Florida Administrative Code › 59 - AGENCY FOR HEALTH CARE ADMINISTRATION › 59A - Health Facility and Agency Licensing › Chapter 59A-3 - HOSPITAL LICENSURE › Section 59A-3.275 - Organized Medical Staff

Current through Reg. 50, No. 138; July 16, 2024
(1) Each hospital
				shall have an organized medical staff organized under written by-laws approved
				by the governing board and responsible to the governing board of the hospital
				for the quality of all health care provided to patients in the facility and for
				the ethical and professional practices of its members.
(2) Each hospital's organized medical staff
				shall determine its appropriate committee structure and shall provide that the
				following required committee functions are carried out with sufficient
				periodicity to assure their objectives being achieved by separate committee,
				combined committees, or committee of the whole:
(a) Coordination of the activities and
				general policies of the various departments.
(b) Interim decision making for the organized
				medical staff between staff meetings, under such limitations as shall be set by
				the organized medical staff.
(c)
				Follow-up and appropriate disposition of all reports dealing with the various
				staff functions.
(d) Review of all
				applications for appointment and reappointment to all categories of staff, and
				recommendations on each to the governing board, including delineation of
				privileges to be granted in each case, and right of hearing and appearance.
				Except in emergency cases, recommendations to the governing board for
				withdrawal of any privileges of a member of the organized medical staff or
				dismissal from the organized medical staff will be made only after a thorough
				investigation by the organized medical staff or a committee thereof, with the
				subject member being given the right of hearing before the organized medical
				staff or a committee thereof, if requested within a reasonable time as
				specified in the hospital's by-laws.
(e) Medical records currently maintained
				describing the condition, treatment, and progress of patient in sufficient
				completeness to assure transferable comprehension of the case at any
				time.
(f) Clinical evaluation of
				the quality of medical care provided to all categories of patients on the basis
				of documented evidence.
(g) Review
				of hospital admissions with respect to need for admission, length of stay,
				discharge practices and evaluation of the services ordered and
				provided.
(h) Surveillance of
				hospital infection potentials and cases and the promotion of a preventive and
				corrective program designed to minimize these hazards.
(i) Surveillance of pharmacy and therapeutic
				policies and practices within the institution.
(j) Hospital tests may be ordered only by the
				attending physician, or by another licensed health professional if that
				licensed health professional is acting within his scope of practice as defined
				by applicable laws and rules of the agency. Nothing herein shall be construed
				to expand or restrict such laws and rules pertaining to the practice of the
				various health professions.