SECTION 511.50. Medical Staff

(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.

(f) The medical staff shall periodically conduct appraisals of its members according to medical staff bylaws.

(g) The medical staff shall examine credentials of a candidate for medical staff membership and make a recommendation to the LSRH's governing body on the candidate's appointment.

(h) When the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy.

(i) An LSRH shall maintain records of medical staff meetings.

(j) The medical staff shall adopt, implement, and enforce written bylaws, rules, and regulations to carry out its responsibilities. The bylaws shall:

(1) be approved by the governing body;

(2) include a statement of the duties and privileges of each category of medical staff (for example, active, courtesy, etc.);

(3) describe the organization of the medical staff;

(4) describe the candidate qualifications needed for the medical staff to recommend the candidate's appointment by the governing body; and

(5) include criteria for granting privileges to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. For distant-site physicians and practitioners requesting privileges to provide telemedicine services under an agreement with the LSRH, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in the Code of Federal Regulations Title 42 (42 CFR) §485.510(a)(8) and §485.512(a)(9).

(k) To be privileged as an emergency room physician, the physician shall:

(1) be currently board certified in emergency medicine; or

(2) have a minimum of one year experience in emergency services and current certification in advanced cardiac life support, pediatric advanced life support, and advanced trauma life support.

(l) The LSRH shall comply with applicable telemedicine requirements in 42 CFR §485.512.

Source Note: The provisions of this §511.50 adopted to be effective October 5, 2023, 48 TexReg 5668