W. Va. Code R. § 64-12-11

Current through Register Vol. XLI, No. 36, September 6, 2024

Section 64-12-11 - Medical Staff

11.1. Each hospital shall have an organized medical staff that is composed of one or more licensed physicians and may include other practitioners, in accordance with state law, that operates under by-laws approved by the governing authority. The medical staff is accountable to the governing body for the quality of medical care provided to the patients.

11.2. The governing authority of the hospital shall appoint the medical staff in accordance with its by-laws, rules, and regulations.

11.3. The medical staff periodically conduct appraisals of its members as defined by hospital policy.

11.4. The medical staff shall examine credentials of candidates for medical staff membership and make recommendations to the governing body on the appointment of candidates.

11.5. Medical staff recommendations to the governing authority for new members shall be specific to the type of appointment and extent of clinical privileges.

11.6. The governing authority shall delineate clinical privileges of each medical staff member in writing.

11.7. The governing authority shall approve the manner of organization of the medical staff.

11.8. If the medical staff has an executive committee, a majority of the members shall be physicians licensed in the state of West Virginia.

11.9. The medical staff shall adopt and enforce by-laws, rules, and regulations consistent with standard medical staff practices. These shall be reviewed and revised as appropriate, but no less than every two years.

11.10. The by-laws shall:

11.10.1. Be approved by the governing body;

11.10.2. Include a statement of the duties and privileges of each category of medical staff;

11.10.3. Describe the organization of the medical staff; and

11.10.4. Describe the qualifications to be met by a candidate in order for the medical staff to recommend that the candidate be appointed by the governing body.

11.11. All medical staff members shall sign a document that specifies they have read the bylaws, rules, and regulations. These rules, regulations, and policies shall specifically provide for:

11.11.1. Requiring departmentalized medical staffs to meet every other month if the executive committee meets monthly. The full medical staff shall meet annually. In the event the executive committee does not meet monthly, then the departmental meeting of the medical staff shall be monthly. Non-departmentalized medical staffs shall have monthly meetings of the executive committee and the full medical staff shall meet every other month. In the event there is no executive committee, the full medical staff shall meet monthly;

11.11.2. Staff review and analysis of clinical experiences in the various departments of the hospital such as medicine, surgery, obstetrics, and other specialties. The clinical records of patients shall be the basis of the review and analysis;

11.11.3. The performance of committee functions in at least the following areas: credentials, medical records, case and utilization review, quality assurance/improvement, infection control mortality, pharmacy and therapeutic practices, and any other committees the hospital considers necessary; and

11.11.4. A chief of staff with direct responsibility for the organization and administration of the medical staff in accordance with the terms of the medical by-laws, rules, and regulations.

The chief of staff shall be responsible for the functioning of the clinical organization of the hospital and maintaining careful supervision over the clinical work in all departments of the hospital.

W. Va. Code R. § 64-12-11