OAR 333-505-0005: Governing Body Responsibility

(1) In a multi-hospital system, one governing body may oversee multiple hospitals. (2) The governing body of a hospital shall be responsible for the operation of the hospital, the selection of the medical staff and the quality of care rendered in the hospital. The governing body shall ensure that: (a) All health care personnel for whom a state license or registration is required are currently licensed or registered; (b) Qualified individuals allowed to practice in the hospital are credentialed and granted privileges consistent with their individual training, experience and other qualifications; (c) Procedures for granting, restricting and terminating privileges exist and that such procedures are regularly reviewed to assure their conformity to applicable law; (d) It has an organized medical staff responsible for reviewing the professional practices of the hospital for the purpose of reducing morbidity and mortality and for the improvement of patient care; (e) A physician is not denied medical staff privileges at the facility solely on the basis that the physician holds medical staff membership or privileges at another health care facility; (f) Licensed podiatric physicians and surgeons are permitted to use the hospital in accordance with ORS 441.063; and (g) All hospital employees and health care practitioners granted hospital privileges have been tested for tuberculosis in compliance with OAR 333-505-0070. (3) A hospital may grant privileges to nurse practitioners or physician associates in accordance with ORS 441.064 and subject to hospital rules governing credentialing and staff privileges. Privileges granted to certified nurse midwives, if any, must be consistent with privileges granted to other medical staff and include: (a) Admitting privileges that do not require a certified nurse midwife to co-admit a patient with a physician who is a member of the medical staff; and (b) Voting rights; (4) A hospital shall require that every patient admitted shall be and remain under the care of a member of the medical staff as specified under the medical staff by-laws.