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.
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.
- Policy 9512 System Dress Code Policy
To provide dress and grooming standards appropriate to the work environment. To enhance the customers’ image of the organization by establishing consistent guidelines for the personal/professional appearance of Staff Members. To communicate to Staff Members that personal appearance and appropriate dress are regarded as important aspects of a Staff Member’s overall effectiveness.
- Policy 12702 Scribes in Banner Health Facilities
To define the role and scope of Scribes in Banner Health Facilities.
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.
- 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).
- Policy 2400 HIPAA: Disclosures of Protected Health Information (PHI) to Family Members and Persons Involved in an Individual’s Care
This policy identifies the circumstances in which 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. It also allows disclosures of Protected Health Information (PHI) to disaster relief organization to assist in notifying family and friends.
- 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
- 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).
- 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.
- 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.
- 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.
- 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.
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Policy 13607 Ongoing Professional Practice Evaluation
To define a process to evaluate the performance of all Providers on an ongoing basis.
- 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.
- Policy 9171 Pain Management
Patient reports or exhibits behaviors that indicate a safe and acceptable level of comfort.
- 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.
- 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.
- Policy 9542 – Safe Surgery Policy
The purpose of this policy is 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 – Vaginal Birth Sponge, Sharps, and Instruments Count Policy
Eliminate unintentionally retained foreign objects following a vaginal delivery.