Current through Register Vol. 47, No. 6, September 18, 2024
All hospitals providing surgical services shall be properly
organized and equipped to provide for the safe and aseptic treatment of
surgical patients.
(1) Written
policies and procedures governing surgical services shall be developed and
implemented in consultation with the hospital's medical staff and, at a
minimum, provide for:
a. Surgical services
under the direction of a qualified doctor of medicine or osteopathy.
b. Delineation of the privileges and
qualifications of individuals authorized to provide surgical services as set
forth in the hospital's medical staff bylaws and in accordance with subrule
51.5(4), including a periodic review and update of surgical privileges not to
exceed every three years or other term permitted by an accrediting organization
approved by CMS for federal certification, whichever is longer. The surgical
service must maintain a roster of these individuals specifying the surgical
privileges of each.
c. Immediate
availability of at least one registered nurse for the operating room suites to
respond to emergencies.
d. The
qualifications and job descriptions of nursing personnel, surgical technicians,
and other support personnel and continuing education required.
e. Appropriate staffing for surgical
services, including physician and anesthesia coverage and other support
personnel.
f. Availability of
ancillary services for surgical patients, including but not limited to blood
banking, laboratory, radiology, and anesthesia.
g. Infection control and disease prevention,
including aseptic surveillance and practice, identification of infected and
noninfected cases, sterilization and disinfection procedures, and ongoing
monitoring of infections and infection rates.
h. Housekeeping requirements.
i. Safety practices.
j. Ongoing quality assessment, performance
improvement, and process improvement.
k. The pathological examination of tissue
specimens either directly or through contractual arrangements.
l. Appropriate preoperative teaching and
discharge planning.
(2)
Policies and procedures may be adjusted as appropriate to reflect the provision
of surgical services in inpatient, outpatient or one-day surgical
settings.
(3) There must be an
appropriate history and physical workup documented and a properly executed
consent form in the chart of each patient prior to surgery, except in the event
of an emergency.
(4) A full
operative report must be written or dictated within 24 hours following surgery
and signed by the individual conducting the surgery.
(5) Equipment available in the operating
room, recovery room, outpatient surgical areas, and for postsurgical care must
be consistent with the needs of the patient.
