................................... 25
RULE 3-15 MEMBER OBJECTION WITHHOLDING / WITHDRAWING LIFE-SUSTAINING TREATMENT................................. 25
RULE 3-16 |
TREATMENT OF FAMILY MEMBERS AND SELF.................................... 26 |
A. |
AMA GUIDELINE.................................................................................... 26 |
B. |
RULE FOR MEMBERS TREATING FAMILY MEMBERS.................. 26 |
RULE 4-1 OCCURRENCE REPORTS............................................................................... 27
RULE 4-2 |
CONFIDENTIALITY OF MEDICAL STAFF RECORDS............................ 27 |
A. |
APPLICABILITY...................................................................................... 27 |
B. |
LOCATION OF RECORDS...................................................................... 27 |
C. |
ACCESS TO RECORDS........................................................................... 27 |
1. |
Access for Official Hospital or Medical Staff Functions............... 27 |
2. |
General Access by Practitioners to Medical Staff Records........... 28 |
3. |
Access by Outside Persons or Organizations................................. 28 |
D. |
SUBPOENAS............................................................................................ 29 |
RULE 5-1 ORGANIZATION AND FUNCTIONS MANUAL.......................................... 29
Section 1. Organization and Functions of the Staff............................................................ 29 1.1 Responsibilities for Medical Staff Functions............................................. 29 1.2 Description of Medical Staff Functions..................................................... 29 1.2.1 Governance, Direction, Coordination, and Action........................ 30 1.2.2 Medical Care Evaluation / Performance Improvement /
Patient Safety Activities................................................................. 31 1.2.3 Hospital Performance Improvement and Patient Safety Programs.......................................................... 31 1.2.4 Information Management............................................................... 32 1.2.5 Emergency Preparedness............................................................... 32 1.2.6 Strategic Planning.......................................................................... 32 1.2.7 Bylaws Review.............................................................................. 33 1.2.8 Nominating.................................................................................... 33 1.2.9 Infection Control Oversight........................................................... 33 1.2.10 Pharmacy and Therapeutics Functions.......................................... 34 1.2.11 Practitioner Health......................................................................... 35 1.2.12 Utilization Management................................................................. 35
Section 2. General Language Governing Committees....................................................... 36 2.1 MEC........................................................................................................... 36 2.2 Credentials Committee............................................................................... 36 2.3 Medical Staff Quality Improvement( MSQI) Committee.......................... 37 2.4 Bylaws Committee..................................................................................... 37
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