La. Admin. Code tit. 48 § I-9321

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-9321 - Medical Staff

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.

La. Admin. Code tit. 48, § I-9321

Promulgated by the Department of Health and Human Resources, Office of the Secretary, LR 13:246 (April 1987), amended by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 21:177 (February 1995), LR 29:2406 (November 2003), Amended by the Department of Health, Health Standards Section, LR 501481 (10/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S.36:254 and R.S. 40:2100-2115.