Medical staff

1. The general acute hospital shall have an organized medical staff that is accountable to the governing body in accordance with written bylaws, rules, and regulations approved by the governing body. The medical staff shall adopt and enforce bylaws, rules, and regulations to carry out its responsibilities which specifically provide, but are not limited to, the following: a. Describe the organization, composition, and accountability of the medical staff. b. The mechanism for appointment, reappointment, and renewal of medical staff membership, and the granting of clinical privileges initially and at least every thirty-six months as a part of an evaluation of staff membership. Medical staff membership and clinical privileges shall be granted by the governing body based on medical staff recommendations in accordance with the bylaws, rules, regulations, and policies of the medical staff and the hospital. c. The acceptance and processing of initial applications for medical staff membership, granting and denying of medical staff reappointment, and medical staff membership or disciplinary matters related to clinical privileges. d. The equal application of procedures for evaluating eligible licensed health care practitioners for staff membership, including procedures for determination of qualifications, credentials, and privileges; criteria for evaluation of qualifications; procedures requiring information about current mental and physical health status; current license status in this state; procedures to address the issue of staff members who are reportedly impaired by substance abuse; and current competence in delivering health care services. (1) The following information must be collected from a licensed health care practitioner prior to appointment or reappointment to the medical staff and the granting or renewing of clinical privileges or association in any capacity with the hospital: (a) The name of any hospital or facility with which the licensed health care practitioner has had any association, employment, privileges, or practice and, if such association, employment, privileges, or practice have been suspended, restricted, terminated, curtailed or not renewed, the reasons for such. (b) The substance of any pending professional liability actions or other professional misconduct proceedings in this or any other state. (c) Any judgment or settlement of any professional liability action and any finding of professional misconduct in this or any other state. (d) Any information relative to findings pertinent to violations of patients' rights. (e) A waiver by the licensed health care practitioner of any confidentiality provisions concerning the information. (2) Prior to granting or renewing privileges or association to any licensed health care practitioner, the hospital shall query the national practitioner data bank regarding physicians and request all previous hospital or clinical practice information. (3) A file must be maintained on each licensed health care practitioner granted privileges or otherwise associated with the hospital which must contain the information collected. This file must be updated at least every twenty-four months and contain all relevant information gathered in accordance with this section. (4) A physician assistant and advanced registered nurse practitioner shall keep on file at the hospital and available for review by the department, upon request, documents that are required to be filed with the board of medical examiners or the board of nursing as appropriate. e. A statement of the duties, privileges, and responsibilities of each category of medical staff. (1) Regardless of any other categories having privileges in the hospital, there must be an active staff that includes physicians and may also include other licensed health care practitioners which is organized and which performs all the duties pertaining to medical staff, including the maintenance of the proper quality of all medical care and treatment of inpatients and outpatients in the hospital. (2) Active medical staff meetings must be held regularly and written minutes of all meetings must be kept. Documentation on meetings must be prepared and reported through established channels. f. Additional privileges may be granted a staff member for the use of their employed allied health personnel in the hospital in accordance with policies and procedures recommended by the medical staff and approved by the governing body. The staff member requesting this additional privilege shall submit for review and approval by the medical staff and the governing body: (1) The curriculum vitae of the identified allied health personnel. (2) Written protocol with a description of duties, assignments, and functions including a description of the manner of performance within the hospital by the allied health personnel in relationship with other hospital staff. g. The responsibility for such quality improvement activities as pharmacy and therapeutics, surgical case and tissue review, infection control, utilization review, patient care evaluation, use of blood and blood components, review of unexpected mortalities, review of morbidities in circumstances other than those related to the natural course of disease or illness, and the maintenance of complete medical records. h. That the findings of tissue removed at operation which is examined by a pathologist be made a part of the patient's medical record. i. The maintenance and continuous collection of information concerning the hospital's experience with negative health care outcomes and incidents injurious to patients; patient grievances; professional liability insurance premiums, settlements, awards, and costs incurred by the hospital for patient injury prevention; and safety improvement activities. j. The identification of clinical conditions and procedures requiring consultation. k. The provision for the exchange of information between medical, administrative, and nursing staffs. l. The procedure for submitting recommendations to the governing body regarding matters within the purview of the medical staff. m. The procedures to be used to grant to current medical staff members formal professional review for actions involving credentialing, competence, or professional conduct concerning hospital privileges. The formal professional review must be conducted in accordance with a fair hearing and appeal process identified in the medical staff bylaws, substantially in the following manner: (1) The medical staff member must be given a notice stating: (a) That a professional review action has been proposed to be taken against the medical staff member. (b) The reasons for the proposed action. (c) That the medical staff member has the right to request a hearing on the proposed action. (d) Any time limit, which may not be less than thirty days, within which to request such a hearing. (e) A summary of the medical staff member's rights in a hearing. (2) If a hearing is requested, the medical staff member involved must be given notice of the hearing on a timely basis. (3) Any action relating to professional incompetence or professional conduct adversely affecting the clinical privileges of the medical staff member must be reported by the governing body of the hospital, within fifteen days, to the state board charged with responsibility for licensure of the professional practice and any disciplinary action affecting practice longer than thirty days must be reported to the national data bank. 2. The primary care hospital shall have a medical staff that includes at least one or more physician, physician assistant, or advanced registered nurse practitioner which does the following: a. Adopts bylaws, rules, and regulations for self-governance of medical staff activities and enforces the bylaws, rules, and regulations after their approval by the governing body. The bylaws, rules, and regulations must at least contain the following: (1) A description of the qualifications a medical staff candidate must meet in order to be recommended to the governing body for appointment. (2) A statement of the duties and privileges of each category of medical staff. (3) The requirement for a physical examination to be made and the medical history taken of a patient by a member of the medical staff no more than fourteen days before or twenty-four hours after the patient's admission to the primary care hospital. b. Responsible for quality improvement activities including pharmacy and therapeutics, infection control, utilization review, patient care evaluation, use of blood and blood components, review of unexpected mortalities, review of morbidities in circumstances other than those related to the natural course of the disease or illness, and maintenance of complete medical records. c. A licensed health care practitioner on staff must: (1) Provide health care services to the patients in the hospital whenever needed and requested. (2) Prepare guidelines for the medical management of health problems, including conditions requiring medical consultation and patient referral. (3) Provide medical direction for the hospital's health care activities. (4) Participate in developing, executing, and periodically reviewing the hospital's written policies and the services provided to patients. (5) Review and sign the records of each patient admitted and treated no later than one month after that patient's discharge from the hospital. (6) Arrange for, or refer patients to, needed services that are not provided at the hospital. (7) Assure that adequate patient medical records are maintained and transferred as necessary when a patient is referred. d. A physician assistant or advanced registered nurse practitioner must keep on file at the primary care hospital and available for review by the department, upon request, documents that are required to be filed with the board of medical examiners or the board of nursing as appropriate. 3. Specialized hospitals are subject to the medical staff requirements for general acute hospitals in this section, with the exception of rural emergency hospitals, which are subject to the medical staff requirements for primary care hospitals in this section.