Kansas Administrative Regulations › Agency 28 - DEPARTMENT OF HEALTH AND ENVIRONMENT › Article 34 - HOSPITALS › Section 28-34-54 - Medical staff

Current through Register Vol. 43, No. 28, July 11,
			 2024
(a) The ambulatory
			 surgical center shall have an organized medical staff, responsible to the
			 governing authority of the ambulatory surgical center for the quality of all
			 medical care provided to patients in the ambulatory surgical center and for the
			 ethical and professional practices of its members.
(b) In each ambulatory surgical center, the
			 medical staff, with the approval of and subject to final action by the
			 governing authority, shall formulate and approve medical staff bylaws,
			 policies, and procedures for the proper conduct of its activities and recommend
			 to the governing authority practitioners considered eligible for membership on
			 the medical staff, in accordance with K.A.R. 28-34-50(u).
(c) Each member of the medical staff shall be
			 granted privileges that are commensurate with the member's qualifications,
			 experience, and present capabilities and that are within the practitioner's
			 scope of practice.
(d) Each member
			 of the medical staff shall submit a written application for staff membership on
			 a form prescribed by the governing authority. After considering medical staff
			 recommendations, the governing authority shall affirm, deny, or modify each
			 recommendation for appointment to the medical staff.
(e) Surgical procedures shall be performed
			 only by practitioners who have been granted privileges by the governing
			 authority to perform surgical procedures.
(f) The medical staff of each ambulatory
			 surgical center shall develop a policy stipulating which surgically removed
			 tissues will be sent to a pathologist for review. This policy shall be approved
			 by the governing authority.
(g)
			 The medical staff bylaws shall require at least one physician member of the
			 medical staff to be available to the ambulatory surgical center at all times
			 that a patient is receiving or recovering from local, general, or intravenous
			 sedation. The staffing shall meet the needs of the patients.
(h) The medical staff shall hold regular
			 meetings for which records of attendance and minutes shall be kept.
(i) Medical staff committee minutes and
			 information shall neither be a part of individual patient records nor be
			 subject to review by other than medical staff members, except as otherwise
			 provided by the governing authority.
(j) The medical staff shall review and
			 analyze at regular intervals the clinical experience of its members and the
			 medical records of patients on a sampling or other basis. All techniques and
			 procedures involving the diagnosis and treatment of patients shall be reviewed
			 periodically and shall be subject to change by the medical staff.
(k) The medical staff shall participate in
			 risk management activities, in accordance with K.S.A. 65-4921 et seq., and
			 amendments thereto, and K.A.R. 28-52-1 through 28-52-4, and with the ambulatory
			 surgical center's risk management plan. Any ambulatory surgical center having a
			 medical staff with fewer than two physician members shall include provisions
			 for outside peer review in the risk management plan.
(l) All medical orders shall be given by a
			 practitioner and recorded in accordance with the medical staff policies and
			 procedures. All orders shall be signed or either countersigned or initialed by
			 the attending physician, dentist, or podiatrist.
(m) The medical staff and the governing
			 authority shall review the medical staff privileges at least every two years.