The organized medical staff oversees the quality of patient care, treatment, and services pro...

(1)

The hospital has an organized medical staff that operates under bylaws approved by the governing body and that is responsible for the quality of medical care provided by the hospital.

(2)

Physician members of the organized medical staff are designated to perform the oversight activities of the organized medical staff.

(3)

Physicians and other licensed practitioners practice only within the scope of their privileges as determined through mechanisms defined by the organized medical staff.

(4)

The organized medical staff, through its designated mechanisms, provides leadership in activities related to patient safety.

(5)

The organized medical staff provides oversight in the process of analyzing and improving patient satisfaction.

(7)

The organized medical staff does the following: - Defines when a medical history and physical examination must be validated and countersigned by a physician with appropriate privileges - Specifies the minimal content and scope of medical histories and physical examinations, which may vary by setting or level of care, treatment, and services, including non-inpatient services - Monitors the quality of medical histories and physical examinations

(9)

If the hospital provides emergency services, the medical staff establishes and is continually responsible for the policies and procedures governing emergency medical care.

(10)

If the medical staff chooses to develop and maintain a policy for the identification of specific patients to whom the assessment requirements would apply in lieu of a comprehensive medical history and physical examination, the policy is based on the following: - Patient age, diagnoses, the type and number of surgeries and procedures scheduled to be performed, comorbidities, and the level of anesthesia required for the surgery or procedure - Nationally recognized guidelines and standards of practice for assessment of particular types of patients prior to specific outpatient surgeries and procedures - Applicable state and local health and safety laws The hospital demonstrates evidence that the policy applies only to those patients receiving specific outpatient surgical or procedural services. Note: For hospitals that use Joint Commission accreditation for deemed status purposes: For law and regulation guidance pertaining to the medical history and physical examination at 42 CFR 482.22(c)(5)(iii), refer to https://www.ecfr.gov/.

(11)

For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff determines the qualifications of the radiology staff who use equipment and administer procedures. Note: Technologists who perform diagnostic computed tomography exams will, at a minimum, meet the requirements specified at NPG.13.01.01, EP 1.

(12)

For hospitals that use Joint Commission accreditation for deemed status purposes: The medical staff approves the nuclear services director's specifications for the qualifications, training, functions, and responsibilities of the nuclear medicine staff.