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Here you will find information realted to providing?patient care that may be unique to Island Health. It is essential that you know this information prior to providing patient care in Island Health.

Medical Staff Rules & Bylaws

Medical staff are required to know their responsibilities under, and act in accordance with, the Medical Staff Bylaws and Rules including, but not limited to, the sections outlined below.


Hospital care in British Columbia is governed under the Hospital Act. The?Hospital Act is the foundation for Island Health's Medical Staff Bylaws and Rules, which guide how Medical Staff work within our health authority. All Medical staff are required to sign in agreement to these terms and conditions before working with Island Health. It is very important that physicians understand their full responsibilities under the Medical Staff Bylaws and Rules. Excerpts represented in this orientation should not replace thorough review by physicians of these documents:


  • Responsibility for the Provision of Medical Care (Bylaws, Section 5; Rules, Section 2)
  • Admission, Transfer and Discharge of Patient (Rules, Section 3)
  • Consultations (Rules, Section 4)
  • Schedules Treatments and Procedures (Rules, Section 5)
  • Health Records (Rules, Section 6)
  • Pronouncement of Death, Autopsy, and Pathology (Rules, Section 10)

Medical Staff Bylaws?*?

Medical Staff Rules?*

Find out more about the?role of the Coroner in BC.

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Most Responsible Practitioner Policy

Medical staff are required to know their responsibilities as Most Responsible Practitioner (MRP), as outlined by the Medical Staff Rules, and act in accordance with this policy.


The Most Responsible Practitioner Policy * is defined in Section 3.1 of Island Health's Medical Staff Rules as: “an appropriately privileged physician, midwife or dentist member who has primary responsibility for the care of the patient.” Please review the policy for further responsibilities outlined within.

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Medical Staff Health & Safety

Medical staff are responsible for taking appropriate precautions to protect personal health and safety, and responding appropriately to workplace incidents.


Our Occupational Health and Safety department is a resource to physicians and staff. Learn more at Occupational Health and Safety.?


Physicians must know how to prevent and/or respond appropriately to the following workplace risks and/or incidents:

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Quality, Research, and Safety

Medical staff are responsible for commitment to Island Health’s quality and patient safety initiatives.

Read about our new physician-led initiatives on Individual Physician Quality?(.pdf).

Quality at Island Health means a dedication to providing the highest standard of care and a commitment to improving the care and safety of patients every day.?View Improving Care and Safety for information on programs, tools and resources that support quality at.

These are foundational programs you need to know about:


Medication Safety?

Safeguards in medication systems and processes reduce the risk of medication errors at the three main points of the medication process: ordering, dispensing and administration.

Hand Hygiene?

Clean hands are the cornerstone to preventing healthcare-associated?infections.?Island Health asks for 100% compliance with hand hygiene in non-emergency situations.?Hand Hygiene Audits are?conducted regularly across the health authority. Please review the Hand Hygiene Policy.

Immunization Policy?*
Physicians with privileges at?Island Health?and with other health authorities across the province are asked to take specific measures to protect vulnerable patients and seniors from influenza. All health care workers who come in contact with patients at health care facilities, including long-term care facilities, are required to get the influenza vaccine or wear a surgical or procedure mask during influenza season. This policy is part of the?comprehensive infection control measures developed by health authorities in collaboration with the provincial Medical Health Officer, the Health Employers Association of BC and the BC Ministry of Health.?

Infection Prevention and Control

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Framework for Reviews?(.pdf)

Respectful Workplace

Medical staff are required to know their responsibilities under, and act in accordance with, Island Health’s respectful workplace policy and Medical Staff Rules, Section 17.


Island Health is committed to providing a respectful workplace for all individuals. Our?Respectful Workplace Policy*?applies to all physicians with privileges at any site.


The?Medical Staff Rules?of Island Health, section 17, also outline requirements with regard to professional conduct and repercussions concerning disruptive behaviour.


Contact a?Respectful Workplace Specialist for more?information.

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Cultural Safety

Medical staff are responsible for creating a culturally safe environment for both clients and staff.


Cultural safety is part of Island Health's values.?It is one way to help improve the health of the residents we serve?and our Aboriginal?residents in particular.?Why an Aboriginal focus? The right to feel culturally safe is for everyone. Yet, we focus on Aboriginal people because of the significant population of first nations people in our health region.


The?Cultural Safety * homepage provides vital information, resources, and education. Resources on this site also provide information about Aboriginal health.

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Teaching Environment

Medical staff are responsible for promoting and fostering a positive learning environment and participating in the teaching and mentoring of learners at? Island Health.?

Island Health is a learning organization working closely with the Island Medical Program, nursing and allied health programs at island colleges and universities, as well as paramedic and other health and support service teaching programs throughout the island.

Island Health has 85 clinical elective sites for medical students, and over 600 local physicians make up the Island Medical Program clinical faculty.? Faculty contributes to student learning as tutor and preceptors in the Region’s major hospitals, as well as in many smaller facilities throughout the health authority.

The continual development of academic learning spaces across Island Health acknowledges the importance we place on medical education and training – and furthers our goal of drawing the best and brightest physicians to our region.