Cal. Code Regs. Tit. 22, § 70703 - Organized Medical Staff
(a) Each hospital shall have an organized
medical staff responsible to the governing body for the adequacy and quality of
the care rendered to patients.
(1) The
medical staff shall be composed of physicians and, where dental or podiatric
services are provided, dentists or podiatrists.
(2) As required by section
1316.5
of the Health and Safety Code:
(A) Where
clinical psychological services are provided by clinical psychologists, in a
health facility owned and operated by the state, the facility shall establish
rules and medical staff bylaws that include provisions for medical staff
membership and clinical privileges for clinical psychologists within the scope
of their licensure as psychologists.
(B) Where clinical psychological services are
provided by clinical psychologists, in a health facility not owned or operated
by this state, the facility may enable the appointment of clinical
psychologists to the medical staff.
(b) The medical staff, by vote of the members
and with the approval of the governing body, shall adopt written by-laws which
provide formal procedures for the evaluation of staff applications and
credentials, appointments, reappointments, assignment of clinical privileges,
appeals mechanisms and such other subjects or conditions which the medical
staff and governing body deem appropriate. The medical staff shall abide by and
establish a means of enforcement of its by-laws. Medical staff by-laws, rules
and regulations shall not deny or restrict within the scope of their licensure,
the voting right of staff members or assign staff members to any special class
or category of staff membership, based upon whether such staff members hold an
M.D., D.O., D.P.M., or D.D.S. degree or clinical psychology license.
(c) The medical staff shall meet regularly.
Minutes of each meeting shall be retained and filed at the hospital.
(d) The medical staff by-laws, rules, and
regulations shall include, but shall not be limited to, provision for the
performance of the following functions: executive review, credentialing,
medical records, tissue review, utilization review, infection control, pharmacy
and therapeutics, and assisting the medical staff members impaired by chemical
dependency and/or mental illness to obtain necessary rehabilitation services.
These functions may be performed by individual committees, or when appropriate,
all functions or more than one function may be performed by a single committee.
Reports of activities and recommendations relating to these functions shall be
made to the executive committee and the governing body as frequently as
necessary and at least quarterly.
(e) The medical staff shall provide in its
by-laws, rules and regulations for appropriate practices and procedures to be
observed in the various departments of the hospital. In this connection the
practice of division of fees, under any guise whatsoever, shall be prohibited
and any such division of fees shall be cause for exclusion from the
staff.
(f) The medical staff shall
provide for availability of staff physicians or psychologists for emergencies
among the in-hospital population in the event that the attending physician or
psychologist or his or her alternate is not available.
(g) The medical staff shall participate in a
continuing program of professional education. The results of retrospective
medical care evaluation shall be used to determine the continuing education
needs. Evidence of participation in such programs shall be available.
(h) The medical staff shall develop criteria
under which consultation will be required. These criteria shall not preclude
the requirement for consultations on any patient when the director of the
service, chairman of a department or the chief of staff determines a patient
will benefit from such consultation.
Notes
2. Amendment of subsection (d) filed 10-3-88; operative 11-2-88 (Register 88, No. 41).
3. Amendment filed 6-15-89 as an emergency; operative 6-15-89 (Register 89, No. 25). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 10-13-89.
4. Certificate of Compliance as to 6-15-89 order transmitted to OAL on 10-13-89 and disapproved by OAL on 11-13-89 (Register 89, No 46).
5. Amendment refiled 11-16-89 as an emergency; operative 11-16-89 (Register 89, No. 46). A Certificate of Compliance must be transmitted to OAL within 120 days or the section will be reinstated as it existed prior to the emergency on 3-16-90.
6. Certificate of Compliance as to 11-16-89 order transmitted to OAL 3-15-90 and filed 4-16-90 (Register 90, No. 17).
7. Amendment of section and NOTE filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
Note: Authority cited: Sections 1275, 100275 and 131200, Health and Safety Code. Reference: Sections 1276, 1315, 1316, 1316.5, 131050, 131051 and 131052, Health and Safety Code.
2. Amendment of subsection (d) filed 10-3-88; operative 11-2-88 (Register 88, No. 41).
3. Amendment filed 6-15-89 as an emergency; operative 6-15-89 (Register 89, No. 25). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 10-13-89.
4. Certificate of Compliance as to 6-15-89 order transmitted to OAL on 10-13-89 and disapproved by OAL on 11-13-89 (Register 89, No 46).
5. Amendment refiled 11-16-89 as an emergency; operative 11-16-89 (Register 89, No. 46). A Certificate of Compliance must be transmitted to OAL within 120 days or the section will be reinstated as it existed prior to the emergency on 3-16-90.
6. Certificate of Compliance as to 11-16-89 order transmitted to OAL 3-15-90 and filed 4-16-90 (Register 90, No. 17).
7. Amendment of section and Note filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).
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