Texas Administrative Code › Title 26 - HEALTH AND HUMAN SERVICES › Part 1 - HEALTH AND HUMAN SERVICES COMMISSION › Chapter 511 - LIMITED SERVICES RURAL HOSPITALS › Subchapter C - OPERATIONAL REQUIREMENTS › Section 511.50 - Medical Staff

Current through Reg. 49, No. 28; July 12, 2024
(a) A limited
				  services rural hospital (LSRH) shall have an organized medical staff that
				  operates under bylaws approved by the LSRH's governing body, and which is
				  responsible for the quality of medical care provided to patients by the
				  LSRH.
(b) The medical staff shall
				  be composed of physicians and may also include podiatrists, dentists, and other
				  practitioners appointed by the LSRH's governing body.
(c) The medical staff shall be
				  well-organized, in a manner approved by the LSRH's governing body, and
				  accountable to the governing body for the quality of the medical care provided
				  to patients.
(d) The responsibility
				  for organization and conduct of the medical staff must be assigned to a
				  physician.
(e) When an LSRH is part
				  of a system consisting of multiple separately certified hospitals, critical
				  access hospitals, or LSRHs, and the system elects to have a unified and
				  integrated medical staff, each separately certified LSRH must demonstrate:
(1) the decision to have a unified and
				  integrated medical staff is in accordance with all applicable state and local
				  laws;
(2) the medical staff members
				  of each separately certified LSRH in the system (that is, all medical staff
				  members who hold specific privileges to practice at that LSRH) have voted by
				  majority, in accordance with medical staff bylaws, either to accept a unified
				  and integrated medical staff structure or to opt out of such a structure and to
				  maintain a separate and distinct medical staff for their respective
				  LSRH;
(3) the unified and
				  integrated medical staff has bylaws, rules, and requirements describing:
(A) its processes for self-governance,
				  appointment, credentialing, privileging, and oversight;
(B) its peer review policies and due process
				  rights guarantees; and
(C) a
				  process to advise the members of the medical staff of each separately certified
				  LSRH (that is, all medical staff members who hold specific privileges to
				  practice at that LSRH) of their right to opt out of the unified and integrated
				  medical staff structure in accordance with paragraph (2) of this
				  subsection;
(4) the
				  unified and integrated medical staff is established in a manner that considers
				  each member LSRH's unique circumstances and any significant differences in
				  patient populations and services offered in each hospital, critical access
				  hospital (CAH), and LSRH;
(5) the
				  unified and integrated medical staff establishes and implements policies and
				  procedures to ensure that the needs and concerns expressed by members of the
				  medical staff, at each of its separately certified hospitals, CAHs, and LSRHs,
				  regardless of practice or location, are given due consideration; and
(6) the unified and integrated medical staff
				  has mechanisms in place to ensure that issues localized to particular
				  hospitals, CAHs, and LSRHs are duly considered and addressed.