10A NCAC 13B .3705 MEDICAL STAFF BYLAWS, RULES OR REGULATIONS
(a) The active medical staff shall develop and adopt, subject to the approval of the governing body, a set of bylaws, rules or regulations, to establish a framework for self governance of medical staff activities and accountability to the governing body.
(b) The medical staff bylaws, rules and regulations shall provide for at least the following:
(1) organizational structure;
(2) qualifications for staff membership;
(3) procedures for admission, retention, assignment, and reduction or withdrawal of privileges;
(4) procedures for fair hearing and appellate review mechanisms for denial of staff appointments, reappointments, suspension, or revocation of clinical privileges;
(5) composition, functions and attendance of standing committees;
(6) policies for completion of medical records and procedures for disciplinary actions;
(7) formal liaison between the medical staff and the governing body;
(8) methods developed to formally verify that each medical staff member on appointment or reappointment agrees to abide by current medical staff bylaws and facility bylaws; and
(9) procedures for members of medical staff participation in quality assurance functions.
History Note: Authority G.S. 131E-79;
Eff. January 1, 1996.