Kan. Admin. Regs. § 28-34-6a - Medical staff

(a) General provision. Each hospital shall maintain an organized medical staff. Admission to the staff and clinical privileges associated with membership shall be granted by the governing authority through a mechanism that evaluates each member's qualifications to engage in that member's area of clinical practice. Admitting privileges may be granted to any practitioner as defined in K.A.R. 28-34-1a(w).

(b) Membership. The medical staff shall be limited to practitioners who have made application in accordance with the bylaws of the medical staff and the governing body. The medical staff shall adopt bylaws that define the requirements for admission to staff membership and for the delineation and retention of clinical and admitting privileges. Each member shall be granted privileges that are commensurate with the member's qualifications, experience, and present capabilities and that are within the member's scope of practice. Although certification, fellowship, membership on a specialty board or society, or the completion of a general practice residency may be considered in determining an individual's qualifications for medical staff membership, membership decisions shall not be made solely upon any one of these factors.

(c) Medical staff status.

(1) Each hospital shall have an active medical staff to deliver the preponderance of medical services within the hospital. The active medical staff shall have primary responsibility for the organization and administration of the medical staff. Each member of the active medical staff shall be eligible to vote at staff meetings, hold office, and serve on staff committees.

(2) In addition to the active medical staff, the hospital may provide for additional kinds of medical staff privileges. These additional staff categories shall in no way modify the privileges, duties, and responsibilities of the active medical staff. These additional staff categories may be eligible to vote at staff meetings, hold office, and serve on staff committees.

(d) Appointment and reappointment. After considering medical staff recommendations, the governing body shall affirm, deny, or modify each recommendation for appointment to the medical staff and the granting of clinical privileges to any practitioner. Formal application for membership and for the granting of clinical privileges shall follow established procedures set forth in the bylaws, policies, and procedures of the medical staff.

(e) Medical staff bylaws, policies, and procedures. The medical staff shall develop and adopt, subject to the approval of the governing body, a set of bylaws that shall provide for at least the following:

(1) The organizational structure of the medical staff;

(2) qualifications for staff membership and procedures for admission, retention, assignment, and either reduction or withdrawal of privileges;

(3) procedures and standards for the review of staff credentials;

(4) a mechanism for an appeal by a practitioner who receives an unfavorable medical staff recommendation;

(5) delineation of clinical privileges and duties of professional personnel who function in a clinical capacity and who are not members of the medical staff;

(6) methods for the selection of officers and department or service chairpersons and a description of their duties and responsibilities;

(7) the composition and function of standing committees;

(8) requirements regarding the completion of medical records, including a system of disciplinary action for failure to complete the records of discharged patients within 30 days after dismissal or current records within 48 hours of admission;

(9) a mechanism by which the medical staff consults with and reports to the governing body;

(10) medical staff meetings for the purpose of reviewing the performance of the medical staff and each department or service and reports and recommendations of the medical staff and multidisciplinary committees; and

(11) a mechanism for review of medical staff performance that shall include consideration of relevant ethics and statutory codes of conduct.

(f) Medical care review. The medical staff shall develop and implement a system to review medical services rendered, evaluate their quality, and provide an educational program for medical staff members. This system shall include written criteria for the evaluation of medical care that shall cover admission, length of stay, and professional services furnished and shall be conducted on at least a sample basis.

(g) Medical orders.

(1) Medication or treatment shall be administered only upon written and signed orders of a practitioner who is acting within the scope of that practitioner's license and who is qualified according to medical staff bylaws.

(2) A practitioner may give verbal orders, including telephone orders, for medication or treatment to personnel who are qualified according to medical staff bylaws. The person entering these orders into the medical record shall sign and date the entry as soon as possible. These orders shall be authenticated by the prescribing or covering practitioner within 72 hours of the patient's discharge or 30 days, whichever occurs first.

Notes

Kan. Admin. Regs. § 28-34-6a

Authorized by and implementing K.S.A. 65-431; effective June 28, 1993; amended Feb. 9, 2001.