Jump to Home Page Jump to page copy Banner Health
Provider Orientation & Resources  

Banner System Policies

 

Learn more about:

Policy # Title Effective Date and Comments
Emergency Management
Policy 6015 Facility Emergency/Incident Code Naming Conventions
To provide Banner Health with a standardized system-wide naming convention and designation for codes used in the facilities that are not apparent based upon the name of the code. To assure that when a code is announced, staff will have a clear understanding of the emergency/incident being designated.
06/28/12
Health Care Personnel
Policy 13740 Influenza Vaccination of Health Care Personnel
To decrease the risk of transmitting the influenza virus to patients, staff, and visitors and to comply with applicable laws and regulations.
11/14/12
HIMS and HIPAA
Policy 678 HIMS: Medical Record Documentation
This policy outlines general guidance to support accurate and complete medical record documentation in all Banner system clinical applications and EMR.
09/09/12
Policy 3174

HIPAA: Confidentiality
This policy outlines Banner Health’s legal and ethical responsibility to safeguard Confidential Information and establish confidentiality obligations for BH Workforce including employees, professional/medical staff, volunteers, and students (non-BH employees).

12/23/11
EMTALA
Policy 2795

EMTALA – Medical Screening Examination and Stabilization Treatment
This policy outlines compliance with Emergency Medical Treatment and Active Labor Act (“EMTALA”) and related laws and requirements

08/12/09
Policy 2859 EMTALA – Qualified Medical Personnel Authorized to Perform Medical Screening Examinations
This policy is to designate those categories of providers who, in addition to physicians, are deemed qualified to perform medical screening examinations in order to comply with the Emergency Medical Treatment and Active Labor Act (EMTALA).
10/21/10
Compliance
Policy 2861 Compliance: Excluded Staff Professionals and Disallowed Doctors
The purpose of this policy is to assure that (a) Excluded Staff Practitioners do not provide items or services to patients enrolled in any Government Sponsored Health Care Programs and Banner Health facilities do not submit a claim for any such item or services, and (b) Disallowed Doctors do not refer any patient to the relevant Banner facility and the facility does not submit any claim to any Stark Related Programs for such services.
01/07/10
Policy 7330

Equal Employment Opportunity & Affirmative Action Policy
This policy provides guidance and establishes standards to assist Banner Health in maintaining an effective equal employment opportunity program by (i) providing equal employment and advancement opportunities to all individuals, (ii) making employment decisions based on merit, qualifications, abilities and other non-discriminatory considerations, and (iii) engaging in employment practices that are not influenced or affected by an Applicant’s or employee’s race, creed, color, religion, sex, sexual orientation, age, national origin, disability or veteran status, or other statutorily protected criteria.

12/05/07
Policy 9494 Medical Interpreter Services
This policy provides meaningful access to appropriate communication for patients, patients’ legally authorized representative(s), and other individuals whom the patient authorizes, who are Limited English Proficient (LEP) or who demonstrate Limited English Proficiency.
02/01/12
Policy 9495

Compliance: OIG/GSA Exclusion Review
This policy establishes an Initial and Recurring OIG/GSA Screening process at Banner Health to prevent hiring or entering into a relationship with an Ineligible Person.

05/29/10
Policy 13458 Patient Photography, Videotaping, and Other Visual Imaging in the Clinical Setting for Treatment or Training
This policy is to protect the privacy of patients and provide guidance to staff when obtaining a patient photograph for treatment or training and provide photo documentation when appropriate of a patient’s care during initial assessment and at scheduled intervals to monitor progress in response to treatment.
12/23/11
*Currently being revised
Policy

Code of Conduct
This policy outlines the purpose of Banner Health’s Code of Conduct and commitment to processing and demonstrating the reliability, honesty, trustworthiness and high degree of integrity expected of a leading healthcare organization and a participant in federally funded health-care programs.  This policy educates employees on the Compliance Program, Handbook and Policies including the ComplyLine contact information on identifying and resolving compliance issues or any questions.

03/13/11
Medical Staff and Peer Review
Policy 2863

Indemnification of Claims Arising from Medical Staff Activities
The purpose of this policy is to outline the indemnification of Medical Staff Members against Claims arising from their participation in Medical Staff Activities at Banner Health (BH) hospitals and surgery centers and for BH health plans in order to enable BH to comply with state and federal law and to operate BH hospitals, surgery centers and health plans.

09/15/09
Policy 5872

Sharing of Peer Review Information
This policy outlines the process in which Banner Health Hospitals ensures that the exchange of specified, practitioner-specific Peer Review Information is performed in a manner designed to preserve confidentiality and statutory privileges and is consistent with state peer review/quality improvement laws.

03/06/12
Policy 7414

Medical Staff Professional Liability Insurance Requirements
This policy outlines the Professional Liability coverage and limit requirements for all Medical Staff, Allied Health Staff and other practitioners permitted to provide care in BH facilities.

06/17/10
Policy 9063

Disclosure of Unanticipated Outcomes
This policy establishes an Initial and Recurring OIG/GSA Screening process at Banner Health to prevent hiring or entering into a relationship with This policy outlines the circumstances in which a patient or their legally authorized representatives be informed of outcomes of care including unanticipated outcomes.  n Ineligible Person.

12/14/11
Policy 9642

Access to Confidential Strategic and Business Information by Medical Staff Members with Significant Adverse Relationships
This policy ensures that Medical Staff Members with Significant Adverse Relationships do not have access to Confidential Strategic and Business Information that may be used against Banner Health, any Medical Center or other facility owned or operated by Banner Health, or the Medical Staffs of such Medical Centers and other facilities.

03/02/12
Policy 11853 Photo Identification Badges for Physicians and Allied Health Practitioners
To establish a photo identification badging process to ensure consistency of look of photo ID badges and access for providers across Banner facilities.
12/16/09
Policy 13606 Focused Professional Practice Evaluation
To define a process to evaluate performance of all providers when 1) new privileges are requested, or 2) when there is a question regarding a currently privileged provider’s ability to provide safe, high quality patient care.
02/10/12
Policy 13607 Ongoing Professional Practice Evaluation
To define a process to evaluate the performance of all Providers on an ongoing basis.
02/10/12
Patient Care
Policy 12419 Provision of Appropriate End of Life Care (Allowing Natural Death)Provide a framework for the provision of appropriate end of life care/withdrawal of life support in compliance with legal and ethical standards of care. Promote respect for the patient’s rights in the decision to withdraw/withhold life-sustaining procedures. Delineate a framework for decision-making in clinical situations in which conflicts exist relating to the initiation or continuation of medical treatment. Provide guidance to a treating physician who is contemplating the withdrawal or withholding of life-sustaining treatment of a patient, including where the patient/surrogate disagree. Define the role of physicians, nurses, clinical personnel, patients, family members, and surrogates in the decision to withdraw/withhold treatment. Provide for the inclusion of patients’ spiritual and cultural beliefs in decisions whether or not to withdraw life support or withhold treatment. 01/02/12
Restraints
Policy 12414 

Restraint Use in Non-Violent Situations
This policy outlines the circumstance in which Restraints in Non-Violent Situations are used to promote patient safety, rights, dignity and well being in accordance with applicable Federal and State regulations.

02/01/12
Policy 12415

Restraint Use in Violent Situations
This policy outlines the circumstance in which Restraints in Violent Situations are used to promote patient safety, rights, dignity and well being in accordance with applicable Federal and State regulations.

06/01/11


Jump to top links