Section 107.26. Additional committees

(a) There shall be such additional committees as are necessary to organize and conduct the operations of the medical staff. All rules and proceedings of any additional committees shall be permanently recorded and kept available for inspections by members of the medical staff and the governing body.

(b) The following additional committees are mandatory:

(1) A credentials committee which shall make recommendations for staff appointments and reappointments, promotions, demotions, and clinical privileges. The credentials committee shall be advisory and investigative and shall report to the executive committee of the medical staff.

(2) A tissue committee, which shall review and evaluate surgery performed in the hospital when there is a disagreement among the preoperative, post-operative, and pathological diagnoses, or where a question of the acceptability of the procedure undertaken has been raised. The tissue committee shall meet at least once monthly, and its reports should be made available to the medical care evaluation committee.

(3) A medical records committee or its equivalent, which shall supervise the maintenance of medical records at the required standard of completeness. The medical records committee shall recommend for discipline any member of the medical staff whose medical records practices fail to conform with necessary record keeping requirements. The medical records committee shall have at least four meetings annually.

(4) A medical care evaluation committee.

(5) A pharmacy-therapeutics committee in accordance with § 113.5 (relating to pharmacy and therapeutics committee).

(6) A radiation safety committee.

(7) A bylaws committee.

(8) Such other committees as the medical staff deems appropriate.

(c) Committees may be labeled other than in subsection (b), and functions of committees may be combined, provided that all functions are appropriately performed.

The provisions of this § 107.26 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial pages (37801) and (37802).

Notation

Authority

The provisions of this § 107.26 issued under 67 Pa.C.S. § § 6101—6104; and Reorganization Plan No. 2 of 1973 (71 P. S. § 755-2).

Cross References

This section cited in 28 Pa. Code § 107.12 (relating to content of bylaws, rules and regulations); and 28 Pa. Code § 115.34 (relating to medical records review).