( 7 ) “ RESTRICTION ” means a professional review action based on clinical competence or professional conduct which results in the inability of an individual to exercise their own independent judgment for a period longer than 14 days ( for example , a mandatory concurring consultation , where the consultant must approve the proposed procedure or treatment before privileges may be exercised , or other requirement that another physician must agree before privileges can be exercised ). Conditions built into a performance improvement plan are not considered a restriction .
1 . B . TIME LIMITS
Time limits referred to in this Manual and related bylaws , policies and manuals are advisory only and are not mandatory , unless it is expressly stated .
1 . C . DELEGATION OF FUNCTIONS
( 1 ) When a function is to be carried out by a Medical Staff Leader , a Medical Staff committee , or a member of Administration , the individual , or the committee through its chair , may delegate performance of the function to one or more designees . Any such designee must treat and maintain all credentialing , privileging , and peer review information in a strictly confidential manner and is bound by all other terms , conditions , and requirements of the Medical Staff Bylaws and related policies .
( 2 ) When a member of the Medical Staff is unavailable or unable to perform an assigned function , one or more of the Medical Staff Leaders may perform the function personally or delegate it to another appropriate individual .
1 . D . CONFIDENTIALITY AND PEER REVIEW PROTECTION 1 . D . 1 . Confidentiality :
Actions taken and recommendations made pursuant to this Manual will be strictly confidential . There should be no disclosure of any of this information ( discussions or documentation ) outside of committee meetings , except :
( a ) to another authorized individual or body and for the purpose of conducting professional review activity ;
( 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 or legal action . Breaches of confidentiality will not
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