Apply policies and procedures to ensure the accuracy and integrity of health data

Subdomain I.C. Data Governance

1. Apply policies and procedures to ensure the accuracy and integrity of health data

After reviewing the attached Table of Contents of Sunny View Hospital Bylaws, discuss the question below.

What is the purpose of medical staff bylaws?

Is a hospital required to have bylaws, and, if so, who requires it?

What are the main topics addressed in a medical staff bylaws? What is the importance of addressing those topics?

Bylaws Sunny View Hospital ARTICLE 6.0: EXECUTIVE MEDICAL BOARD 56 6.1: Membership .. 56 6.2: Duties of the Executive Medical Board . 58 6.3: Meetings of the Executive Medical Board . 59 ARTICLE 7.0: COMMITTEES OF THE MEDICAL STAFF . 59 7.1: Membership …. 59 7.2: Meetings . 60 7.3: Authority and Responsibility .. 60 7.4: Standing Committees . 60 7.5: Special Committees .. 64 ARTICLE 8.0: MEETINGS . 65 8.1: Annual Meeting …. 65 8.2: Special Meetings. 65 8.3: Department Meetings and Educational Conferences . 65 8.4: Voting ……. 65 ARTICLE 9.0: RULES AND REGULATIONS AND POLICIES .. 65 9.1: Rules and Regulations …. 65 9.2: Policies….. 66 9.3: Notices . 67 9.4: Conflict Management … 67 ARTICLE 10.0: AMENDMENT OF BYLAWS . 67 10.1: Amendment Procedure . 67 10.2: Interim Amendment of Bylaws 67 10.3: Technical and Editorial Amendments .. 68 ARTICLE 11.0: ADOPTION OF BYLAWS . 68 ARTICLE 12.0: CONFIDENTIALITY … 68 12.1: General … 68 12.2: Breach of Confidentiality .. 68 12.3: Immunity and Releases . 69 ARTICLE 13.0: OTHER RIGHTS AND RESPONSIBILITIES OF THE MEDICAL STAFF . 70 13.1: Legal Counsel . 70 13.2: Disputes with the Governing Body …. 70 2 |Page

Bylaws Sunny View Hospital Table of Contents PREAMBLE . UT DEFINITIONS . ARTICLE 1.0: NAME AND DESCRIPTION OF MEDICAL STAFF ORGANIZATION 1.1: Name .. 1.2: Relationship between Medical Staff, Medical Center and Medical School … 8 ARTICLE 2.0: PREROGATIVES AND PURPOSE . ARTICLE 3.0: MEMBERSHIP AND/OR CLINICAL PRIVILEGES .. 10 3.1: Eligibility and General Responsibilities of Membership and/or Clinical Privileges … 10 3.2: General Requirements for Non-Physician Members . 11 3.3: General Requirements for Medical Staff and Non-Physician Members .. 12 3.4: Waiver of Qualifications 13 3.5: General Responsibilities of Membership . 13 3.6: Categories of Membership . 14 3.7: Advanced Health Practitioners (AHP) .. 16 3.8: Leave of Absence ….. 18 3.9: Procedure for Appointment. 18 3.10: Term of Appointment. 24 3.11: Privileges … 24 3.12: Evaluation and Monitoring .. 28 3.13: Standard of Conduct .. 31 3.14: Termination or Suspension of Medical Staff Membership, Reduction of Clinical Privileges, and Other Corrective Action … 32 3.15: Fair Hearing Plan .. 41 3.16: Waiting Period After Adverse Action 51 ARTICLE 4.0: ORGANIZATION .. 53 4.1: Departments .. 53 4.2: Department Chairs . 53 ARTICLE 5.0: OFFICERS OF THE MEDICAL STAFF 55 5.1: Officers and Their Duties . 55 5.2: Election and Tenure of Offices 55 1 | Page

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