New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS
Part 12 - REQUIREMENTS FOR ACUTE CARE, LIMITED SERVICES AND SPECIAL HOSPITALS
Section 8.370.12.26 - MEDICAL STAFF
Universal Citation: 8 NM Admin Code 8.370.12.26
Current through Register Vol. 35, No. 18, September 24, 2024
A. General requirements:
(1)
Organization and Accountability: The hospital shall have a medical staff
organized under by-laws approved by the governing body. The medical staff shall
be responsible to the governing body of the hospital for the quality of all
medical care provided patients in the hospital and for the ethical and
professional practices of its members.
(2) Responsibility of members: Members of the
medical staff shall comply with medical staff and hospital policies. The
medical staff by-laws shall prescribe disciplinary procedures for infraction of
hospital and medical staff policies by members of the medical staff. There
shall be evidence that the disciplinary procedures are applied where
appropriate.
B. Membership:
(1) Active staff: A
hospital shall have an active medical staff, which performs all the
organizational duties pertaining to the medical staff. Active staff membership
shall be limited to individuals, as defined in Subsection LL of 8.370.12.7 NMAC
of these requirements, who are currently licensed. Individuals may be granted
membership in accordance with the medical staff by-laws and rules, and in
accordance with the by-laws of the hospital.
(2) Other staff: The medical staff may
include one or more categories defined in the medical staff by-laws in addition
to the active staff including a category to cover appointment during periods of
disaster and emergency.
C. Appointment:
(1) Governing body responsibilities:
(a) medical staff appointments shall be made
by the governing body, taking into account recommendations made by the active
medical staff;
(b) the governing
body shall biennially ensure that members of the medical staff are qualified
legally and professionally for the position to which they are
appointed;
(c) the hospital,
through its medical staff, shall require applicants for medical staff
membership to provide, in addition to other medical staff requirements, a
complete list of all hospital medical staff memberships held within five years
prior to application; and
(d)
hospital medical staff applications shall require reporting any malpractice
action, any previously successful and currently pending challenges to licensure
in this or another state, and any loss or pending action affecting medical
staff membership or privileges at another hospital.
(2) Medical staff responsibilities:
(a) to select its members and delineate their
privileges, the hospital medical staff shall have a system, based on specific
standards for evaluation of each applicant by a credentials committee, which
makes recommendations to the medical staff and to the governing body;
and
(b) the medical staff may
include one or more categories of medical staff defined in the medical staff
by-laws in addition to the active medical staff, including a category to cover
appointment during periods of disaster and emergency, but this in no way
modifies the duties and responsibilities of the active staff.
D. Criteria for appointment:
(1) Criteria for selection
shall include the individual's current licensure, health status, professional
performance, judgment and clinical and technical skills.
(2) All qualified candidates shall be
considered by the credentials committee or during periods of disaster and
emergency by a member of the medical staff or administration who represents the
credentials committee.
(3)
Reappointments shall be made at least biennially and recorded in the minutes or
files of the governing body. Reappointment policies shall provide for a
periodic appraisal of each member of the staff, including consideration at the
time of reappointment of information concerning the individual's current
licensure, health status, professional performance, judgment and clinical and
technical skills. Recommendations for reappointments shall be noted in the
minutes of the meetings of the appropriate committee.
(4) Temporary staff privileges may be granted
for a limited period if the individual is qualified for membership on the
medical staff.
(5) Disaster and
emergency privileges may be granted to qualified individuals during disasters
and emergencies.
(6) A copy of the
scope of privileges to be accorded the individual shall be distributed to
appropriate hospital staff. The privileges of each staff member shall be
specifically stated or the medical staff shall define a classification system.
If a system involving classifications is used, the scope of the categories
shall be well defined, and the standards that must be met by the applicant,
shall be clearly stated for each category.
(7) If other categories of staff membership
are to be established for allied health personnel, the necessary
qualifications, privileges and rights shall be delineated in accordance with
the medical staff by-laws.
E. Consultations:
(1) The medical staff must have established
policies concerning the holding of consultations.
(2) Except in an emergency, consultations are
required when:
(a) the patient is not a good
medical or surgical risk;
(b) the
diagnosis is obscure;
(c) there is
doubt as to the best therapeutic measures to be utilized; or
(d) when the patient, or legally authorized
person, requests such consultation.
(3) Consultations must be included in the
medical record. When operative procedures are involved, the consultation note,
except in an emergency, shall be recorded prior to the operation.
(4) The patient's physician or authorized
licensed independent practitioner is responsible for requesting consultations
when indicated. It is the duty of the medical staff to make certain that
members of the medical staff contact consultants as needed.
F. By-laws:
(1) Adoption and purpose: By-laws shall be
adopted by the medical staff and approved by the governing body to govern and
enable the medical staff to carry out its responsibilities. The by-laws of the
medical staff shall be a precise and clear statement of the policies under
which the medical staff regulates itself.
(2) Content: medical staff by-laws and rules
shall include:
(a) a descriptive outline of
the medical staff organization;
(b)
a statement of the necessary qualifications which each member must possess to
be privileged to work in the hospital, during periods of routine operation, as
well as during periods of disaster and emergency, and of the duties and
privileges of each category of medical staff;
(c) a procedure for granting or withdrawing
privileges to each member; and an appeal process for privilege withdrawal or
refusal;
(d) a mechanism for appeal
of decisions regarding medical staff membership and privileges;
(e) provision for regular meetings of the
medical staff;
(f) provision for
keeping timely, accurate and complete records;
(g) provisions for routine examination of all
patients upon admission and recording of the preoperative diagnosis prior to
surgery;
(h) a stipulation that a
surgical operation is permitted only with the consent of the patient or legally
authorized person except in emergencies;
(i) statements concerning the request for the
performance of consultations, and instances where consultations are require;
and
(j) a statement specifying
categories of personnel duly authorized to accept and implement medical staff
orders.
G. Governance:
(1) The medical staff
shall have the numbers and kinds of officers necessary for the governance of
the staff.
(2) Officers shall be
members of the active staff and shall be elected by the active medical
staff.
H. Meetings:
(1) Number and
frequency: The number and frequency of medical staff meetings shall be
determined by the active medical staff and clearly stated in the by-laws of the
medical staff. At a minimum the executive committee of the medical staff shall
meet at least quarterly.
(2)
Attendance: Attendance records shall be kept of medical staff meetings.
Attendance requirements for each individual member shall be clearly stated in
the by-laws of the medical staff.
(3) Purpose: Full medical staff meetings
shall be held to conduct the general business of the medical staff and to
review the significant findings identified through the quality improvement
program.
(4) Minutes: Minutes of
all meetings shall be kept.
I. Committees.
(1) Establishment: The medical staff shall
establish committees of the medical staff and is responsible for their
performance.
(2) Executive
committee: The medical staff shall have an executive committee to coordinate
the activities and general policies of the various departments, act for the
staff as a whole under limitations that may be imposed by the medical staff
bylaws, and receive and act upon the reports of all other medical staff
committees.
J. Administrative structure: Hospitals may create services to fulfill medical staff responsibilities. Services are responsible for the quality of care rendered to patients under their care.
Disclaimer: These regulations may not be the most recent version. New Mexico 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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
