Current through Vol. 41, No. 13, March 15, 2024
(a)
General. The CAH shall have an organized medical and professional
staff responsible for the quality of care provided to all patients. The staff
shall operate under bylaws approved by the governing body.
(b)
Composition. The CAH shall
have a medical and professional staff composed of one (1) or more physicians
and which may also include one (1) or more licensed independent practitioners
with privileges at the CAH. Privileges may also be extended to other health
care professionals who are authorized by state law to provide treatment
services.
(1) The staff shall periodically
reexamine credentials and conduct appraisals of its members and make
recommendations regarding reappointments and privilege delineations to the
governing body. The staff shall also examine credentials of candidates for
staff membership and make recommendations regarding appointments and privileges
extended.
(2) Temporary staff
privileges may be extended to qualified physicians, licensed independent
practitioners and other professional staff as specified in the medical and
professional staff bylaws.
(3)
Patient admission quotas or revenue generation minimums shall not be a
condition for appointment or reappointment.
(c)
Organization and
accountability. The medical and professional staff shall be well
organized and accountable to the governing body for the quality of medical care
provided to patients.
(1) The staff shall be
organized and elect officers as required by approved medical staff bylaws.
Officers of the staff shall hold active privileges and may include elected
licensed independent practitioners. The chief of staff (or equivalent) shall be
a physician who shall be responsible for organization and enforcement of the
bylaws.
(2) The staff shall meet at
least monthly as a committee of the whole to review the quality of medical care
provided, fulfill committee functions specified in the staff bylaws, and to
consider and recommend actions to the governing body. Meetings may include
staff from the affiliated general medical surgical hospital or other off-site
physicians or practitioners who have privileges at the CAH and may be conducted
by teleconference. Minutes of meetings shall be maintained and available for
review at the CAH.
(d)
Medical and professional staff bylaws. The medical and
professional staff shall adopt and enforce bylaws to carry out their
responsibilities. The medical staff bylaws shall:
(1) Be approved by the governing
body.
(2) Include a statement of
the duties and privileges of each category of the medical and professional
staff. These categories shall include a category of licensed independent
practitioner, and may include a category of supervised practitioner in addition
to other categories; e.g, active, courtesy, consulting, etc.
(3) Describe the organization of the medical
and professional staff.
(4)
Describe the qualifications for each category of the medical and professional
staff.
(5) Require each inpatient
to have a history and physical examination performed no more than thirty (30)
days before, or forty-eight (48) hours after, admission by a physician or
licensed independent practitioner. The examination shall be approved and signed
by the physician or licensed independent practitioner. The approval and
signature may be performed electronically or by facsimile.
(6) When the medical history and physical
examination are completed within thirty (30) days before admission, the
hospital must ensure that an updated medical record entry documenting an
examination for any changes in the patient's condition is completed. A timely
review of the prior history and physical examination or an updated examination
must be completed and documented in the patient's medical record within
forty-eight (48) hours.
(7) Specify
the procedure for determining the privileges to be granted to individual
physicians and practitioners initially and on reappointment and the process for
physicians and practitioners to request these privileges.
(8) Specify the mechanism to withdraw
privileges of staff members and the circumstances when privileges shall be
withdrawn.
(9) Specify the
mechanism for appeal of decisions regarding staff membership and privilege
delineations.
(10) Specify the
mechanism for monitoring and controlling the use of preventive antibiotics and
the use of antibiotics in the presence of infection.
Added at 12 Ok Reg 1555,
eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 17 Ok
Reg 692, eff 12-16-99 (emergency); Amended at 17 Ok Reg 2992, eff 7-13-00;
Amended at 20 Ok Reg 1664, eff 6-12-03; Amended at 24 Ok Reg 1189, eff 4-2-07
(emergency); Amended at 25 Ok Reg 2472, eff
7-11-08
