Ala. Admin. Code r. 420-5-7-.09

Current through Register Vol. 43, No. 1, October 31, 2024

Section 420-5-7-.09 - Medical Staff

(1) The hospital shall have an organized medical staff that operates under bylaws approved by the governing authority and is responsible for the quality of medical care provided to patients by the hospital.

(2) Composition of the medical staff. The medical staff shall be composed of doctors of medicine or osteopathy and may also be composed of other practitioners appointed by the governing authority.

(a) The medical staff shall periodically conduct appraisals of its members.

(b) The medical staff shall examine credentials of candidates for medical staff membership and make recommendations to the governing authority on the appointment of the candidates.

(c) Hospitals may provide telemedicine services to their patients if these medical services are provided pursuant to a written contract. If these services are provided by contract with another hospital that hospital shall be a Medicare-participating hospital and assure the physicians providing the telemedicine services are privileged to offer the services in the second hospital and are licensed in Alabama. If these services are provided by a distant-site telemedicine entity other than a Medicare-participating hospital, the physicians must be appropriately credentialed to provide these services and must be licensed in Alabama.

(3) Medical staff organization and accountability. The medical staff shall be well organized and accountable to the governing authority for the quality of the medical care provided to patients.

(a) The medical staff shall be organized in a manner approved by the governing authority.

(b) If the medical staff has an executive committee, a majority of the members of the committee shall be doctors of medicine or osteopathy.

(c) The responsibility for organization and conduct of the medical staff shall be assigned only to an individual doctor of medicine or osteopathy.

(4) Medical staff bylaws. The medical staff shall adopt and enforce bylaws to carry out its responsibilities. The bylaws shall:

(a) Be approved by the governing authority;

(b) Include a statement of the duties and privileges of each category of medical staff (such as active or courtesy);

(c) Describe the organization of the medical staff;

(d) Describe the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing authority;

e) Include a requirement that:

1. A medical history and physical examination be completed and documented for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. The medical history and physical examination shall be completed and documented by a physician, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with hospital policy.

2. An updated examination of the patient, including any changes in the patient's condition, be completed and documented within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, when the medical history and physical examination are completed within 30 days before admission or registration. The updated examination of the patient, including any changes in the patient's condition, shall be completed and documented by a physician, an oromaxillofacial surgeon, or other qualified licensed individual in accordance with hospital policy.

f) Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges.

(5) Autopsies. The medical staff should attempt to secure autopsies in all cases of unusual deaths and deaths of medical-legal and educational interest. The mechanism for documenting permission to perform an autopsy shall be defined. There shall be a system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed.

Ala. Admin. Code r. 420-5-7-.09

Filed September 1, 1982. Repealed and New Rule: Filed November 18, 1994; effective December 23, 1994. Repealed and New Rule: Filed August 24, 2012; effective September 28, 2012.

Rule .08 was renumbered to .09 as per certification filed August 24, 2012; effective September 28, 2012.

Author: W.T. Geary, Jr., M.D., Carter Sims

Statutory Authority:Code of Ala. 1975, §§ 22-21-20, et seq.