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.
Notes
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 (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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