Cal. Code Regs. Tit. 22, § 71503 - Organized Medical Staff

Current through Register 2021 Notice Reg. No. 52, December 24, 2021

(a) Each hospital shall have an organized medical staff responsible to the governing body for the fitness, adequacy and quality of the care rendered to patients.
(b) Medical staff membership.
(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.
(c) The medical staff, by vote of the members and with the approval of the governing body, shall adopt written bylaws 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 bylaws. Medical staff by-laws, rules and regulations shall not deny or restrict, within the scope of their licensure, the voting rights 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. or D.P.M. degree or clinical psychology license.
(d) The medical staff shall meet regularly. Minutes of each meeting shall be retained and filed at the hospital.
(e) The medical staff bylaws, 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.
(f) The medical staff shall provide in its bylaws, 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.
(g) The medical staff shall provide for availability of a staff physician or psychologist for emergencies among the in-hospital population in the event that the attending physician or psychologist or his or her alternate is not available.
(h) 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.
(i) The medical staff shall provide at least one physician to participate as a member of the hospital infection control committee.


Cal. Code Regs. Tit. 22, § 71503

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.

1. Amendment filed 2-8-83; designated effective 3-2-83 (Register 83, No. 7).
2. Amendment of subsection (e) filed 10-3-88; operative 11-2-88 (Register 88, No. 41).
3. Amendment of subsections (a) and (b)(2), new subsections (b)(2)(A)-(B) and amendment of subsection (g) and Note filed 3-3-2010; operative 4-2-2010 (Register 2010, No. 10).

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