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.