BOP Program Statement 6013.01 § 8

the Assistant Director, Health Services Division, and the

authority of the Medical Director, a National Health Services

Governing Body has been established, including these members:

a. Assistant Director, Health Services Division, Chair;

b. Medical Director;

c. Assistant Director, General Counsel and Review;

d. Assistant Director, Human Resource Management;

e. Assistant Director, Correctional Programs;

f. Assistant Director, Administration Division;

g. All Regional Directors;

h. All Medical Referral Center (MRC) Wardens; and

i. Wardens representing two non-MRC institutions.

The Bureau's Governing Body, which meets at least annually re-delegates the daily operation and decision-making authority,

regarding institution health care programs to the institution.

At the institution level, the Warden is the representative to the

National Health Services Governing Body. The institution

Governing Body, at a minimum, consists of the Warden, Associate

Warden, Clinical Director (CD), and HSA (or designees). The

union will be a member of the institution Governing Body. When

issues are discussed which may lead to discipline of staff or may

prompt an investigation into staff members, or are similarly

sensitive, these discussions will take place without the union

present. The Warden may appoint additional members to the local

Governing Body.

The local Governing Body will meet at least quarterly but

meetings may occur more frequently if deemed necessary. Among

the topics to be discussed at these meetings are:

! Appointments/Privileging/Practice Agreements of staff;

! Biomedical ethics;

! Quality improvement activities, including an assessment of

the plan;

! Risk management issues;

! Potential or actual sentinel events; and

! Other pertinent health services issues.