10A NCAC 13B .3705      MEDICAL STAFF BYLAWS, Rules, and REGULATIONS

(a)  The active medical staff shall develop and adopt, subject to the approval of the governing body, a set of bylaws, rules, and 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 the following:

(1)           organizational structure;

(2)           qualifications for medical staff membership;

(3)           procedures for granting or renewing, denying, modifying, suspending, and revoking clinical privileges;

(4)           procedures for disciplinary or corrective actions;

(5)           procedures for fair hearing and appellate review mechanisms for denying, modifying, suspending, and revoking clinical privileges;

(6)           composition, functions and attendance of standing committees;

(7)           policies for completion of medical records;

(8)           formal liaison between the medical staff and the governing body;

(9)           methods developed to formally verify that each medical staff member on appointment or reappointment agrees to abide by current medical staff bylaws, rules, and regulations, and the facility bylaws, rules, policies, and regulations;

(10)         procedures for participation in quality assurance functions by medical staff members;

(11)         the process for the selection and election and removal of medical staff officers; and

(12)         procedures for the proposal, adoption, and amendment, and approval of medical staff bylaws, rules, and regulations.

(c)  Neither the medical staff, the governing body, nor the facility administration may unilaterally amend the medical staff bylaws, rules, and regulations.

(d)  Neither the medical staff, the governing body, nor the facility administration may waive any provision of the medical staff bylaws, rules, and regulations, except in an emergency circumstance. For purposes of this Rule, an "emergency circumstance" means a situation of urgency that justifies immediate action and when there is not sufficient time to follow the applicable provisions and procedures of the medical staff bylaws. Examples of an emergency circumstance include an immediate threat to the life or health of an individual or the public, a natural disaster, or a judicial or regulatory order. The duration of a waiver permitted by this Rule will be only so long as the emergency circumstance exists.

History Note:        Authority G.S. 131E-79;

Eff. January 1, 1996;

Readopted Eff. July 1, 2020.