Fla. Admin. Code R. 59A-3.275

Current through Reg. 50, No. 235-239, December 10, 2024

Section 59A-3.275 - Organized Medical Staff

(1) Each hospital shall have an organized medical staff organized under written by-laws approved by the governing board and responsible to the governing board of the hospital for the quality of all health care provided to patients in the facility and for the ethical and professional practices of its members.

(2) Each hospital's organized medical staff shall determine its appropriate committee structure and shall provide that the following required committee functions are carried out with sufficient periodicity to assure their objectives being achieved by separate committee, combined committees, or committee of the whole:

(a) Coordination of the activities and general policies of the various departments.

(b) Interim decision making for the organized medical staff between staff meetings, under such limitations as shall be set by the organized medical staff.

(c) Follow-up and appropriate disposition of all reports dealing with the various staff functions.

(d) Review of all applications for appointment and reappointment to all categories of staff, and recommendations on each to the governing board, including delineation of privileges to be granted in each case, and right of hearing and appearance. Except in emergency cases, recommendations to the governing board for withdrawal of any privileges of a member of the organized medical staff or dismissal from the organized medical staff will be made only after a thorough investigation by the organized medical staff or a committee thereof, with the subject member being given the right of hearing before the organized medical staff or a committee thereof, if requested within a reasonable time as specified in the hospital's by-laws.

(e) Medical records currently maintained describing the condition, treatment, and progress of patient in sufficient completeness to assure transferable comprehension of the case at any time.

(f) Clinical evaluation of the quality of medical care provided to all categories of patients on the basis of documented evidence.

(g) Review of hospital admissions with respect to need for admission, length of stay, discharge practices and evaluation of the services ordered and provided.

(h) Surveillance of hospital infection potentials and cases and the promotion of a preventive and corrective program designed to minimize these hazards.

(i) Surveillance of pharmacy and therapeutic policies and practices within the institution.

(j) Hospital tests may be ordered only by the attending physician, or by another licensed health professional if that licensed health professional is acting within his scope of practice as defined by applicable laws and rules of the agency. Nothing herein shall be construed to expand or restrict such laws and rules pertaining to the practice of the various health professions.

Fla. Admin. Code Ann. R. 59A-3.275

Rulemaking Authority 395.1055 FS. Law Implemented 395.0191, 395.1055 FS.

New 9-4-95, Formerly 59A-3.220.