26 Tex. Admin. Code § 509.45 - Medical Staff

(a) The medical staff shall periodically conduct appraisals of its members according to medical staff bylaws.

(b) The medical staff shall examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of the candidate.

(c) The medical staff shall be well-organized and accountable to the governing body for the quality of the medical care provided to patients.

(1) The medical staff shall be organized in a manner approved by the governing body.

(2) If the medical staff has an executive committee, the members of the committee shall be doctors of medicine or osteopathy.

(3) The facility shall maintain records of medical staff meetings.

(4) The governing body shall assign responsibility for organization and conduct of the medical staff only to an individual physician.

(5) Each medical staff member shall sign a statement signifying they will abide by medical staff and facility policies.

(d) The medical staff shall adopt, implement, and enforce written bylaws, rules, and regulations to carry out its responsibilities. The bylaws shall:

(1) be approved by the governing body;

(2) include a statement of the duties and privileges of each category of medical staff (e.g., active, courtesy, consultant);

(3) describe the organization of the medical staff;

(4) describe the qualifications a candidate must meet for the medical staff to recommend the governing body appoint the candidate; and

(5) include criteria for determining the privileges to be granted and a procedure for applying the criteria to individuals requesting privileges. To be privileged, a physician must have at least one year of experience in emergency services, and current certification in advanced cardiac life support, pediatric advanced life support, and advanced trauma life support.

Notes

26 Tex. Admin. Code § 509.45

Adopted by Texas Register, Volume 48, Number 48, December 1, 2023, TexReg 7072, eff. 12/4/2023