Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING › Article 2 - HOSPITALS › Section R9-10-207 - Medical Staff

Current through Register Vol. 30, No. 28, July 12, 2024
A. A governing
				authority shall ensure that:
1. The organized
				medical staff is directly accountable to the governing authority for the
				quality of care provided by a medical staff member to a patient in a
				hospital;
2. The medical staff
				bylaws and medical staff regulations are approved according to the medical
				staff bylaws and governing authority requirements;
3. A medical staff member complies with
				medical staff bylaws and medical staff regulations;
4. The medical staff of a general hospital or
				a special hospital includes at least two physicians who have clinical
				privileges to admit inpatients to the general hospital or special
				hospital;
5. The medical staff of a
				rural general hospital includes at least one physician who has clinical
				privileges to admit inpatients to the rural general hospital and one additional
				physician who serves on a committee according to subsection
				(A)(7)(c);
6. A medical staff
				member is available to direct patient care;
7. Medical staff bylaws or medical staff
				regulations are established, documented, and implemented for the process of:
a. Conducting peer review according to A.R.S.
				Title 36, Chapter 4, Article 5;
b.
				Appointing members to the medical staff, subject to approval by the governing
				authority;
c. Establishing
				committees including identifying the purpose and organization of each
				committee;
d. Appointing one or
				more medical staff members to a committee;
e. Obtaining and documenting permission for
				an autopsy of a patient, performing an autopsy, and notifying, if applicable,
				the medical practitioner coordinating the patient's medical services when an
				autopsy is performed;
f. Requiring
				that each inpatient has a medical practitioner who coordinates the inpatient's
				care;
g. Defining the
				responsibilities of a medical staff member to provide medical services to the
				medical staff member's patient;
h.
				Defining a medical staff member's responsibilities for the transport or
				transfer of a patient;
i.
				Specifying requirements for oral, telephone, and electronic orders, including
				which orders require identification of the time of the order;
j. Establishing a time-frame for a medical
				staff member to complete a patient's medical record;
k. Establishing criteria for granting,
				denying, revoking, and suspending clinical privileges;
l. Specifying pre-anesthesia and
				post-anesthesia responsibilities for medical staff members; and
m. Approving the use of medication and
				devices under investigation by the U.S. Department of Health and Human
				Services, Food and Drug Administration including:
i. Establishing criteria for patient
				selection;
ii. Obtaining informed
				consent before administering the investigational medication or device; and
iii. Documenting the
				administration of and, if applicable, the adverse reaction to an
				investigational medication or device; and
8. The organized medical staff reviews the
				medical staff bylaws and the medical staff regulations at least once every
				three years and updates the bylaws and regulations as needed.