North Dakota Administrative Code › Title 33 - State Department of Health › Article 33-07 - Licensing Medical Hospitals › Chapter 33-07-01.1 - Hospitals › Section 33-07-01.1-15 - Medical staff

Current through Supplement No. 393, July, 2024
1. The general
				acute hospital shall have an organized medical staff that is accountable to the
				governing body in accordance with written bylaws, rules, and regulations
				approved by the governing body. The medical staff shall adopt and enforce
				bylaws, rules, and regulations to carry out its responsibilities which
				specifically provide, but are not limited to, the following:
a. Describe the organization, composition,
				and accountability of the medical staff.
b. The mechanism for appointment,
				reappointment, and renewal of medical staff membership, and the granting of
				clinical privileges initially and at least every thirty-six months as a part of
				an evaluation of staff membership. Medical staff membership and clinical
				privileges shall be granted by the governing body based on medical staff
				recommendations in accordance with the bylaws, rules, regulations, and policies
				of the medical staff and the hospital.
c. The acceptance and processing of initial
				applications for medical staff membership, granting and denying of medical
				staff reappointment, and medical staff membership or disciplinary matters
				related to clinical privileges.
d.
				The equal application of procedures for evaluating eligible licensed health
				care practitioners for staff membership, including procedures for determination
				of qualifications, credentials, and privileges; criteria for evaluation of
				qualifications; procedures requiring information about current mental and
				physical health status; current license status in this state; procedures to
				address the issue of staff members who are reportedly impaired by substance
				abuse; and current competence in delivering health care services.
(1) The following information must be
				collected from a licensed health care practitioner prior to appointment or
				reappointment to the medical staff and the granting or renewing of clinical
				privileges or association in any capacity with the hospital:
(a) The name of any hospital or facility with
				which the licensed health care practitioner has had any association,
				employment, privileges, or practice and, if such association, employment,
				privileges, or practice have been suspended, restricted, terminated, curtailed
				or not renewed, the reasons for such.
(b) The substance of any pending professional
				liability actions or other professional misconduct proceedings in this or any
				other state.
(c) Any judgment or
				settlement of any professional liability action and any finding of professional
				misconduct in this or any other state.
(d) Any information relative to findings
				pertinent to violations of patients' rights.
(e) A waiver by the licensed health care
				practitioner of any confidentiality provisions concerning the
				information.
(2) Prior to
				granting or renewing privileges or association to any licensed health care
				practitioner, the hospital shall query the national practitioner data bank
				regarding physicians and request all previous hospital or clinical practice
				information.
(3) A file must be
				maintained on each licensed health care practitioner granted privileges or
				otherwise associated with the hospital which must contain the information
				collected. This file must be updated at least every twenty-four months and
				contain all relevant information gathered in accordance with this
				section.
(4) A physician assistant
				and advanced registered nurse practitioner shall keep on file at the hospital
				and available for review by the department, upon request, documents that are
				required to be filed with the board of medical examiners or the board of
				nursing as appropriate.
e. A statement of the duties, privileges, and
				responsibilities of each category of medical staff.
(1) Regardless of any other categories having
				privileges in the hospital, there must be an active staff that includes
				physicians and may also include other licensed health care practitioners which
				is organized and which performs all the duties pertaining to medical staff,
				including the maintenance of the proper quality of all medical care and
				treatment of inpatients and outpatients in the hospital.
(2) Active medical staff meetings must be
				held regularly and written minutes of all meetings must be kept. Documentation
				on meetings must be prepared and reported through established
				channels.
f. Additional
				privileges may be granted a staff member for the use of their employed allied
				health personnel in the hospital in accordance with policies and procedures
				recommended by the medical staff and approved by the governing body. The staff
				member requesting this additional privilege shall submit for review and
				approval by the medical staff and the governing body:
(1) The curriculum vitae of the identified
				allied health personnel.
(2)
				Written protocol with a description of duties, assignments, and functions
				including a description of the manner of performance within the hospital by the
				allied health personnel in relationship with other hospital staff.
g. The responsibility for such
				quality improvement activities as pharmacy and therapeutics, surgical case and
				tissue review, infection control, utilization review, patient care evaluation,
				use of blood and blood components, review of unexpected mortalities, review of
				morbidities in circumstances other than those related to the natural course of
				disease or illness, and the maintenance of complete medical records.
h. That the findings of tissue removed at
				operation which is examined by a pathologist be made a part of the patient's
				medical record.
i. The maintenance
				and continuous collection of information concerning the hospital's experience
				with negative health care outcomes and incidents injurious to patients; patient
				grievances; professional liability insurance premiums, settlements, awards, and
				costs incurred by the hospital for patient injury prevention; and safety
				improvement activities.
j. The
				identification of clinical conditions and procedures requiring
				consultation.
k. The provision for
				the exchange of information between medical, administrative, and nursing
				staffs.
l. The procedure for
				submitting recommendations to the governing body regarding matters within the
				purview of the medical staff.
m.
				The procedures to be used to grant to current medical staff members formal
				professional review for actions involving credentialing, competence, or
				professional conduct concerning hospital privileges. The formal professional
				review must be conducted in accordance with a fair hearing and appeal process
				identified in the medical staff bylaws, substantially in the following manner:
(1) The medical staff member must be given a
				notice stating:
(a) That a professional review
				action has been proposed to be taken against the medical staff
				member.
(b) The reasons for the
				proposed action.
(c) That the
				medical staff member has the right to request a hearing on the proposed
				action.
(d) Any time limit, which
				may not be less than thirty days, within which to request such a
				hearing.
(e) A summary of the
				medical staff member's rights in a hearing.
(2) If a hearing is requested, the medical
				staff member involved must be given notice of the hearing on a timely
				basis.
(3) Any action relating to
				professional incompetence or professional conduct adversely affecting the
				clinical privileges of the medical staff member must be reported by the
				governing body of the hospital, within fifteen days, to the state board charged
				with responsibility for licensure of the professional practice and any
				disciplinary action affecting practice longer than thirty days must be reported
				to the national data bank.