Louisiana Administrative Code
Title 48 - PUBLIC HEALTH-GENERAL
Part I - General Administration
Subpart 3 - Licensing and Certification
Chapter 93 - Hospitals
Subchapter B - Hospital Organization and Services
Section I-9321 - Medical Staff
Universal Citation: LA Admin Code I-9321
Current through Register Vol. 50, No. 12, December 20, 2024
A. The medical staff develops and adopts bylaws and rules for self-governance of professional activity and accountability to the governing body. In addition to physicians and dentists, the medical staff membership shall include licensed healthcare practitioners as appropriate to adequately meet the needs of the patients served by the hospital. The bylaws and rules shall contain provisions for at least the following.
1. The medical executive
committee shall:
a. develop the structure of
the medical staff and categories of membership;
b. develop and implement a mechanism to
review credentials, at least every three years, and delineate individual
privileges;
c. develop and
implement a mechanism for determining that all medical staff hold current
Louisiana licenses;
d. make
recommendations for membership to medical staff, for approval by the governing
body, with initial appointments and reappointments not to exceed two
years;
e. develop and implement a
mechanism for suspension and/or termination of membership to the medical
staff;
f. develop and implement a
mechanism for fair hearings and appellate reviews for both potential (new)
applicants and current members of the medical staff;
g. define the required functions of the
medical staff to include:
i. basic medical
record review, drug usage review, pharmacy and therapeutics review, infection
control and utilization review;
ii.
if applicable, surgical and other invasive procedures and blood
usage.
2. The
medical staff shall provide a mechanism to monitor and evaluate the quality of
patient care and the clinical performance of individuals with delineated
clinical privileges.
3. Each person
admitted to the hospital shall be under the care of a member of the medical
staff and shall not be admitted except on the recommendation of a medical staff
member.
4. There shall be a member
of the medical staff on call at all times for emergency medical care of
hospital patients.
5. The medical
staff bylaws shall include specifications for orders for the care or treatment
of patients that are given to the hospital verbally or transmitted to the
hospital electronically, whether by telephone, facsimile transmission, or
otherwise. Such bylaws may grant the medical staff up to 10 calendar days
following the date an order is transmitted verbally or electronically to
provide the signature or countersignature for such orders. Orders entered via
use of computerized provider order entry (CPOE) do not require a signature if
the CPOE used has an immediate download into the provider's electronic health
record (EHR) as the order would be dated, timed, authenticated, and promptly
placed in the medical record.
6.
There shall be a single chief of medical staff who reports directly to the
governing body and who is responsible for all medical staff activities for the
entire hospital, including any offsite facilities operating under the license
of the hospital.
7. There shall be
total integration of the organized medical staff as evidenced by these factors:
a. all medical staff members have privileges
at all off-site campuses;
b. all
medical staff committees are responsible for their respective areas of
responsibility at all off-site campuses of the hospital; and
c. the medical director of the off-site
campus (if the off-site campus has a medical director) maintains a day-to-day
reporting relationship to the chief medical officer or other similar official
of the provider.
AUTHORITY NOTE: Promulgated in accordance with R.S.36:254 and R.S. 40:2100-2115.
Disclaimer: These regulations may not be the most recent version. Louisiana may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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