| (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.
(c) The medical staff shall be well-organized and accountable
to the governing body for the quality of the medical care provided
to patients.
(1) The medical staff shall be organized in a manner
approved by the governing body.
(2) If the medical staff has an executive committee,
the members of the committee shall be doctors of medicine or osteopathy.
(3) The facility shall maintain records of medical
staff meetings.
(4) The governing body shall assign responsibility
for organization and conduct of the medical staff only to an individual
physician.
(5) Each medical staff member shall sign a statement
signifying they will abide by medical staff and facility policies.
(d) The medical staff shall adopt, implement, and enforce
written bylaws, rules, and regulations to carry out its responsibilities.
The bylaws shall:
(1) be approved by the governing body;
(2) include a statement of the duties and privileges
of each category of medical staff (e.g., active, courtesy, consultant);
(3) describe the organization of the medical staff;
(4) describe the qualifications a candidate must meet
for the medical staff to recommend the governing body appoint the
candidate; and
(5) include criteria for determining the privileges
to be granted and a procedure for applying the criteria to individuals
requesting privileges. To be privileged, a physician must have at
least one year of experience in emergency services, and current certification
in advanced cardiac life support, pediatric advanced life support,
and advanced trauma life support.
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