PAGE
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
4879-7702-4986 , v . 1 d