| (V) In granting or refusing medical staff membership
or privileges, a hospital may not differentiate on the basis of the
academic medical degree held by a physician.
(VI) Graduate medical education may be used as a standard
or qualification for medical staff membership or privileges for a
physician, provided that equal recognition is given to training programs
accredited by the Accreditation Council for Graduate Medical Education
and by the American Osteopathic Association.
(VII) Board certification may be used as a standard
or qualification for medical staff membership or privileges for a
physician, provided that equal recognition is given to certification
programs approved by the American Board of Medical Specialties and
the Bureau of Osteopathic Specialists.
(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 nurses 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 advanced practice nurses or physician assistants, an individual
advanced practice nurse 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 advanced practice nurse 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 advanced practice nurse or physician
assistant. At a minimum, the hospital shall provide the advanced practice
nurse 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 advanced practice nurse or physician assistant conditioned on the
advanced practice nurse or physician assistant having a sponsoring
or collaborating relationship with a physician and that relationship
ceases to exist, the advanced practice nurse 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 advanced practice nurse or physician assistant
and the physician, the hospital shall be deemed to have met its obligations
under this section by notifying the advanced practice nurse or physician
assistant in writing that the advanced practice nurse'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, advanced
practice nurses, or physician assistants.
(V) This clause does not apply to an employer-employee
relationship between an advanced practice nurse 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.
(7) Services. The governing body shall be responsible
for all services furnished in the hospital, whether furnished directly
or under contract. The governing body shall ensure that services are
provided in a safe and effective manner that permits the hospital
to comply with applicable rules and standards. At hospitals that have
a mental health service unit, the governing body shall adopt, implement,
and enforce procedures for the completion of criminal background checks
on all prospective employees that would be considered for assignment
to that unit, except for persons currently licensed by this state
as health professionals.
(8) Nurse Staffing. The governing body shall adopt,
implement and enforce a written nurse staffing policy to ensure that
an adequate number and skill mix of nurses are available to meet the
level of patient care needed. The governing body policy shall require
that hospital administration adopt, implement and enforce a nurse
staffing plan and policies that:
(A) require significant consideration be given to the
nurse staffing plan recommended by the hospital's nurse staffing committee
and the committee's evaluation of any existing plan;
(B) are based on the needs of each patient care unit
and shift and on evidence relating to patient care needs;
(C) ensure that all nursing assignments consider client
safety, and are commensurate with the nurse's educational preparation,
experience, knowledge, and physical and emotional ability;
(D) require use of the official nurse services staffing
plan as a component in setting the nurse staffing budget;
(E) encourage nurses to provide input to the nurse
staffing committee relating to nurse staffing concerns;
Cont'd... |
