Current through Reg. 50, No. 187; September 24, 2024
(1) The licensee
shall have a governing board responsible for the conduct of the hospital as a
functioning institution.
(2) The
governing board shall be organized under written bylaws, rules and regulations
which it reviews at least every two years, dates to indicate time of last
review, revises as necessary, and enforces. Governing board by-laws shall:
(a) State the role and purpose of the
hospital, including an organizational chart defining the lines of authority.
The description of the structure of the hospital shall include full disclosure
in writing of the names and addresses of all owners and persons controlling 5
percent or more interest in the hospital. In the case of corporations, holding
companies, partnerships, and similar organizations, the names and addresses of
officers, directors, and stockholders, both beneficial and of record, when
holding 5 percent or more interest, shall be disclosed.
(b) State the qualifications for governing
board membership, and the method of selecting members as well as the terms of
appointment or election of members, officers and chairmen of
committees.
(c) Provide for the
designation of officers, their duties, and for the organization of the
governing board into essential committees with the number and type consistent
with the size and scope of the hospital's activities.
(d) Coordinate through an executive committee
or the governing board as a whole, the policies and activities of the facility
and special committees established by the governing board.
(e) Specify the frequency of meetings, at
regularly stated intervals, the number or percentage of members constituting a
quorum, and require that minutes be recorded and made available to all members
of the governing board.
(3) The governing board shall establish the
position of chief executive officer or other similarly titled position, and
define in writing the responsibility, authority and accountability of the chief
executive officer for operation and maintenance of the hospital.
(4) The governing board shall approve the
by-laws, rules and regulations of the organized medical staff, provide for the
appointment, reappointment, or dismissal of members of the organized medical
staff, and provide a procedure for hearings and appeals on all actions
concerning appointment, reappointment or dismissal. No action on appointment,
reappointment, or dismissal of a member of the organized medical staff shall be
taken without prior referral to the organized medical staff for their
recommendation, except in emergency cases.
(a)
The governing board shall provide that no qualified applicant is denied
organized medical staff privileges or clinical privileges solely because the
applicant is licensed as a physician, dentist or podiatrist, psychologist,
advanced practice registered nurse, or physician assistant.
(b) The governing board shall set standards
and procedures to be applied by the hospital and the organized medical staff in
considering and acting upon applications for staff membership or professional
privileges, including delineation of privileges. Such standards or procedures
shall be available for public inspection, and shall not operate to deny staff
privileges or clinical privileges in an arbitrary, unreasonable or capricious
manner, or on the basis of sex, race, creed, or national origin.
(c) When the standards and procedures
established by the governing board require, as a precondition to obtaining
staff membership or professional clinical privileges, the completion of or
eligibility in, a program established by the American Medical Association or
the Liaison Committee on Graduate Medical Education, the governing board shall
also make available staff membership or privileges to physicians who have
obtained the completion of or eligibility in, any program which is in the same
area of medical specialization established by the American Osteopathic
Association.
(d) The governing
board shall require a delineation of privileges for each member of the
organized medical staff. The delineation of privileges shall not be stated
simply as a specialty designation, such as "general surgery" or "general
medicine" unless such terms are specifically defined elsewhere.
(e) The governing board shall require that
eligibility for privileges, delineation of privileges, and reappointments, be
based on the applicant's background, experience, health, training, demonstrated
current competence, adherence to applicable professional ethics, reputation,
ability to work with others, ability of the hospital to provide adequate
facilities and supportive services for the applicant and his patients, and such
other elements as the governing board determines that are not inconsistent with
this part.
(f) The governing board
shall establish a procedure, within a time-limited period, for approving,
approving in part, or denying an applicant's request for privileges.
(g) The governing board shall establish a
procedure for an applicant for privileges to appeal an adverse decision, and
shall establish a time-limited period for rendering a final decision after the
appeal.
(h) The governing board
shall set standards and procedures which provide for reasonable access by
licensed chiropractors to the reports of diagnostic x-rays and laboratory tests
of the institutions licensed facilities, subject to the same standards and
procedures as other licensed physicians. However, nothing contained in the
provisions of this section shall require a licensed facility to grant staff
privileges to a chiropractor.
(5) Within 30 days of receipt of a written
request, either by an applicant for staff privileges, or by a member of the
organized medical staff whose privileges have been suspended, denied, revoked
or curtailed, whether in whole or in part, the licensed facility shall supply
the reasons for such action in writing to the requesting applicant or staff
member. A denial of staff membership or professional clinical privileges to any
applicant shall be submitted, in writing, to the applicant's respective
licensing board.
(6) Nothing herein
shall prohibit the licensee of the facility from acting as the governing board,
provided that the articles of incorporation or other written organizational
plan describe the manner in which the licensee executes the governing board's
responsibility.
Rulemaking Authority 395.1055 FS. Law Implemented 395.0191,
395.0193, 395.0195, 395.1055 FS.
New 9-4-95, Formerly
59A-3.217, Amended
11-21-18.
