Current through Register Vol. 42, No. 11, August 30, 2024
(1) A hospital shall have an effective
governing authority that is legally responsible for the conduct of the hospital
as an institution.
(2) Medical
staff. The governing authority shall:
(a)
Appoint members of the medical staff after considering the recommendations of
the existing members of the medical staff;
(b) Assure that the medical staff has
bylaws;
(c) Approve medical staff
bylaws and other medical staff rules and regulations;
(d) Ensure that the medical staff is
accountable to the governing body for the quality of care provided to
patients;
(e) Ensure the criteria
for selection are individual character, competence, training, experience, and
judgment; and
(f) Ensure that under
no circumstances the accordance of staff membership or professional privileges
in the hospital is dependent solely upon certification, fellowship, or
membership in a specialty body or society.
(3) Chief executive officer. The governing
authority shall appoint a chief executive officer who is responsible for
managing the hospital.
(4) Care of
patients. In accordance with hospital policy, the governing authority shall
ensure that the following requirements are met:
(a) Every patient is under the care of:
1. A doctor of medicine or osteopathy (this
provision is not to be construed to limit the authority of a doctor of medicine
or osteopathy to delegate tasks to other qualified health care personnel to the
extent permitted under applicable state law);
2. A doctor of dental surgery or dental
medicine who is legally authorized to practice dentistry in Alabama and who is
acting within the scope of his or her license;
3. A doctor of podiatric medicine licensed in
Alabama, but only with respect to functions which he or she is legally
authorized to perform;
4. A doctor
of optometry who is legally authorized to practice optometry in Alabama, and
who is acting within the scope of his or her license;
5. A chiropractor who is licensed in Alabama,
but only with respect to treatment by means of manual manipulation of the spine
to correct a subluxation demonstrated by x-ray to exist;
6. A clinical psychologist licensed in
Alabama, but only with respect to clinical psychologist services; and
7. These rules do not mandate that any
particular individual health care practitioner be allowed medical staff
membership.
(b) Patients
are admitted to the hospital only on the recommendation of a licensed
practitioner. If a patient is admitted by a practitioner not specified in this
rule, that patient is under the care of a doctor of medicine or
osteopathy.
(c) A doctor of
medicine or osteopathy is on duty or on call at all times.
(d) A doctor of medicine or osteopathy is
responsible for the care of each patient with respect to any medical or
psychiatric problem that:
1. Is present on
admission or develops during hospitalization; and
2. Is not specifically within the scope of
practice of a doctor of dental surgery, dental medicine, podiatric medicine, or
optometry; a chiropractor; or clinical psychologist, as that scope is:
(i) Defined by the medical staff;
(ii) Permitted by law; and
(iii) Limited, under this rule, with respect
to chiropractors.
(5) Contracted services. The governing
authority shall be responsible for services furnished in the hospital whether
or not they are furnished under contracts. The governing authority shall ensure
that a contractor of services (including one for shared services and joint
ventures) furnishes services that permit the hospital to maintain compliance
with the requirements of these rules.
(a) The
governing authority shall ensure that the services performed under a contract
are provided in a safe and effective manner.
(b) The hospital shall maintain a list of all
contracted services, including the scope and nature of the services
provided.
Rule .06 was renumbered to .04 as per certification filed
August 24, 2012; effective September 28,
2012.
Author: W.T. Geary, Jr., M.D., Carter
Sims
Statutory Authority:
Code of Ala.
1975, §§
22-21-20, et seq.
