Current through Register Vol. 43, No. 39, September 26, 2024
(a) General
provision. Each hospital shall maintain an organized medical staff. Admission
to the staff and clinical privileges associated with membership shall be
granted by the governing authority through a mechanism that evaluates each
member's qualifications to engage in that member's area of clinical practice.
Admitting privileges may be granted to any practitioner as defined in K.A.R.
28-34-1a(w).
(b) Membership. The
medical staff shall be limited to practitioners who have made application in
accordance with the bylaws of the medical staff and the governing body. The
medical staff shall adopt bylaws that define the requirements for admission to
staff membership and for the delineation and retention of clinical and
admitting privileges. Each member shall be granted privileges that are
commensurate with the member's qualifications, experience, and present
capabilities and that are within the member's scope of practice. Although
certification, fellowship, membership on a specialty board or society, or the
completion of a general practice residency may be considered in determining an
individual's qualifications for medical staff membership, membership decisions
shall not be made solely upon any one of these factors.
(c) Medical staff status.
(1) Each hospital shall have an active
medical staff to deliver the preponderance of medical services within the
hospital. The active medical staff shall have primary responsibility for the
organization and administration of the medical staff. Each member of the active
medical staff shall be eligible to vote at staff meetings, hold office, and
serve on staff committees.
(2) In
addition to the active medical staff, the hospital may provide for additional
kinds of medical staff privileges. These additional staff categories shall in
no way modify the privileges, duties, and responsibilities of the active
medical staff. These additional staff categories may be eligible to vote at
staff meetings, hold office, and serve on staff committees.
(d) Appointment and reappointment.
After considering medical staff recommendations, the governing body shall
affirm, deny, or modify each recommendation for appointment to the medical
staff and the granting of clinical privileges to any practitioner. Formal
application for membership and for the granting of clinical privileges shall
follow established procedures set forth in the bylaws, policies, and procedures
of the medical staff.
(e) Medical
staff bylaws, policies, and procedures. The medical staff shall develop and
adopt, subject to the approval of the governing body, a set of bylaws that
shall provide for at least the following:
(1)
The organizational structure of the medical staff;
(2) qualifications for staff membership and
procedures for admission, retention, assignment, and either reduction or
withdrawal of privileges;
(3)
procedures and standards for the review of staff credentials;
(4) a mechanism for an appeal by a
practitioner who receives an unfavorable medical staff recommendation;
(5) delineation of clinical
privileges and duties of professional personnel who function in a clinical
capacity and who are not members of the medical staff;
(6) methods for the selection of officers and
department or service chairpersons and a description of their duties and
responsibilities;
(7) the
composition and function of standing committees;
(8) requirements regarding the completion of
medical records, including a system of disciplinary action for failure to
complete the records of discharged patients within 30 days after dismissal or
current records within 48 hours of admission;
(9) a mechanism by which the medical staff
consults with and reports to the governing body;
(10) medical staff meetings for the purpose
of reviewing the performance of the medical staff and each department or
service and reports and recommendations of the medical staff and
multidisciplinary committees; and
(11) a mechanism for review of medical staff
performance that shall include consideration of relevant ethics and statutory
codes of conduct.
(f)
Medical care review. The medical staff shall develop and implement a system to
review medical services rendered, evaluate their quality, and provide an
educational program for medical staff members. This system shall include
written criteria for the evaluation of medical care that shall cover admission,
length of stay, and professional services furnished and shall be conducted on
at least a sample basis.
(g)
Medical orders.
(1) Medication or treatment
shall be administered only upon written and signed orders of a practitioner who
is acting within the scope of that practitioner's license and who is qualified
according to medical staff bylaws.
(2) A practitioner may give verbal orders,
including telephone orders, for medication or treatment to personnel who are
qualified according to medical staff bylaws. The person entering these orders
into the medical record shall sign and date the entry as soon as possible.
These orders shall be authenticated by the prescribing or covering practitioner
within 72 hours of the patient's discharge or 30 days, whichever occurs first.
