Section 410 IAC 15-2.5-4 - Medical staff; anesthesia and surgical servicesAuthority: IC 16-21-1-7
Affected: IC 16-18-2-14; IC 16-21-1; IC 25-22.5
Sec. 4.
(a) The medical staff of the center is accountable to the governing body of the center. The medical staff must be organized and operate under bylaws approved by the governing body. The medical staff is responsible to the governing board for the quality of medical care and surgical services provided to patients. The medical staff must be composed of one (1) physician, dentist, or podiatrist. The medical staff shall do the following:(1) Conduct outcome-oriented performance evaluations of its member at least biennially.(2) Examine credentials of candidates for appointment and reappointment to the medical staff by using sources in accordance with center policy and applicable state and federal law.(3) Make recommendations to the governing body on the appointment or reappointment of the applicant for a period not to exceed two (2) years.(4) Maintain a reasonably accessible hard copy or electronic file for each member of the medical staff, which 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 current copy of the individual's credentials as follows:(i) Indiana license showing date of licensure and number or available data 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 appropriate licensing board.(ii) Indiana controlled substance registration showing number as applicable. (iii) Drug Enforcement Agency registration showing number as applicable.(iv) Documentation of experience in the practice of medicine.(v) Documentation of specialty board certification as applicable.(vi) Documentation of privilege to perform surgical procedures in a hospital in accordance with IC 16-18-2-14(3)(C).(D) Category of medical staff appointment and delineation of privileges approved.(E) A signed statement to abide by the rules of the center.(F) Documentation of current health status as established by center and medical staff policy and procedure and federal and state requirements.(G) Other items specified by the center and medical staff.(b) The medical staff shall adopt and enforce bylaws and rules to carry out its responsibilities. These bylaws and rules must be as follows:(1) Be approved by the governing board.(2) Be reviewed at least triennially.(3) Include, at a minimum, the following:(A) A description of the medical staff organization structure. If the organization calls for an executive committee, a majority of the members must be practitioners on the active medical staff.(B) Meeting requirements of the medical staff to include, at a minimum, the following: (i) Frequency, at least quarterly.(C) A provision for maintaining records of all meetings of the medical staff and its committees.(D) A procedure for designating an individual practitioner 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 body.(I) 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 enforcement actions against practitioners who fail to comply with the center and medical staff bylaws and rules.(J) A requirement that each physician's services, dentist's services, and podiatrist's services are to be reviewed and analyzed at specified intervals at regular meetings, including, but not limited to, the following:(i) Appropriateness of diagnoses and treatments rendered related to a standard of care and anticipated or expected results.(ii) Performance evaluation based on clinical performance indicated in part by the results or outcome of surgical intervention.(iii) Scope and frequency of procedures.(K) A process for appeals of decisions regarding medical staff membership and privileges.(L) A provision for physician coverage of emergency care which addresses at least the following: (i) A definition of emergency care.(M) A requirement that a medical history and physical examination be performed as follows: (i) In accordance with medical staff requirements on history and physical examination consistent with the scope and complexity of the procedure to be performed.(ii) On each patient admitted by a physician, dentist, or podiatrist who has been granted such privileges by the medical staff or by another member of the medical staff.(iii) Within the time frame specified by the medical staff prior to date of admission and documented in the record with a durable, legible copy of the report and with an update and changes noted in the record on admission in accordance with center policy.(N) A requirement that all practitioner orders are in writing or acceptable computerized form and must be authenticated by a responsible practitioner as allowed by medical staff policies and within the time frames specified by the medical staff and center policy not to exceed thirty (30) days.(O) A provision for personnel authorized to take a verbal order.(P) A requirement that the final diagnosis be documented along with completion of the medical record within thirty (30) days following discharge.(Q) A requirement for a center that permits patient care responsibilities by practitioners other than physicians, to have established policies and procedures, approved by the governing body, for overseeing and evaluating the nonphysician practitioners.(R) A requirement that a physician shall be available to the center during the period any patient is present in the center.(c) The anesthesia services of the center must meet the needs of the patient, within the scope of the services offered, in accordance with acceptable standards of practice, and must be under the direction of a licensed physician with specialized training or experience in the administration of anesthetics. The anesthesia service is responsible for all anesthesia administered in the center as follows: (1) The medical staff shall write and implement policies and procedures and the governing body shall approve policies and procedures which include, but are not limited to, the following: (A) A requirement that a licensed physician with specialized training or experience in the administration of an anesthetic supervise the administration of the anesthetic to a patient and remain present in the facility during the surgical procedure, except when only a local infiltration anesthetic is administered.(B) The use of the following: (i) Monitored anesthesia care (MAC).(iii) Regional anesthesia.(vi) Intravenous anesthesia.(C) Personnel permitted to administer anesthesia. Anesthesia must only be administered by an individual privileged by the medical staff and who is a: (i) qualified physician with appropriate training, experience, and privileges;(ii) practitioner holding a current permit to administer a specific form of anesthesia or otherwise authorized to administer topical, local, regional, or general anesthesia by state law or rule; or(iii) registered nurse acting under the direction of and in the immediate presence of the operating physician or other physician and who holds a certificate of completion of a course in anesthesia approved by the American Association of Nurse Anesthetists or a course approved by the appropriate licensing board.(D) Safety rules to be followed.(E) Safety training required of personnel.(F) The delineation of preanesthesia, intra-operative, and postanesthesia responsibilities as follows: (i) The completion, within forty-eight (48) hours before surgery, of a preanesthesia evaluation for each patient by an individual qualified to administer anesthesia for all types of anesthetics other than local and updated according to center policy (when more than forty-eight (48) hours) before surgery.(ii) The completion by the practitioner administering anesthesia of intra-operative anesthesia monitoring and notations, to include vitals signs, on each patient in accordance with the center policy.(iii) The completion of a postanesthetic evaluation for proper anesthesia recovery of each patient prior to discharge in accordance with written policies and procedures approved by the medical staff.(iv) The requirement that all postoperative patients shall be discharged from the postanesthetic care unit by the practitioner described in clause (C) as responsible for the patient's care in accordance with center policy.(2) A requirement that anesthesia equipment must be checked for operational readiness and safety prior to patient administration. Documentation to that effect shall be included in the patient's medical record.(3) A requirement that all anesthetic agents, flammable and/or potentially flammable liquids or agents, will be stored or used in the center in accordance with current standards of practice and as required by NFPA.(d) Surgical services must be organized according to scope of the services offered, to meet the needs of the patient, in accordance with acceptable standards of practice and safety. Requirements for surgical services include the following: (1) Surgical services are under the direction of a physician, dentist, or podiatrist qualified by experience and training.(2) Surgical services shall develop, implement, and maintain written policies governing surgical care designed to assure the achievement and maintenance of standards of medical and patient care as follows:(A) A mechanism must be maintained which specifies the delineated surgical privileges of each practitioner.(B) A requirement that an appropriate history and physical workup must be in the chart of every patient before surgery. If this has been dictated, but not yet recorded in the patient's chart, there shall be a statement to that effect and an admission note in the chart by the admitting practitioner which includes, but is not limited to, vital signs, allergies, any significant risk factors, and date written.(C) A provision for the following equipment and supplies to be available to the surgical and recovery areas:(i) Emergency call system.(iii) Resuscitation equipment.(viii) Suction equipment.(ix) Other supplies and equipment specified by the medical staff.(D) A requirement for adequate provision of immediate postoperative care.(E) A requirement that the patient register is complete and up to date.(F) A requirement for an operative report describing techniques, findings, and tissue removed or altered to be written or dictated immediately following surgery and authenticated by the surgeon in accordance with center policy and governing body approval.(G) A requirement that a list of tissues excluded from microscopic examination, if applicable, be maintained in surgical services.Indiana State Department of Health; 410 IAC 15-2.5-4; filed Dec 1, 1999, 3:44 p.m.: 23 IR 789; errata filed Dec 14, 1999, 23 IR 814; errata filed Feb 15, 2000, 8:05 a.m.: 23 IR 1657; readopted filed Jul 15, 2005, 8:00 a.m.: 28 IR 3661; 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