OAR 333-505-0020: Medical Staff

(1) The medical staff is responsible for reviewing the professional practices of the hospital for the purpose of reducing morbidity and mortality and for the improvement of patient care, and is accountable to the governing body. (2) The hospital’s medical staff organized pursuant to OAR 333-505-0005(1) shall include Medical Doctors and Doctors of Osteopathy, and may include other licensed health care practitioners as permitted by the governing body. (3) The medical staff shall adopt and enforce by-laws, medical staff policies, and medical staff rules and regulations to carry out its responsibilities. The by-laws, medical staff policies, and medical staff rules and regulations must be approved by the governing body. (4) By-laws, medical staff policies, and medical staff rules and regulations shall include but are not limited to: (a) The organization of the medical staff, including qualifications for serving on the medical staff, nominations, election, appointment or removal of officers, and periodic review of its members; (b) Criteria for credentialing health care practitioners and the process for applying for credentials; (c) Criteria for restricting or terminating hospital privileges and the process for restricting or terminating hospital privileges; (d) A process for periodically reviewing the procedures for granting, restricting, or terminating hospital privileges to ensure that procedures are being followed; (e) Procedures for insuring that licensed health care practitioners with hospital privileges are acting within their scope of practice and acting consistent with the privileges granted; (f) Procedures for the acceptance of verbal orders by those individuals authorized by law or their scope of practice to accept verbal orders; (g) Criteria for tissue specimens and appliances that are subject to a macroscopic or microscopic pathology examination; (h) Procedures for responding to medical emergencies, including contacting at least one physician in the event of a medical emergency; and (i) Procedures for notifying patients orally and in writing of any financial interest as required by ORS 441.098. (5) Amendments to medical staff by-laws shall be accomplished through a cooperative process involving both the medical staff and the governing body. Medical staff by-laws shall be adopted, repealed or amended when approved by the medical staff and the governing body. Approval shall not be unreasonably withheld by either. Neither the medical staff nor the governing body shall withhold approval if such appeal, amendment or adoption is mandated by law, statute or regulation or is necessary to obtain or maintain accreditation or to comply with fiduciary responsibilities or if the failure to approve would subvert the stated moral or ethical purposes of this institution. (6) Physicians and all other health care practitioners with individual admitting privileges are subject to applicable provisions of the medical staff by-laws and rules governing admission and staff privileges.