Section 124.12. Medical staff.

 

(1)   Definition. In this section, "privileges"means the right to provide care to hospital patients in the area in which the person has expertise as a result of education, training and experience.

(2)   General requirements.

(a) Organization and accountability. The hospital shall have a medical staff organized under by-laws approved by the governing body. The medical staff shall be responsible to the governing body of the hospital for the quality of all medical care provided patients in the hospital and for the ethical and professional practices of its members.

(b) Responsibility of members. Members of the medical staff shall comply with medical staff and hospital policies. The medical staff by-laws shall prescribe disciplinary procedures for infraction of hospital and medical staff policies by members of the medical staff. There shall be evidence that the disciplinary procedures are applied where appropriate.

(3)   Membership.

(a) Active staff. Regardless of any other categories of medical staff having privileges in the hospital, a hospital shall have an active staff which performs all the organizational duties pertaining to the medical staff. Active staff membership shall be limited to individuals who are currently licensed to practice medicine, podiatric medicine or dentistry. These individuals may be granted membership in accordance with the medical staff by-laws and rules, and in accordance with the by-laws of the hospital. A majority of the members of the active staff shall be physicians.

(b) Other staff. The medical staff may include one or more categories defined in the medical staff by-laws in addition to the active staff.

(4)   Appointment.

(a) Governing body responsibilities.

1. Medical staff appointments shall be made by the governing body, taking into account recommendations made by the active staff.

2. The governing body shall ensure at least biennially that members of the medical staff are qualified legally and professionally for the positions to which they are appointed.

3. The hospital, through its medical staff, shall require applicants for medical staff membership to provide, in addition to other medical staff requirements, a complete list of all hospital medical staff memberships held within the 5 years prior to application.

4. Hospital medical staff applications shall require reporting of any malpractice action, any previously successful or currently pending challenge to licensure in this or another state, and any loss or pending action affecting medical staff membership or privileges at another hospital. The application shall permit use of the information only for purposes of determining eligibility for medical staff membership, and shall release the hospital from civil liability resulting from this use of the information. Pending actions may not be used as the sole criterion to deny membership or privileges.

(b) Medical staff responsibilities.

1. To select its members and delineate their privileges, the hospital medical staff shall have a system, based on definite workable standards, for evaluation of each applicant by a credentials committee which makes recommendations to the medical staff and to the governing body.

2. The medical staff may include one or more categories of medical staff defined in the medical staff by-laws in addition to the active staff, but this in no way modifies the duties and responsibilities of the active staff.

(c) Criteria for appointment.

1. Criteria for appointment shall include individual character, competence, training, experience and judgment.

2. All qualified candidates shall be considered by the credentials committee.

3. Reappointments shall be made at least biennially and recorded in the minutes or files of the governing body. Reappointment policies shall provide for a periodic appraisal of each member of the staff, including consideration at the time of reappointment of information concerning the individual's current licensure, health status, professional performance, judgment and clinical and technical skills. Recommendations for reappointments shall be noted in the minutes of the meetings of the appropriate committee.

4. Temporary staff privileges may be granted for a limited period if the individual is otherwise properly qualified for membership on the medical staff.

5. A copy of the scope of privileges to be accorded the individual shall be distributed to appropriate hospital staff. The privileges of each staff member shall be specifically stated or the medical staff shall define a classification system. If a system involving classification is used, the scope of the categories shall be well-defined, and the standards which must be met by the applicant shall be clearly stated for each category.

6. If categories of hospital staff membership are established for allied health personnel not employed by the hospital, the necessary qualifications, privileges and rights shall be delineated in accordance with the medical staff by-laws.

(5)   By-laws.

(a) Adoption and purpose. By-laws shall be adopted by the medical staff and approved by the governing body to govern and enable the medical staff to carry out its responsibilities. The by-laws of the medical staff shall be a precise and clear statement of the policies under which the medical staff regulates itself.

(b) Content. Medical staff by-laws and rules shall include:

1. A descriptive outline of medical staff organization;

2. A statement of the necessary qualifications which each member must possess to be privileged to work in the hospital, and of the duties and privileges of each category of medical staff;

3. A procedure for granting and withdrawing privileges to each member;

4. A mechanism for appeal of decisions regarding medical staff membership and privileges;

5. A definite and specific statement forbidding the practice of the division of fees between medical staff members;

6. Provision for regular meetings of the medical staff;

7. Provision for keeping timely, accurate and complete records;

8. Provision for routine examination of all patients upon admission and recording of the preoperative diagnosis prior to surgery;

9. A stipulation that a surgical operation is permitted only with the consent of the patient or the patient's legally authorized representative except in emergencies;

10. Statements concerning the request for and performance of consultations, and instances in which consultations are required; and

11. A statement specifying categories of personnel duly authorized to accept and implement medical staff orders. All orders shall be recorded and authenticated. All verbal and telephone orders shall be authenticated by the prescribing member of the medical staff in writing within 24 hours of receipt.

(6)   Governance.

(a) General. The medical staff shall have the numbers and kinds of officers necessary for the governance of the staff.

(b) Officers. Officers shall be members of the active staff and shall be elected by the active staff, unless this is precluded by hospital by-laws.

(7)   Meetings.

(a) Number and frequency. The number and frequency of medical staff meetings shall be determined by the active staff and clearly stated in the by-laws of the medical staff.

(b) Attendance. Attendance records shall be kept of medical staff meetings. Attendance requirements for each individual member shall be clearly stated in the by-laws of the medical staff.

(c) Purpose. Full medical staff meetings shall be held to conduct the general business of the medical staff and to review the significant findings identified through the quality assurance program.

(d) Minutes. Adequate minutes of all meetings shall be kept that are sufficient to document for those members who did not attend the meeting the general nature of the business conducted, the decisions reached, and the findings and recommendations of the medical staff.

(8)   Committees.

(a) Establishment. The medical staff shall establish committees of the medical staff and is responsible for their performance.

(b) Executive committee. The medical staff shall have an executive committee to coordinate the activities and general policies of the various departments, act for the staff as a whole under limitations that may be imposed by the staff, and receive and act upon the reports of all other medical staff committees.

(9)   Administrative structure.

(a) Services. Hospitals may create services to fulfill medical staff responsibilities. Each autonomous service shall be organized and function as a unit.

(b) Chief of service. Each service shall have a chief appointed in accordance with the medical staff by-laws. The chief of service shall be a member of the service and be qualified by training and experience to serve as chief of service. The chief of service shall be responsible for:

1. The administration of the service;

2. The quality of patient care;

3. Making recommendations to the hospital's administrative staff and governing board concerning the qualifications of the members of the service;

4. Making recommendations to the hospital's administrative staff regarding the planning of hospital facilities, equipment, routine procedures and any other matters concerning patient care;

5. Arranging and implementing inpatient and outpatient programs, which include organizing, engaging in educational activities and supervising and evaluating the clinical work;

6. Enforcing the medical staff by-laws and rules within the service;

7. Cooperating with the hospital's administrative staff on purchase of supplies and equipment;

8. Formulating special rules and policies for the service;

9. Maintaining the quality of the medical records; and

10. Representing the service in a medical advisory capacity to the hospital's administrative staff and governing body.

Cr. Register, January, 1988, No. 385 , eff. 2-1-88.