scope:

Purpose. To provide medical staff bylaws for Department of the Navy (DON) fixed medical treatment facilities (MTF), per references (a) through (c). References (d) through (l) provide additional guidance. These bylaws constitute a framework in which medical staff members may act with a reasonable degree of freedom and confidence for self-governance of professional activities and ensure accountability to the governing body. This instruction has been completely revised and must be read in its entirety.

Applicability. This instruction applies to all active duty and Reserve military and civilian health care practitioners, as defined in reference (e), who are assigned to, employed by, contracted to, or under partnership agreement with DON activities that are required by reference (a) to seek accreditation by JCAHO under references (b) or (c). The operational forces, while exempt from the JCAHO accreditation requirement, must establish and implement comparable quality of care oversight mechanisms for operational medical units as required by references (a) and (m).