Proposed Revisions to Medical Staff Rules/Regulations and Policies/Procedures

The Medical Staff Bylaws require that the Medical Executive Committee only act on proposed revisions to Rules/Regulations and Policies/ Procedures after the Medical Staff has had a reasonable opportunity to review and comment on the proposed revisions. In some cases, documents have not been revised. These are still required to be reviewed triennial and are marked “no revision”. Please click on the name of each policy listed below (in green) to view the entire document and revisions, if any.

  1. Policy/Procedure (no revision): Professional Practice Evaluation
  2. Policy/Procedure (no revision): Patient Attribution Plan
  3. Policy/Procedure (no revision): Crimson Site Security
  4. Policy/Procedure (no revision): Practitioner Well Being: Blood Alcohol Testing
  5. Policy/Procedure (no revision): Practitioner Well Being: Practitioner Return to Work
  6. Policy/Procedure (no revision): Practitioner Well Being: Reasonable Cause for Testing of Practitioner
  7. Policy/Procedure (revised): Practitioner Well Being: Practitioner Health Issues
  8. Policy/Procedure (revised): Professional Relations Committee
  9. Policy/Procedure (revised): Disaster Privileges
  10. Policy/Procedure (revised): Medical Staff Confidentiality
  11. Policy/Procedure (revised): Non-Medical Staff Physicians and Others Observing in Patient Care Areas
  12. Policy/Procedure (revised): Proctoring
  13. Policy/Procedure (revised): Reappointment Process
  14. General Staff Rules and Regulations (revised)

Please forward comments to the Medical Staff Services Department by email to or by fax to 310-784-8762 (Attention: Peg Mooney) no later than November 11, 2017. Comments will be summarized and provided to the Medical Executive Committee when action is taken on the proposed revisions.

Posted: October 26, 2017