Resources & Orientation

Banner System Policies

Banner Health system policies are located on the Employee Website. You can search the Policies and Procedures Database, located in the right hand navigation of the Home page, by policy number.

If a non-employed physician needs to access a policy, he or she can only access the Policies & Procedure database from within a Banner Health facility. The physician can use a generic computer and bring up the employee website from Internet Explorer. On the right side of the home page under Systemwide Links, click on Policies & Procedures, select the facility, enter either the policy number or a keyword in the keyword field and click Search. The policy can be opened by clicking on the policy title.

Policy 678 HIMS: Medical Record Documentation
To provide general guidance to support accurate and complete medical record documentation in all Banner system clinical applications defined on the Banner Health EHR map.

Policy 3174 Workforce Confidentiality
Banner Health (BH) has a legal and ethical responsibility to safeguard Confidential Information. The purpose of this policy is to establish confidentiality obligations for BH Workforce including employees, professional/medical staff, volunteers, and students (non-BH employees)

Policy 2400 HIPAA: Disclosures of Protected Health Information (PHI) to Family Members and Persons Involved in an Individual's Care
To identify the circumstances in which Banner Health (BH) personnel may disclose Protected Health Information to a Individual’s family member, relative, friend, or other person the Individual identifies as being involved in the Individual’s care. 

Policy 2795 EMTALA - Medical Screening Examination and Stabilization Treatment
To ensure compliance with Emergency Medical Treatment and Active Labor Act (“EMTALA”) and related laws and requirements

Policy 2859 EMTALA – Qualified Medical Personnel Authorized to Perform Medical Screening Examinations 
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).

Policy 2861 Compliance: Excluded Staff Professionals and Disallowed Doctors
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 (Banner) 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 Banner facility does not submit any claim to any Stark Related Programs for such services.

Policy 4585 Guidelines for Patients with Barriers to Communication
To provide appropriate communication for patients, their legally authorized representative, and other individuals whom the patient authorizes, who have barriers to communication. This service is available free of charge to patients, their legally authorized representative, and other individuals whom the patient authorizes

Policy 9495 Compliance: Federal and State Exclusion Review
To establish an initial and recurring federal/state exclusion screening process at Banner Health, including all of its subsidiaries and affiliates, excluding Sonora Quest Laboratories (collectively, “Banner”), to prevent hiring or entering into a relationship with an Ineligible Person or Entity and to identify persons or entities that have become or have been notified of their ineligibility after they are employed or have entered into a relationship with Banner

Policy 13458 HIPAA: Patient Photography, Videotaping, and Other Visual Imaging in the Cliinical Setting for Treatment or Training
To protect the privacy of patients and provide guidance to staff when obtaining a patient photograph for treatment or training.

Policy 13740 Influenza Vaccination of Health Care Personnel
The purpose of this policy is to decrease the risk of transmitting the influenza virus to patients, staff, and visitors and to comply with applicable laws and regulations.

Policy 2863 Indemnification for Claims Arising from Medical Staff Activities
The purpose of this policy is to indemnify 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.

Policy 5872 Sharing of Peer Review Information
In the interest of patient safety and welfares, and to ensure that the exchange of specified, practitioner-specific Peer Review Information among Banner Hospitals where the affected practitioner has (or has applied for) privileges, or is employed, is done in a manner designed to preserve confidentiality and statutory privileges and is consistent with state peer review/quality improvement laws.

Policy 9063 Disclosure: Communication and Optimal Resolution of Unanticipated Outcomes
To promote safe patient care through candid empathetic communication and accomplish timely resolution for patients or their Legally Authorized Representative in response to an Unanticipated Outcome.

Policy 9642 Arizona - Access to Confidential Strategic and Business Information by Medical Staff with Significant Adverse Relationships
To ensure 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.

Policy 1514 Western Region - Access to Confidential Strategic and Business Information by Medical Staff with Significant Adverse Relationships
To ensure 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.

Policy 13606 Medical Staff Focused Professional Practice Evaluation
The purpose of this policy is to define a process to evaluate performance of all Providers when 1) newly appointed, 2) new privileges are requested, or 3) when there is a question regarding a currently privileged Provider’s ability to provide safe, high quality patient care

Policy 13607 Medical Staff Ongoing Professional Practice Evaluation
The purpose of this policy is to define a process to evaluate the performance of all Providers on an ongoing basis.

Policy 1331 For Cause Drug and Alcohol Testing for the Medical or Allied Health Staff 
The purpose of this policy is: 1. To safeguard the health of providers, ensure patient safety, and provide a safe work environment for all caregivers in the Medical Center. 2. To direct staff who suspect that a physician or allied health professional might be working while impaired.

Policy 12419 Provision of Appropriate End of Life Care (Allowing Natural Death)
Provide a framework for the provision of appropriate end of life (EOL) care including withholding/withdrawal of life sustaining treatment/technology (LST) in compliance with legal and ethical standards of care.

Policy 9171 Pain Management
Patient reports or exhibits behaviors that indicate a safe and acceptable level of comfort.

Policy 12414 Restraint Use for Non-Violent and Violent Situations
To ensure that the use of Restraint or Seclusion promotes patient safety, rights, dignity and well-being in accordance with applicable federal and state regulations.

Policy 9542 – Safe Surgery Policy
To standardize safe practices to ensure correct patient, correct procedure, and the correct procedural site/side for procedures performed in the all operating rooms and labor and delivery rooms.

Policy 12688 – Counts: Sponge, Sharp and Instrument
Counts are performed to account for items and to prevent injury to a patient as a result of retained surgical items.

Policy 12698 – WIS-Vaginal Birth Sponge, Sharps and Instruments Count Policy
Eliminate unintentionally retained foreign objects following a vaginal delivery.

Get the latest health tips!

Sign up for our healthy living newsletter