Indiana Administrative Code
Title 410 - INDIANA DEPARTMENT OF HEALTH
Article 15 - HOSPITAL LICENSURE RULES
Rule 1.5 - Required Hospital Services
Section 1.5-5 - Medical staff
Universal Citation: 410 IN Admin Code 1.5-5
Current through March 20, 2024
Authority: IC 16-21-1-7
Affected: IC 16-21-1; IC 25-22.5
Sec. 5.
(a) The hospital shall have an organized medical staff that operates under bylaws approved by the governing board and is responsible to the governing board for the quality of medical care provided to patients. The medical staff shall be composed of two (2) or more physicians and other practitioners as appointed by the governing board and do the following:
(1)
Conduct outcome oriented performance evaluations of its members at least
biennially.
(2) Examine credentials
of candidates for appointment and reappointment to the medical staff by using
sources in accordance with hospital policy and applicable state and federal
law.
(3)
(Voided by
P.L.
190-2023,
SECTION
39, effective July 1,
2023.)
(4) Maintain a file
for each member of the medical staff that includes, but is not limited to, the
following:
(A) A completed, signed
application.
(B) The date and year
of completion of all Accreditation Council for Graduate Medical Education
(ACGME) accredited residency training programs, if applicable.
(C) A copy of the member's current Indiana
license showing the date of licensure and current number or an available
certified list provided by the health professions bureau. A copy of practice
restrictions, if any, shall be attached to the license issued by the health
professions bureau through the medical licensing board.
(D) A copy of the member's current Indiana
controlled substance registration showing the number, as applicable.
(E) A copy of the member's current Drug
Enforcement Agency registration showing the number, as applicable.
(F) Documentation of experience in the
practice of medicine.
(G)
Documentation of specialty board certification, as applicable.
(H) Category of medical staff appointment and
delineation of privileges approved.
(I) A signed statement to abide by the rules
of the hospital.
(J) Documentation
of current health status as established by hospital and medical staff policy
and procedure and federal and state requirements.
(K) Other items specified by the hospital and
medical staff.
(b) The medical staff shall adopt and enforce bylaws and rules to carry out its responsibilities. These bylaws and rules shall:
(1) be approved by the governing
board;
(2) be reviewed at least
triennially; and
(3) include, but
not be limited to, the following:
(A) A
description of the medical staff organizational structure. If the organization
calls for an executive committee, a majority of the members shall be physicians
on the active medical staff.
(B)
Meeting requirements of the staff.
(C) A provision for maintaining records of
all meetings of the medical staff and its committees.
(D) A procedure for designating an individual
physician with current privileges as chief, president, or chairperson of the
staff.
(E) A statement of duties
and privileges for each category of the medical staff.
(F) A description of the medical staff
applicant qualifications.
(G)
Criteria for determining the privileges to be granted to individual
practitioners and a procedure for applying the criteria to individuals
requesting privileges.
(H) A
process for review of applications for staff membership, delineation of
privileges in accordance with the competence of each practitioner, and
recommendations on appointments to the governing board.
(I) A process for appeals of decisions
regarding medical staff membership and privileges.
(J) A process for medical staff performance
evaluations based on clinical performances indicated in part by the results of
quality assessment and improvement activities.
(K) A process for reporting practitioners who
fail to comply with state professional licensing law requirements as found in
IC 25-22.5, and for documenting appropriate enforcement actions against
practitioners who fail to comply with the hospital and medical staff bylaws and
rules.
(L) A provision for
physician coverage of emergency care that addresses at least the following:
(i) A definition of emergency care to
include, but not be limited to, the following:
(AA) Inpatient emergencies.
(BB) Emergency services
emergencies.
(ii) A
timely response.
(M) A
requirement that a complete physical examination and medical history be
performed:
(i) on each patient admitted by a
practitioner who has been granted such privileges by the medical staff;
(ii) within seven (7) days prior to
date of admission and documented in the record with a durable, legible copy of
the report and changes noted in the record on admission; or
(iii) within forty-eight (48) hours after an
admission.
(N) A
requirement that all physician orders shall be:
(i) in writing or acceptable computerized
form; and
(ii) authenticated by the
responsible individual in accordance with hospital and medical staff policies.
(O) A requirement that
all verbal orders must be authenticated by the responsible individual in
accordance with hospital and medical staff policies. The individual receiving a
verbal order shall date, time, and sign the verbal order in accordance with
hospital policy. Authentication of a verbal order must occur within forty-eight
(48) hours unless a read back and verify process described under items (i) and
(ii) is utilized. If a patient is discharged within forty-eight (48) hours of
the time that the verbal order was given, authentication shall occur within
thirty (30) days after the patient's discharge.
(i) As an alternative, hospital policy may
provide for a read back and verify process for verbal orders. Any read back and
verify process must require that the individual receiving the order shall
immediately read back the order to the ordering physician or other responsible
individual who shall immediately verify that the read back order is
correct.
(ii) The individual
receiving the verbal order shall document in the patient's medical record that
the order was read back and verified. Where the read back and verify process is
followed, the hospital shall require authentication of the verbal order not
later than thirty (30) days after the patient's discharge.
(P) A requirement that the final diagnosis be
documented along with completion of the medical record within thirty (30) days
following discharge.
(c) The medical staff should attempt to secure autopsies in all cases of unusual deaths and educational interest. There shall be the following:
(1) A mechanism for
documenting in writing the following:
(A) That
permission to perform an autopsy was obtained.
(B) The source of the
permission.
(2) A system
for notifying the medical staff, and specifically the attending practitioner,
when an autopsy is being performed.
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