Kansas Administrative Regulations
Agency 28 - DEPARTMENT OF HEALTH AND ENVIRONMENT
Article 34 - HOSPITALS
Section 28-34-54 - Medical staff

(a) The ambulatory surgical center shall have an organized medical staff, responsible to the governing authority of the ambulatory surgical center for the quality of all medical care provided to patients in the ambulatory surgical center and for the ethical and professional practices of its members.

(b) In each ambulatory surgical center, the medical staff, with the approval of and subject to final action by the governing authority, shall formulate and approve medical staff bylaws, policies, and procedures for the proper conduct of its activities and recommend to the governing authority practitioners considered eligible for membership on the medical staff, in accordance with K.A.R. 28-34-50(u).

(c) Each member of the medical staff shall be granted privileges that are commensurate with the member's qualifications, experience, and present capabilities and that are within the practitioner's scope of practice.

(d) Each member of the medical staff shall submit a written application for staff membership on a form prescribed by the governing authority. After considering medical staff recommendations, the governing authority shall affirm, deny, or modify each recommendation for appointment to the medical staff.

(e) Surgical procedures shall be performed only by practitioners who have been granted privileges by the governing authority to perform surgical procedures.

(f) The medical staff of each ambulatory surgical center shall develop a policy stipulating which surgically removed tissues will be sent to a pathologist for review. This policy shall be approved by the governing authority.

(g) The medical staff bylaws shall require at least one physician member of the medical staff to be available to the ambulatory surgical center at all times that a patient is receiving or recovering from local, general, or intravenous sedation. The staffing shall meet the needs of the patients.

(h) The medical staff shall hold regular meetings for which records of attendance and minutes shall be kept.

(i) Medical staff committee minutes and information shall neither be a part of individual patient records nor be subject to review by other than medical staff members, except as otherwise provided by the governing authority.

(j) The medical staff shall review and analyze at regular intervals the clinical experience of its members and the medical records of patients on a sampling or other basis. All techniques and procedures involving the diagnosis and treatment of patients shall be reviewed periodically and shall be subject to change by the medical staff.

(k) The medical staff shall participate in risk management activities, in accordance with K.S.A. 65-4921 et seq., and amendments thereto, and K.A.R. 28-52-1 through 28-52-4, and with the ambulatory surgical center's risk management plan. Any ambulatory surgical center having a medical staff with fewer than two physician members shall include provisions for outside peer review in the risk management plan.

(l) All medical orders shall be given by a practitioner and recorded in accordance with the medical staff policies and procedures. All orders shall be signed or either countersigned or initialed by the attending physician, dentist, or podiatrist.

(m) The medical staff and the governing authority shall review the medical staff privileges at least every two years.