Meetings of the medical staff

(a) Meetings that include the medical staff shall be held at least monthly to review, analyze, and evaluate the clinical work of its members. (1) The number and frequency of these meetings shall be determined by the active staff and clearly stated in the bylaws of the staff. (2) Attendance requirements for each individual member of the staff and for the total attendance at each meeting shall be clearly stated in the bylaws of the staff, and attendance records shall be kept. (3) Adequate minutes of all meetings shall be kept. (4) The method adopted to insure adequate evaluation of clinical practice in the hospital shall be determined by the medical staff, e.g. quality improvement meetings, meetings of medical records and tissue committees in which clinical practice is discussed and evaluated and reports made to the active staff, active staff meetings, etc., and shall be clearly stated in the bylaws. (b) Minutes of such meetings shall provide evidence of the following: (1) A review of the clinical work done by the staff on at least a monthly basis according to policies established by the medical staff to monitor clinical activities. (2) Discussion of agenda items, such as committee reports received. (3) Names of members and staff present. (4) Duration of meeting.