Section R9-10-207. Medical Staff

A.      A governing authority shall ensure that:

1.        The organized medical staff is directly accountable to the governing authority for the quality of care provided by a medical staff member to a patient in a hospital;

2.        The medical staff bylaws and medical staff regulations are approved according to the medical staff bylaws and governing authority requirements;

3.        A medical staff member complies with medical staff bylaws and medical staff regulations;

4.        The medical staff of a general hospital or a special hospi- tal includes at least two physicians who have clinical privileges to admit inpatients to the general hospital or special hospital;

5.        The medical staff of a rural general hospital includes at least one physician who has clinical privileges to admit inpatients to the rural general hospital and one additional physician who serves on a committee according to sub- section (A)(7)(c);

6.        A medical staff member is available to direct patient care;

7.        Medical staff bylaws or medical staff regulations are established, documented, and implemented for the pro- cess of:

a.         Conducting peer review according to A.R.S. Title 36, Chapter 4, Article 5;

b.        Appointing members to the medical staff, subject to approval by the governing authority;

c.         Establishing committees including identifying the purpose and organization of each committee;

d.        Appointing one or more medical staff members to a committee;

e.         Obtaining and documenting permission for an autopsy of a patient, performing an autopsy, and notifying, if applicable, the medical practitioner coordinating the patient’s medical services when an autopsy is performed;

f.         Requiring that each inpatient has a medical practi- tioner who coordinates the inpatient’s care;

g.        Defining the responsibilities of a medical staff mem- ber to provide medical services to the medical staff member’s patient;

h.        Defining a medical staff member’s responsibilities for the transport or transfer of a patient;

i.         Specifying requirements for oral, telephone, and electronic orders including which orders require identification of the time of the order;

j.         Establishing a time-frame for a medical staff mem- ber to complete a patient’s medical record;

k.        Establishing criteria for granting, denying, revoking, and suspending clinical privileges;

l.         Specifying pre-anesthesia and post-anesthesia responsibilities for medical staff members; and

m.       Approving the use of medication and devices under investigation by the U.S. Department of Health and Human Services, Food and Drug Administration including:

i.         Establishing criteria for patient selection;

ii.        Obtaining informed consent before administer- ing the investigational medication or device; and

iii.      Documenting the administration of and, if applicable, the adverse reaction to an investiga- tional medication or device; and

8.        The organized medical staff reviews the medical staff bylaws and the medical staff regulations at least once every three years and updates the bylaws and regulations as needed.

B.       An administrator shall ensure that:

1.        A medical staff member provides evidence of freedom from infectious  tuberculosis according to  the require- ments in R9-10-230(A)(5);

2.        A record for each medical staff member is established and maintained that includes:

a.         A completed application for clinical privileges;

b.        The dates and lengths of appointment and reappoint- ment of clinical privileges;

c.         The specific clinical privileges granted to the medi- cal staff member, including revision or revocation dates for each clinical privilege; and

d.        A verification of current Arizona health care profes- sional active license according to A.R.S. Title 32; and

3.        Except for documentation of peer review conducted according to A.R.S. § 36-445, a record under subsection (B)(2) is provided to the Department for review:

a.         As soon as possible, but not more than two hours after the time of the Department's request, if the individual is a current medical staff member; and

b.        Within 72 hours after the time of the Department's request if the individual is no longer a current medi- cal staff member.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at

20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13;

effective July 1, 2014 (Supp. 14-2).