Idaho Admin. Code r. 16.03.14.250

Current through September 2, 2024

Section 16.03.14.250 - MEDICAL STAFF

The hospital must have an active medical staff organized under bylaws approved by the governing body and responsible to the governing body for the quality of all medical care provided the patients, and for the professional practices and ethical conduct of the members.

01.Medical Staff Qualifications and Privileges. All medical staff members must be qualified legally and professionally for the privileges that they are granted.

a. Privileges must be granted only on the basis of individual training, competence, and experience.

b. The medical staff, with governing body approval, must develop and implement a written procedure for determining qualifications for medical staff appointment, and for determining privileges.

c. The governing body must approve medical staff privileges within the limits of the hospital's capabilities for providing qualified support staff and equipment in specialized areas.

02.Authority to Admit Patients. A hospital may grant to physicians, physician assistants, and advanced practice nurses the privilege to admit patients, provided that admitting privileges be granted only if the privileges are:

a. Recommended by the medical staff at the hospital;

b. Approved by the governing body of the hospital; and

c. Within the scope of practice conferred by the license of the physician, physician assistant, or advanced practice nurse.

d. A hospital must specify in its bylaws the process by which its governing body and medical staff oversee those practitioners granted admitting privileges. Such oversight must include credentialing and competency review.

03.Medical Staff Appointments and Reappointments. Medical staff appointments and reappointments must be made by the governing body upon the recommendation of the active medical staff, or a committee of the active staff.

a. Appointments to the medical staff must include a written delineation of all privileges including surgical procedures, and governing body approval must be documented.

b. Reappointments to the medical staff must be made periodically with appropriate documentation indicating governing body approval.

c. Reappointment procedures must include a means of increasing or decreasing privileges after consideration of the member's physical and mental capabilities.

d. The medical staff and administration with approval of the governing body must develop a written procedure for temporary or emergency medical staff privileges.

04.Required Hospital Functions. Each hospital must have a mechanism in place to perform the following functions:

a. Coordinate all activities of the medical staff;

b. Develop a hospital formulary and procedures for the choice and control of all drugs used in the hospital;

c. Establish procedures to prevent and control infections in the hospital;

d. Develop and monitor standards of medical records contents;

e. Maintain communications between medical staff and the governing body of the hospital; and

f. Review clinical work of the medical staff.

05.Documentary Evidence of Medical Staff Activities. The medical staff or any committees of the staff must meet as often as necessary, but at least twice annually, to assure implementation of the required functions in Subsection 250.04 of this rule. Minutes of all meetings of the medical staff or any committees of the staff must be maintained.

06.Medical Staff Bylaws, Rules, and Regulations. These must specify at least the following:

a. A description of the medical staff organization that includes:

i. Officers and their duties;

ii. Staff committees and their responsibilities;

iii. Frequency of staff and committee meetings; and

iv. Agenda for all meetings and the type of records to be kept.

b. A statement of the necessary qualifications for appointment to the staff, and the duties and privileges of each category of medical staff.

c. A procedure for appointment, granting and withdrawal of privileges.

d. A mechanism for hearings and appeals of decisions regarding medical staff membership and privileges.

e. A statement regarding attendance at staff meetings.

f. A statement of qualifications and a procedure for delineation of clinical privileges for all categories of nonphysician practitioners.

g. A requirement for keeping accurate and complete medical records.

h. A requirement that all tissue surgically removed will be delivered to a pathologist for a report on such specimens, unless the medical staff, in consultation with the pathologist, adopts uniform exceptions to sending tissue specimens to the laboratory for analysis.

i. A statement requiring a medical history and physical examination be performed no more than seven (7) days before or within forty-eight (48) hours after admission. The findings from this history and physical examination, including a provisional diagnosis, must be included in the medical record prior to surgery, except in emergencies.

j. A requirement that consultation is necessary with unusual cases, except in emergencies. Unusual cases must be defined by the hospital medical staff.

07.Review of Policies and Procedures. The medical staff must review and approve all policies and procedures directly related to medical care.

08.Dentists and Podiatrists. If dentists and podiatrists are appointed to the medical staff, the bylaws must specifically refer to services performed by such professionals, and must specify at least the following:

a. Patients admitted for dental or podiatry service must be under the general care of a physician member of the active staff.

b. All medical staff requirements and procedure for privileges must be followed for dentists and podiatrists.

09.Dating of Bylaws. Bylaws must be dated and signed by the current officers of the medical staff or the committee of the whole.

10.Medical Orders. Written, verbal and telephone orders from persons authorized to give medical orders under Idaho law must be accepted by those health care practitioners empowered to do so under Idaho law and written hospital policies and procedures. Verbal and telephone orders must contain the name of the person giving the order, the first initial and last name and professional designation of the health care practitioners receiving the order. The order(s) must be promptly signed or otherwise authenticated by the prescribing practitioner in a timely manner in accordance with the hospital's policy.

Idaho Admin. Code r. 16.03.14.250

Effective November 14, 2023 (Temporary)