Current through Reg. 50, No. 187; September 24, 2024
(1)
Each hospital shall have an organized medical staff organized under written
by-laws approved by the governing board and responsible to the governing board
of the hospital for the quality of all health care provided to patients in the
facility and for the ethical and professional practices of its
members.
(2) Each hospital's
organized medical staff shall determine its appropriate committee structure and
shall provide that the following required committee functions are carried out
with sufficient periodicity to assure their objectives being achieved by
separate committee, combined committees, or committee of the whole:
(a) Coordination of the activities and
general policies of the various departments.
(b) Interim decision making for the organized
medical staff between staff meetings, under such limitations as shall be set by
the organized medical staff.
(c)
Follow-up and appropriate disposition of all reports dealing with the various
staff functions.
(d) Review of all
applications for appointment and reappointment to all categories of staff, and
recommendations on each to the governing board, including delineation of
privileges to be granted in each case, and right of hearing and appearance.
Except in emergency cases, recommendations to the governing board for
withdrawal of any privileges of a member of the organized medical staff or
dismissal from the organized medical staff will be made only after a thorough
investigation by the organized medical staff or a committee thereof, with the
subject member being given the right of hearing before the organized medical
staff or a committee thereof, if requested within a reasonable time as
specified in the hospital's by-laws.
(e) Medical records currently maintained
describing the condition, treatment, and progress of patient in sufficient
completeness to assure transferable comprehension of the case at any
time.
(f) Clinical evaluation of
the quality of medical care provided to all categories of patients on the basis
of documented evidence.
(g) Review
of hospital admissions with respect to need for admission, length of stay,
discharge practices and evaluation of the services ordered and
provided.
(h) Surveillance of
hospital infection potentials and cases and the promotion of a preventive and
corrective program designed to minimize these hazards.
(i) Surveillance of pharmacy and therapeutic
policies and practices within the institution.
(j) Hospital tests may be ordered only by the
attending physician, or by another licensed health professional if that
licensed health professional is acting within his scope of practice as defined
by applicable laws and rules of the agency. Nothing herein shall be construed
to expand or restrict such laws and rules pertaining to the practice of the
various health professions.
Rulemaking Authority 395.1055 FS. Law Implemented 395.0191,
395.1055 FS.
New 9-4-95, Formerly
59A-3.220.
