| (VIII) A hospital's credentials committee shall act
expeditiously and without unnecessary delay when a licensed physician,
podiatrist, or dentist submits a completed application for medical
staff membership or privileges. The hospital's credentials committee
shall take action on the completed application not later than the
90th day after the date on which the application is received. The
governing body of the hospital shall take final action on the application
for medical staff membership or privileges not later than the 60th
day after the date on which the recommendation of the credentials
committee is received. The hospital must notify the applicant in writing
of the hospital's final action, including a reason for denial or restriction
of privileges, not later than the 20th day after the date on which
final action is taken.
(ii) The governing body is authorized to adopt, implement
and enforce policies concerning the granting of clinical privileges
to advanced practice registered nurses (APRNs) and physician assistants,
including policies relating to the application process, reasonable
qualifications for privileges, and the process for renewal, modification,
or revocation of privileges.
(I) If the governing body of a hospital has adopted,
implemented and enforced a policy of granting clinical privileges
to APRNs or physician assistants, an individual APRN or physician
assistant who qualifies for privileges under that policy shall be
entitled to certain procedural rights to provide fairness of process,
as determined by the governing body of the hospital, when an application
for privileges is submitted to the hospital. At a minimum, any policy
adopted shall specify a reasonable period for the processing and consideration
of the application and shall provide for written notification to the
applicant of any final action on the application by the hospital,
including any reason for denial or restriction of the privileges requested.
(II) If an APRN or physician assistant has been granted
clinical privileges by a hospital, the hospital may not modify or
revoke those privileges without providing certain procedural rights
to provide fairness of process, as determined by the governing body
of the hospital, to the APRN or physician assistant. At a minimum,
the hospital shall provide the APRN or physician assistant written
reasons for the modification or revocation of privileges and a mechanism
for appeal to the appropriate committee or body within the hospital,
as determined by the governing body of the hospital.
(III) If a hospital extends clinical privileges to
an APRN or physician assistant conditioned on the APRN or physician
assistant having a sponsoring or collaborating relationship with a
physician and that relationship ceases to exist, the APRN or physician
assistant and the physician shall provide written notification to
the hospital that the relationship no longer exists. Once the hospital
receives such notice from an APRN or physician assistant and the physician,
the hospital shall be deemed to have met its obligations under this
section by notifying the APRN or physician assistant in writing that
the APRN's or physician assistant's clinical privileges no longer
exist at that hospital.
(IV) Nothing in this clause shall be construed as modifying
Subtitle B, Title 3, Occupations Code, Chapter 204 or 301, or any
other law relating to the scope of practice of physicians, APRNs,
or physician assistants.
(V) This clause does not apply to an employer-employee
relationship between an APRN or physician assistant and a hospital.
(G) The governing body shall ensure that the hospital
complies with the requirements concerning physician communication
and contracts as set out in Health and Safety Code, §241.1015
(Physician Communication and Contracts).
(H) The governing body shall ensure the hospital complies
with the requirements for reporting to the Texas Medical Board the
results and circumstances of any professional review action in accordance
with the Medical Practice Act, Occupations Code, §160.002 and §160.003.
(I) The governing body shall be responsible for and
ensure that any policies and procedures adopted by the governing body
to implement the requirements of this chapter shall be implemented
and enforced.
(5) Hospital administration. The governing body shall
appoint a chief executive officer or administrator who is responsible
for managing the hospital.
(6) Patient care. In accordance with hospital policy
adopted, implemented and enforced, the governing body shall ensure
that:
(A) every patient is under the care of:
(i) a physician. This provision is not to be construed
to limit the authority of a physician to delegate tasks to other qualified
health care personnel to the extent recognized under state law or
the state's regulatory mechanism;
(ii) a dentist who is legally authorized to practice
dentistry by the state and who is acting within the scope of his or
her license; or
(iii) a podiatrist, but only with respect to functions
which he or she is legally authorized by the state to perform.
(B) patients are admitted to the hospital only by members
of the medical staff who have been granted admitting privileges;
(C) a physician is on duty or on-call at all times;
(D) specific colored condition alert wrist bands that
have been standardized for all hospitals licensed under Health and
Safety Code, Chapter 241, are used as follows:
(i) red wrist bands for allergies;
(ii) yellow wrist bands for fall risks; and
(iii) purple wrist bands for do not resuscitate status;
(E) the governing body shall consider the addition
of the following optional condition alert wrist bands. This consideration
must be documented in the minutes of the meeting of the governing
body in which the discussion was held:
(i) green wrist bands for latex allergy; and
(ii) pink wrist bands for restricted extremity; and
(F) the governing body shall adopt, implement, and
enforce a policy and procedure regarding the removal of personal wrist
bands and bracelets as well as a patient's right to refuse to wear
condition alert wrist bands; and
(G) the governing body shall adopt, implement, and
enforce policies and procedures regarding DNR orders issued in the
hospital by the attending physician that comply with Health and Safety
Code, Chapter 166, Subchapter E (relating to Health Care Facility
Do-Not-Resuscitate Orders), including policies and procedures regarding
the rights of a patient and person authorized to make treatment decisions
regarding the patient's DNR status; notice and medical record requirements
for DNR orders and revocations; and actions the attending physician
and hospital must take pursuant to Health and Safety Code §166.206
when the attending physician or hospital and the patient or person
authorized to make treatment decisions regarding the patient's DNR
status are in disagreement about the execution of, or compliance with,
a DNR order. The policies and procedures shall include that:
(i) Except in circumstances described by Health and
Safety Code §166.203(a)(2), a DNR order issued for a patient
is valid only if the patient's attending physician issues the order,
the order is dated, and the order is issued in compliance with:
(I) the written and dated directions of a patient who
was competent at the time the patient wrote the directions;
(II) the oral directions of a competent patient delivered
to or observed by two competent adult witnesses, at least one of whom
must be a person not listed under Health and Safety Code §166.003(2)(E)
or (F);
(III) the directions in an advance directive enforceable
under Health and Safety Code §166.005 or executed in accordance
with Health and Safety Code §§166.032, 166.034, or 166.035;
(IV) the directions of a patient's legal guardian or
agent under a medical power of attorney acting in accordance with
Health and Safety Code, Chapter 166, Subchapter D (relating to Medical
Power of Attorney); or
(V) a treatment decision made in accordance with Health
Safety Code §166.039.
(ii) A DNR order that is not issued in accordance with
Health and Safety Code §166.203(a)(1) is valid only if the patient's
attending physician issues the order, the order is dated, and:
(I) the order is not contrary to the directions of
a patient who was competent at the time the patient conveyed the directions;
(II) in the reasonable medical judgment of the patient's
attending physician, the patient's death is imminent, regardless of
the provision of cardiopulmonary resuscitation; and
Cont'd... |
