MECs, Board post changes for review by Jan. 25

Regulatory changes to Rules and Regulations

The Salem Hospital and West Valley Hospital Medical Executive Committees (MEC) and Board of Trustees approved regulatory changes to the Salem Hospital and West Valley Hospital Rules and Regulations as detailed below. These changes were effective Dec. 16, 2025.

The Medical Staff Bylaws allow regulatory changes without advanced Medical Staff posting prior to MEC and Board approval. As part of the process, changes are to be posted and available to the Medical Staff for feedback and questions within a reasonable timeframe following the approval and are to be posted for 14 days for feedback and questions.

Send questions, concerns or feedback to matthew.boles@salemhealth.org no later than Sunday, Jan. 25.

Approved and implemented revisions to the Salem Hospital and West Valley Hospital Rules and Regulations:

Added definitions:

• “Emergency Department (ED) Provider” means Members of the Medical Staff with clinical privileges in Emergency Medicine.
• “Medical Screening Examination” the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether an individual has an Emergency Medical Condition or not, as defined in the “Emergency Medical Treatment-Screening, Stabilization, and Transfer (EMTALA)” policy, the Medical Screening Examination is not an isolated event – it is an on-going process that begins, but typically does not end, with triage.
• “Mental Health (MH) Evaluation (MHE)” means a structured evaluation performed by Qualified Medical Personnel, as part of the Medical Screening Examination. The MHE assesses a person’s emotional, psychological, and behavioral functioning, including, but not limited to, behavioral health and neurocognitive evaluation. For patients with homicidal/suicidal, or assaultive behavior that indicates danger to self or others, an evaluation will include an automated order for a consult with a Behavioral Health Clinician.

Revised Article IX – Part D: Emergency Medical Services, as indicated in red.

(1)          Emergency services and care shall be provided to any person in danger of loss of life or serious injury or illness whenever there are appropriate facilities and qualified personnel available to provide such services or care.  Such emergency services and care shall be provided without regard to the patient’s race, ethnicity, religion, national origin, citizenship, age, gender, gender identity, sexual orientation, , pre-existing medical condition, physical or mental handicap, insurance status, economic status or ability to pay for medical services, except to the extent such circumstance is medically significant to the provision of appropriate care to the patient.

(2)          Medical Screening Examinations, within the capability of the Hospital, will be performed on all individuals who come to the hospital requesting examination or treatment to determine the presence of an emergent medical condition. Qualified Medical Personnel, which includes ED Providers, are qualified to perform a Mental Health Evaluation, as part of their Medical Screening Examination, for patients with behavioral health symptoms.

At West Valley Hospital only:

In addition to the above revisions, the following was struck from Article IX – Part D: Emergency Medical Services as Qualified Medical Personnel at West Valley Hospital as they do not provide OB services.

Labor and Delivery:

(1)          Members of the Medical Staff with OB privileges.

(2)          Registered Nurses who have completed a Labor and Delivery departmental orientation/competency program may perform the initial medical screening in accordance with Labor and Delivery Policies and Procedures.