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 .
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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