| (A) The medical staff shall periodically conduct appraisals
of its members according to medical staff bylaws.
(B) The medical staff shall examine credentials of
candidates for medical staff membership and make recommendations to
the governing body on the appointment of the candidate.
(2) The medical staff shall be well-organized and accountable
to the governing body for the quality of the medical care provided
to patients.
(A) The medical staff shall be organized in a manner
approved by the governing body.
(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) Records of medical staff meetings shall be maintained.
(D) The responsibility for organization and conduct
of the medical staff shall be assigned only to an individual physician.
(E) Each medical staff member shall sign a statement
signifying they will abide by medical staff and hospital policies.
(3) The medical staff shall adopt, implement, and enforce
bylaws, rules, and regulations to carry out its responsibilities.
The bylaws shall:
(A) be approved by the governing body;
(B) include a statement of the duties and privileges
of each category of medical staff (e.g., active, courtesy, consultant);
(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 body; and
(E) include criteria for determining the privileges
to be granted and a procedure for applying the criteria to individuals
requesting privileges.
(i) Mobile, transportable, and relocatable units. If
the facility provides diagnostic procedures or treatments in mobile,
transportable, or relocatable units, the facility shall adopt, implement
and enforce procedures which address the potential emergency needs
for those inpatients who are taken to mobile units on the facility
premises for diagnostic procedures or treatment.
(j) Nurse staffing.
(1) The hospital shall establish a nurse staffing committee
as a standing committee of the hospital. As used in this subsection,
"committee" or "staffing committee" means a nurse staffing committee
established under this paragraph.
(A) The committee shall be composed of:
(i) at least 60% registered nurses who are involved
in direct patient care at least 50% of their work time and selected
by their peers who provide direct care during at least 50% of their
work time;
(ii) members who are representative of the types of
nursing services provided at the hospital; and
(iii) the chief nursing officer of the hospital who
is a voting member.
(B) Participation on the committee by a hospital employee
as a committee member shall be part of the employee's work time and
the hospital shall compensate that member for that time accordingly.
The hospital shall relieve the committee member of other work duties
during committee meetings.
(C) The committee shall meet at least quarterly.
(D) The responsibilities of the committee shall be
to:
(i) develop and recommend to the hospital's governing
body a nurse staffing plan that meets the requirements of paragraph
(2) of this subsection;
(ii) review, assess and respond to staffing concerns
expressed to the committee;
(iii) identify the nurse-sensitive outcome measures
the committee will use to evaluate the effectiveness of the official
nurse services staffing plan;
(iv) evaluate, at least semiannually, the effectiveness
of the official nurse services staffing plan and variations between
the plan and the actual staffing; and
(v) submit to the hospital's governing body, at least
semiannually, a report on nurse staffing and patient care outcomes,
including the committee's evaluation of the effectiveness of the official
nurse services staffing plan and aggregate variations between the
staffing plan and actual staffing.
(2) The hospital shall adopt, implement and enforce
a written official nurse services staffing plan. As used in this subsection,
"patient care unit" means a unit or area of a hospital in which registered
nurses provide patient care.
(A) The official nurse services staffing plan and policies
shall:
(i) 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;
(ii) be based on the needs of each patient care unit
and shift and on evidence relating to patient care needs;
(iii) require use of the official nurse services staffing
plan as a component in setting the nurse staffing budget;
(iv) encourage nurses to provide input to the nurse
staffing committee relating to nurse staffing concerns;
(v) protect nurses who provide input to the nurse staffing
committee from retaliation; and
(vi) comply with this subsection.
(B) The plan shall:
(i) set minimum staffing levels for patient care units
that are:
(I) based on multiple nurse and patient considerations;
an
(II) determined by the nursing assessment and in accordance
with evidence-based safe nursing standards; and
(ii) include a method for adjusting the staffing plan
shift to shift for each patient care unit to provide staffing flexibility
to meet patient needs;
(iii) include a contingency plan when patient care
needs unexpectedly exceed direct patient care staff resources;
(iv) include how on-call time will be used;
(v) reflect current standards established by private
accreditation organizations, governmental entities, national nursing
professional associations, and other health professional organizations;
(vi) include a mechanism for evaluating the effectiveness
of the official nurse services staffing plan based on patient needs,
nursing-sensitive quality indicators, nurse satisfaction measures
collected by the hospital, and evidence based nurse staffing standards;
and
(vii) be used by the hospital as a component in setting
the nurse staffing budget and guiding the hospital in assigning nurses
hospital wide.
(C) The hospital shall make readily available to nurses
on each patient care unit at the beginning of each shift the official
nurse services staffing plan levels and current staffing levels for
that unit and that shift.
(3) The hospital shall annually report to the department
on:
(A) whether the hospital's governing body has adopted
a nurse staffing policy;
(B) whether the hospital has established a nurse staffing
committee that meets the membership requirements of paragraph (1)
of this subsection;
(C) whether the nurse staffing committee has evaluated
the hospital's official nurse services staffing plan and has reported
the results of the evaluation to the hospital's governing body; and
(D) the nurse-sensitive outcome measures the committee
adopted for use in evaluating the hospital's official nurse services
staffing plan.
(4) Mandatory overtime. The hospital shall adopt, implement
and enforce policies on use of mandatory overtime.
(A) As used in this subsection:
(i) "on-call time" means time spent by a nurse who
is not working but who is compensated for availability; and
(ii) "mandatory overtime" means a requirement that
a nurse work hours or days that are in addition to the hours or days
scheduled, regardless of the length of a scheduled shift or the number
of scheduled shifts each week. Mandatory overtime does not include
prescheduled on-call time or time immediately before or after a scheduled
shift necessary to document or communicate patient status to ensure
patient safety.
(B) A hospital may not require a nurse to work mandatory
overtime, and a nurse may refuse to work mandatory overtime.
(C) This section does not prohibit a nurse from volunteering
to work overtime.
(D) A hospital may not use on-call time as a substitute
for mandatory overtime.
(E) The prohibitions on mandatory overtime do not apply
if:
(i) a health care disaster, such as a natural or other
type of disaster that increases the need for health care personnel,
unexpectedly affects the county in which the nurse is employed or
affects a contiguous county;
Cont'd... |
