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  • Information for New Medical Staff Members

    Welcome to the Medical Staff of University Hospitals and Health System! Certain policies, procedures and websites that most affect you as a medical staff member are listed below to assist you in your orientation to our facility.

    If you have any questions about the content below, please feel free to contact the Medical Staff Services office. We are excited to have you as part of our medical staff and look forward to the opportunity to work with you in the future!

     University Hospitals and Health System policy and procedure manuals

    Medical staff bylaws

    Medical staff policies and procedures

    Infection prevention and control
    (includes information related to handwashing compliance and isolation guidelines)  

     Health information services
    (includes information related to dictation, do not use abbreviations, and forms approval procedures) 

    UHHS formulary

    Reporting safety concerns to The Joint Commission

    The University Hospital and Health System is a Joint Commission-accredited health care organization. If you have concerns about the safety or quality of care provided in the hospital, you may report these concerns to The Joint Commission.

    • E-mail:  
    • Fax: Office of Quality Monitoring; (630) 792-5636
    • Mail: Office of Quality Monitoring 
              The Joint Commission 
              One Renaissance Boulevard 
              Oakbrook Terrace, IL 60181

    The reporting of concerns will not result in retaliatory or disciplinary actions.

    Other resources