| (D) In hospitals that provide obstetrical services,
the governing body shall ensure that the hospital implements a newborn
audiological screening program, consistent with the requirements of
Health and Safety Code, Chapter 47 (Hearing Loss in Newborns), and
performs, either directly or through a referral to another program,
audiological screenings for the identification of hearing loss on
each newborn or infant born at the facility before the newborn or
infant is discharged. These audiological screenings are required to
be performed on all newborns or infants before discharge from the
facility unless:
(i) a parent or legal guardian of the newborn or infant
declines the screening;
(ii) the newborn or infant requires emergency transfer
to a tertiary care facility prior to the completion of the screening;
(iii) the screening previously has been completed;
or
(iv) the newborn was discharged from the facility not
more than 10 hours after birth and a referral for the newborn was
made to another program.
(E) In hospitals that provide obstetrical services,
the governing body shall adopt, implement, and enforce policies and
procedures related to the testing of any newborn for critical congenital
heart disease (CCHD) that may present themselves at birth. The facility
shall implement testing programs for all infants born at the facility
for CCHD. In the event that a newborn is presented at the emergency
room following delivery at a birthing center or a home birth that
may or may not have been assisted by a midwife, the facility shall
ascertain if any testing for CCHD had occurred and, if not, shall
provide the testing necessary to make such determination. The rules
concerning the CCHD procedures and requirements are described in Chapter
37, Maternal and Infant Health Services, Subchapter E, Newborn Screening
for Critical Congenital Heart Disease, §§37.75 - 37.79 of
this title.
(F) The governing body shall determine, in accordance
with state law and with the advice of the medical staff, which categories
of practitioners are eligible candidates for appointment to the medical
staff.
(i) In considering applications for medical staff membership
and privileges or the renewal, modification, or revocation of medical
staff membership and privileges, the governing body must ensure that
each physician, podiatrist, and dentist is afforded procedural due
process.
(I) If a hospital's credentials committee has failed
to take action on a completed application as required by subclause
(VIII) of this clause, or a physician, podiatrist, or dentist is subject
to a professional review action that may adversely affect his medical
staff membership or privileges, and the physician, podiatrist, or
dentist believes that mediation of the dispute is desirable, the physician,
podiatrist, or dentist may require the hospital to participate in
mediation as provided in Civil Practice and Remedies Code (CPRC),
Chapter 154. The mediation shall be conducted by a person meeting
the qualifications required by CPRC §154.052 and within a reasonable
period of time.
(II) Subclause (I) of this clause does not authorize
a cause of action by a physician, podiatrist, or dentist against the
hospital other than an action to require a hospital to participate
in mediation.
(III) An applicant for medical staff membership or
privileges may not be denied membership or privileges on any ground
that is otherwise prohibited by law.
(IV) A hospital's bylaw requirements for staff privileges
may require a physician, podiatrist, or dentist to document the person's
current clinical competency and professional training and experience
in the medical procedures for which privileges are requested.
(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 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:
Cont'd... |
