University Policy

Medical Staff

3364-87-01 Confidentiality and Access to Proceedings and Records of Peer Review Committees
3364-87-03 Medical Record Delinquency Policy
3364-87-04 Mandatory ICU Consultation
3364-87-05 Privileges for New Procedures
3364-87-06 Morbidity and Mortality Review
3364-87-07 Dissemination of Information Regarding Granting, Modification, or Restriction of Clinical Privileges
3364-87-08 Laboratory Utilization Review Committee
3364-87-09 Cancer Committee
3364-87-10 Professionalism and Prohibited Disruptive Behavior Regarding Members of the Medical Staff
3364-87-11 Credentials Committee
3364-87-13 Infection Control Committee
3364-87-14 Institutional Ethics Committee
3364-87-15 Standards for Consultation
3364-87-16 Impaired Licensed Independent Practitioners
3364-87-17 Health Information Management Committee
3364-87-19 Pharmacy and Therapeutics Committee
3364-87-20 Quality and Patient Safety Council
3364-87-21 Acutely Impaired Medical Staff Member
3364-87-22 Procedural Case Review Committee
3364-87-23 Bylaws Committee
3364-87-24 Peer Review Committee
3364-87-25 Emergency and Inpatient Coverage Responsibilities
3364-87-26 Resident Supervision
3364-87-27 Peer Review and Ongoing Professional Practice Evaluation
3364-87-29 Tissue or Hardware Removed During Surgery
3364-87-30 Review of Pathology Slides from Outside Facilities
3364-87-31 Determining When Anesthesia Services Are Necessary
3364-87-32 Medicare-Required Physician Acknowledgement Statement
3364-87-33 Physician On Schedule Call
3364-87-38 Focused Professional Practice Evaluation Policy
3364-87-42 Documentation Standards
3364-87-43 Use of Hospital Assigned DEA Numbers
3364-87-45 Escort Policy - General Anesthesia, Opioid, Sedative Administration
3364-87-90 Medical Staff Bylaws




Last Updated: 9/22/23