Section 410 IAC 15-1.5-5 - Medical staffAuthority: IC 16-21-1-7
Affected: IC 16-21-1; IC 25-22.5
Sec. 5.
(a) The hospital shall have an organized medical staff that operates under bylaws approved by the governing board and is responsible to the governing board for the quality of medical care provided to patients. The medical staff shall be composed of two (2) or more physicians and other practitioners as appointed by the governing board and do the following:(1) Conduct outcome oriented performance evaluations of its members at least biennially.(2) Examine credentials of candidates for appointment and reappointment to the medical staff by using sources in accordance with hospital policy and applicable state and federal law.(3)(Voided by P.L. 190-2023, SECTION 39, effective July 1, 2023.)(4) Maintain a file for each member of the medical staff that includes, but is not limited to, the following: (A) A completed, signed application.(B) The date and year of completion of all Accreditation Council for Graduate Medical Education (ACGME) accredited residency training programs, if applicable.(C) A copy of the member's current Indiana license showing the date of licensure and current number or an available certified list provided by the health professions bureau. A copy of practice restrictions, if any, shall be attached to the license issued by the health professions bureau through the medical licensing board.(D) A copy of the member's current Indiana controlled substance registration showing the number, as applicable.(E) A copy of the member's current Drug Enforcement Agency registration showing the number, as applicable.(F) Documentation of experience in the practice of medicine.(G) Documentation of specialty board certification, as applicable.(H) Category of medical staff appointment and delineation of privileges approved.(I) A signed statement to abide by the rules of the hospital.(J) Documentation of current health status as established by hospital and medical staff policy and procedure and federal and state requirements.(K) Other items specified by the hospital and medical staff. (b) The medical staff shall adopt and enforce bylaws and rules to carry out its responsibilities. These bylaws and rules shall: (1) be approved by the governing board;(2) be reviewed at least triennially; and(3) include, but not be limited to, the following:(A) A description of the medical staff organizational structure. If the organization calls for an executive committee, a majority of the members shall be physicians on the active medical staff.(B) Meeting requirements of the staff.(C) A provision for maintaining records of all meetings of the medical staff and its committees.(D) A procedure for designating an individual physician with current privileges as chief, president, or chairperson of the staff.(E) A statement of duties and privileges for each category of the medical staff.(F) A description of the medical staff applicant qualifications.(G) Criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges.(H) A process for review of applications for staff membership, delineation of privileges in accordance with the competence of each practitioner, and recommendations on appointments to the governing board.(I) A process for appeals of decisions regarding medical staff membership and privileges.(J) A process for medical staff performance evaluations based on clinical performances indicated in part by the results of quality assessment and improvement activities.(K) A process for reporting practitioners who fail to comply with state professional licensing law requirements as found in IC 25-22.5, and for documenting appropriate enforcement actions against practitioners who fail to comply with the hospital and medical staff bylaws and rules.(L) A provision for physician coverage of emergency care that addresses at least the following: (i) A definition of emergency care to include, but not be limited to, the following: (AA) Inpatient emergencies.(BB) Emergency services emergencies.(M) A requirement that a complete physical examination and medical history be performed:(i) on each patient admitted by a practitioner who has been granted such privileges by the medical staff; (ii) within seven (7) days prior to date of admission and documented in the record with a durable, legible copy of the report and changes noted in the record on admission; or(iii) within forty-eight (48) hours after an admission.(N) A requirement that all physician orders shall be: (i) in writing or acceptable computerized form; and(ii) authenticated by the responsible individual in accordance with hospital and medical staff policies. (O) A requirement that all verbal orders must be authenticated by the responsible individual in accordance with hospital and medical staff policies. The individual receiving a verbal order shall date, time, and sign the verbal order in accordance with hospital policy. Authentication of a verbal order must occur within forty-eight (48) hours unless a read back and verify process described under items (i) and (ii) is utilized. If a patient is discharged within forty-eight (48) hours of the time that the verbal order was given, authentication shall occur within thirty (30) days after the patient's discharge. (i) As an alternative, hospital policy may provide for a read back and verify process for verbal orders. Any read back and verify process must require that the individual receiving the order shall immediately read back the order to the ordering physician or other responsible individual who shall immediately verify that the read back order is correct.(ii) The individual receiving the verbal order shall document in the patient's medical record that the order was read back and verified. Where the read back and verify process is followed, the hospital shall require authentication of the verbal order not later than thirty (30) days after the patient's discharge. (P) A requirement that the final diagnosis be documented along with completion of the medical record within thirty (30) days following discharge.(c) The medical staff should attempt to secure autopsies in all cases of unusual deaths and educational interest. There shall be the following:(1) A mechanism for documenting in writing the following:(A) That permission to perform an autopsy was obtained.(B) The source of the permission.(2) A system for notifying the medical staff, and specifically the attending practitioner, when an autopsy is being performed.Indiana State Department of Health; 410 IAC 15-1.5-5; filed Dec 21, 1994, 9:40 a.m.: 18 IR 1271; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; filed Jan 2, 2003, 10:22 a.m.: 26 IR 1551; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; filed Feb 12, 2009, 11:30 a.m.: 20090311-IR-410080423FRA; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR-410110253RFAReadopted filed 9/13/2017, 4:08 p.m.: 20171011-IR-410170339RFAReadopted filed 11/28/2023, 12:13 p.m.: 20231227-IR-410230639RFA