Current through Vol. 41, No. 13, March 15, 2024
(a)
General. The EH 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. The medical and
professional staff may function as a part of an affiliated hospital's organized
staff as long as individual physician and practitioner privileges are
independently recommended and approved by the EH governing body. If staff
functions are combined with an affiliated hospital, EH functions required by
the medical and professional staff bylaws shall be independently identified and
reviewed during combined staff meetings.
(b)
Composition. The EH shall
have a medical and professional staff composed of one (1) or more physicians or
licensed independent practitioners. 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 physicians and 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.
(2) The staff shall meet at least quarterly
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 hospitals or other off-site physicians or practitioners who have
privileges at the EH and may be conducted by teleconference. Minutes of
meetings shall be maintained and available for review at the EH.
(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. All
physicians and licensed independent practitioners with privileges may admit
patients for stabilization or observational care.
(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 review
of the prior history and physical examination or an updated examination must be
completed immediately upon admission 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.
Added 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
