7 AAC 12.110 - Medical staff

(a) A general acute care hospital, a rural primary care hospital, a long-term acute care hospital, or a critical access hospital shall have a medical staff.

(b) The medical staff shall organize and adopt, with the approval of the facility's governing body, bylaws and rules that provide for

(1) eligibility for medical staff membership, and recommending appointments to the governing body;

(2) appointment of committees, including executive, credentials, medical records, tissue and transfusion, infection control, pharmacy and therapeutics, and utilization review committees, that shall keep written minutes of each committee meeting, including committee activities and recommendations;

(3) election of officers, including a chief of staff; and

(4) quarterly meetings, with minutes and records of attendance to be maintained for at least five years.

(c) The medical staff shall

(1) recommend to the governing body the appointment of and the medical and surgical privileges for each member of the medical staff annually, or if approved by the governing body, biennially;

(2) ensure that

(A) a physician is available at all times to respond to an emergency in a general acute care hospital or a rural primary care hospital; and

(B) a physician or a mid-level practitioner with training or experience in emergency care is on call and immediately available by telephone or radio contact and available on site within 30 minutes on a 24-hours-per-day basis in a critical access hospital or a long-term acute care hospital;

(3) place each patient under the care of a member of the medical staff;

(4) require that an order of a practitioner, including a telephonic or other oral order, be reduced to writing and, within three days after the order is given, be dated, timed, and either initialed or signed by that practitioner or by another practitioner responsible for the care of the patient, even if the order did not originate with the other practitioner;

(5) ensure that the use of an investigational drug is properly supervised by a member of the medical staff, that an informed consent form provided by the sponsoring company or agency is used, and that complete records on the drug, including protocol and side effects, are maintained;

(6) establish procedures for circumstances in which consultation is required;

(7) establish standards for care by residents, interns, and medical students in accordance with a residency training program approved by the Council on Medical Education of the American Medical Association, the American Dental Association, or an applicable specialty board;

(8) review at regular intervals clinical and scientific work, medical services, and maintenance of accurate medical records;

(9) establish guidelines for referral to a pathologist of anatomical parts, foreign objects, and tissues removed by surgery;

(10) establish procedures for selection and supervision of advanced practice registered nurses and physician assistants;

(11) ensure that the medical history and physical examination for each patient are completed no more than 30 days before, or 24 hours after, admission; if completed within 30 days before admission, the medical staff must ensure that within 24 hours after admission

(A) an updated history and examination are completed to determine any change in the patient's condition; and

(B) the updated history and examination required under (A) of this paragraph are documented in the patient's medical record, with any change noted.

(d) The onsite medical staff of a critical access hospital may consist exclusively of mid-level practitioners if

(1) the hospital is a member of a rural health network as described in 42 C.F.R. 485.603, as amended through July 1, 1999 and adopted by reference;

(2) the mid-level practitioners are subject to the oversight of a physician who is also a member of the medical staff of the critical access hospital, even though the physician might not be present in the facility, if

(A) a physician who is member of the medical staff of the critical access hospital is notified whenever a patient is admitted to the hospital by a mid-level practitioner;

(B) a physician is available through direct radio or telephone communication for consultation, assistance with medical emergencies, or patient referral;

(C) except in extraordinary circumstances, a physician is present in the facility for sufficient periods of time, at least once every two week period, to provide appropriate medical direction, medical care services, consultation, and supervision; however, a site visit by a physician is not required if no patients have been treated since the latest site visit by a physician; and

(D) any extraordinary circumstances that prevent a site visit by a physician when required under (C) of this paragraph are documented in the records of the hospital;

(3) the mid-level practitioners participate

(A) in the development, execution, and periodic review of the written policies governing the services provided by the hospital; and

(B) in a periodic review of the health records of patients with a physician; and

(4) the mid-level practitioners perform the following functions when the functions are not performed by a physician:

(A) provide services in accordance with the hospital's policies;

(B) arrange for, or refer patients to, needed services that cannot be furnished at the hospital;

(C) assure that adequate patient health records are maintained and transferred as required if patients are referred or services are arranged under (B) of this paragraph.

Notes

7 AAC 12.110

Eff. 11/19/83, Register 88; am 5/4/97, Register 142; am 9/1/2000, Register 155; am 6/23/2006, Register 178; am 12/3/2006, Register 180; am 9/30/2007, Register 183; am 5/14/2021, Register 238, July 2021

Authority:AS 47.32.010

AS 47.32.020

AS 47.32.030