333-071-0390 Medical Staff (1) The medical staff is responsible for reviewing the professional practices of the SICF for the purposes of improving patient safety and patient care, and is accountable to the governing body. (2) The SICF's medical staff organized pursuant to OAR 333-071-0360 shall include physicians and may include other licensed health care practitioners as permitted by the governing body. (3) The medical staff shall adopt and enforce by-laws, medical staff policies, and medical staff rules and regulations to carry out its responsibilities. The by-laws, medical staff policies, and medical staff rules and regulations must be approved by the governing body. (4) By-laws, medical staff policies and medical staff rules and regulations shall include, but are not limited to: (a) The organization of the medical staff, including qualifications for serving on the medical staff, nominations, election, appointment or removal of officers, and periodic review of its members; (b) Criteria for credentialing health care practitioners and the process for applying for credentials; (c) Criteria for restricting or terminating facility privileges and the process for restricting or terminating facility privileges; (d) A process for periodically reviewing the procedures for granting, restricting and terminating facility privileges to ensure that procedures are being followed; and (e) Procedures for ensuring that licensed health care practitioners with facility privileges i are acting within their scope of practice and acting consistent with the privileges granted by the governing body; (f) Procedures for the acceptance of verbal orders by those individuals authorized by law or their scope of practice to accept verbal orders; (g) Procedures for responding to medical emergencies, including contacting at least one physician in the event of a medical emergency; and (h) Procedures for notifying patients orally and in writing of any financial interest as required by ORS 441.098. (5) Amendments to medical staff by-laws shall be accomplished through a cooperative process involving both the medical staff and the governing body. Medical staff by-laws shall be adopted, repealed or amended when approved by the medical staff and the governing body. Approval shall not be unreasonably withheld by either. Neither the medical staff nor the governing body shall withhold approval if such repeal, amendment, or adoption is mandated by law, statute or regulation or is necessary to obtain or maintain accreditation or to comply with fiduciary responsibilities or if the failure to approve would subvert the stated moral or ethical purposes of the facility. (6) All health care practitioners with individual admitting privileges are subject to applicable provisions of the medical staff by-laws and rules governing admission and staff privileges. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: ORS 441.025 History: PH 4-2019, amend filed 02/21/2019, effective 02/21/2019 PH 281-2018, renumbered from 333-071-0055, filed 12/19/2018, effective 12/19/2018 OHD 6-1999, f. & cert. ef. 10-22-99 HD 5-1989, f. 7-14-89, cert. ef. 8-1-89 HD 11-1988, f. & cert. ef. 5-27-88 HD 17-1987(Temp), f. 10-13-87, ef. 10-15-87 thru 4-15-88