28 Pa. Code § 135.11. Policies and procedures.

POLICIES

§ 135.11. Policies and procedures.

(a)  The surgical division of the medical staff, shall develop written policies and procedures for surgical services. These policies shall be made available to the medical staff and surgical nursing personnel.
(b)  The policies and procedures of the surgical services shall establish:
   (1)  Appointment procedures which will fairly evaluate the quality and competence of each surgeon seeking appointment to the surgical staff.
   (2)  Reappointment procedures which provide for the periodic reappraisal of the qualifications and competence of each surgeon.
   (3)  Criteria to determine what circumstances require an assistant present at surgery and to determine whether the assistant should be a physician, a professional, or nonprofessional personnel.
   (4)  Surgical specimens that are exempt from pathological review in §  135.15 (relating to surgical specimens).

Authority

   The provisions of this §  135.11 amended under sections 801.1 and 803 of the Health Care Facilities Act (35 P. S. § §  448.801a and 448.803).

Source

   The provisions of this §  135.11 adopted December 9, 1977, effective December 10, 1977, 7 Pa.B. 3631; amended June 9, 1989, effective June 10, 1989, 19 Pa.B. 2445. Immediately preceding text appears at serial pages (77284) to (77285).

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