Ga. Comp. R. & Regs. 111-8-40-.11

Current through Rules and Regulations filed through October 29, 2024

Rule 111-8-40-.11 - Medical Staff

Each hospital shall have an organized medical staff that operates under bylaws adopted by the medical staff and approved by the governing body. The bylaws may provide for the exercise of the medical staff's authority through committees.

(a)Organization of the Medical Staff. The medical staff shall be organized and may operate through defined committees as appropriate.

1. Any physician, podiatrist, or dentist providing patient care, whether directly or by contract with the hospital, shall obtain clinical privileges through the hospital's medical staff credentialing process.

2. The medical staff shall be responsible for the examination of credentials of any candidate for medical staff membership and for any other individuals seeking clinical privileges and for the recommendations to the governing body concerning appointment of such candidates. Minimum requirements for medical staff appointments and clinical privileges shall include:

(i) Valid and current Georgia license to practice the respective profession;

(ii) Confirmed educational qualifications for the position of appointment;

(iii) References for practice and performance background;

(iv) Current health and mental status sufficient to perform medical and professional duties;

(v) Current Drug Enforcement Agency registration; if applicable;

(vi) Evidence of inquiry through relevant practitioner databases, such as databases maintained by licensing boards and the National Practitioner Data Bank; and

(vii) Congruity of the qualifications and/or training requirements with the privilege requested.

3. The medical staff shall evaluate at least biennially the credentials and professional performance of any individual granted clinical privileges for consideration for reappointment.

4. The medical staff shall establish a system for the approval of temporary or emergency staff privileges when needed.

(b)Medical Staff Accountability. The medical staff shall be accountable to the governing body for the quality of medical care provided to all patients.

1. The medical staff shall require that all individuals granted clinical privileges comply with generally accepted standards of practice.

2. The medical staff shall implement measures, including peer review, to monitor the on-going performance of the delivery of patient care by those granted clinical privileges, including monitoring of compliance with the medical staff bylaws, rules and regulations, and hospital policies and procedures.

3. The medical staff shall establish effective systems of accountability for any hospital services ordered by physicians and other practitioners.

4. The medical staff shall review and, when appropriate, recommend to the governing body denial, limitation, suspension, or revocation of the privileges of any practitioner who does not practice in compliance with the scope of privileges, the medical staff bylaws, rules and regulations, generally accepted standards of practice, or hospital policies and procedures.

(c)Medical Staff Bylaws and Rules and Regulations. The medical staff of the hospital shall adopt and enforce bylaws and rules and regulations which provide for the self-governance of medical staff activities and accountability to the governing body for the quality of care provided to all patients. The bylaws and rules and regulations shall become effective when approved by the governing body and shall include at a minimum:

1. A mechanism for participation of medical staff in policy decisions related to patient care in all areas of the hospital;

2. A plan for administrative organization of the medical staff and committees thereof, which clearly delineates lines of authority, delegation, and responsibility for various tasks and functions;

3. Description of the qualifications and performance to be met by a candidate in order for the medical staff to recommend appointment or reappointment by the governing body;

4. Criteria and procedures for recommending the privileges to be granted to individual physicians, dentists, or podiatrists;

5. A requirement that members of the medical staff comply with ethical and professional standards;

6. Requirements for regular health screenings for all active members of the medical staff that are developed in consultation with hospital administration, occupational health, and infection control/ safety staff. The health screenings shall be sufficient to identify conditions which may place patients or other personnel at risk for infection, injury, or improper care. There shall be a mechanism for the reporting of the screening results to the hospital, either through the medical staff or otherwise;

7. A mechanism for ensuring physician response to inpatient emergencies twenty-four (24) hours per day;

8. A mechanism for physician coverage of the emergency department and designation of who is qualified to conduct an emergency medical screening examination where emergency services are provided;

9. A requirement that referral for consultations will be provided to patients when a patient's physical or mental condition exceeds the clinical expertise of the attending member of the medical staff;

10. The requirements for the patient's history and physical examination, which must be performed either within twenty-four (24) hours after admission or within the thirty (30) days prior to admission and updated upon admission. See Rule 111-8-40-.28(a)(2) for history and physical requirements when surgery is being performed;

11. Establishment of procedures for the choice and control of all drugs in the hospital;

12. The requirements for the completion of medical records;

13. The requirements for verbal/telephone orders, to include which Georgia-licensed or Georgia-certified personnel or other qualified individuals may receive verbal/telephone orders, and the acceptable timeline for authentication of the orders, not to exceed the timeline requirements of these rules;

14. A mechanism for peer review of the quality of patient care, which includes, but is not limited to, the investigation of reportable patient incidents involving patient care as described in Rule 111-8-40-.07(2)(a); and

15. A procedure for review and/or update of the bylaws and rules and regulations as necessary, but at least once every three (3) years.

(d)Other Medical Staff Policies. If not addressed through the medical staff bylaws or rules and regulations, the medical staff shall develop and implement policies to address, at a minimum:

1. Criteria for when an autopsy shall be sought and a requirement that the attending physician be notified when an autopsy is performed; and

2. A requirement that every member of the medical staff provide appropriate medical care for each of their patients until the patient is stable for discharge or until care of the patient has been transferred to another member of the medical staff or to another facility.

Ga. Comp. R. & Regs. R. 111-8-40-.11

O.C.G.A. §§ 31-7-2.1 and 31-7-15.

Original Rule entitled "Medical Staff" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.