Section 107.12. Content of bylaws, rules and regulations

The medical staff bylaws, rules and regulations shall provide for at least the following:

(1) Organizational structure. The organizational structure of the medical staff, consistent with § § 107.21—107.26 (relating to organization of the medical staff) shall be delineated.

(2) Staff privileges. Qualifications for staff membership shall be specified, as shall procedures for admission, retention, assignment and reduction or withdrawal of privileges. This delineation of privileges shall also address specifically the privileges of house staff and house staff officers.

(3) Credentials review. The bylaws shall establish procedures and standards whereby staff credentials will be reviewed.

(4) Appeals. The bylaws shall provide for the establishment of fair hearing and appellate review mechanisms, which will be available if requested by the practitioner in connection with medical staff recommendations for denial of staff appointments, as well as the denial of reappointments, or the curtailment, suspension or revocation of privileges. It is recognized that the mechanism for individuals applying for initial medical staff appointments or privileges may differ from that which is applicable to medical staff members.

(5) Nonphysician clinical privileges and duties. Clinical privileges and duties of specified professional personnel, as defined in paragraph (14), as well as responsibilities of the physician members of the medical staff in relation to specified professional personnel, shall be delineated and approved by the medical staff.

(6) Ethics. The bylaws shall require each member of the medical staff and applicant for staff membership to state in writing that:

(i) He may not rebate a portion of a fee or accept other inducements in exchange for a patient referral.

(ii) He may not deceive a patient as to the identity of an operating surgeon, or another medical practitioner providing treatment or services.

(iii) He may not delegate the responsibility for diagnosis or care of hospitalized patients to another medical practitioner unless he believes the practitioner to be qualified to undertake this responsibility.

(7) Officer selection. Methods for the selection of officers and department/service chairmen shall be provided.

(8) Officer and service chairman responsibilities. Duties and responsibilities of the medical staff officers and clinical department/service chairmen shall be stated.

(9) Standing committees. Composition and functions of standing committees shall be specified as required by the complexity of the hospital.

(10) Committee meetings. Requirements regarding the frequency of and attendance at general and departmental meetings of the medical staff shall be established.

(11) Delineation of hospital staff responsibilities. The bylaws shall specify who is authorized to evaluate the significance of medical histories, to authenticate medical histories, to perform and record physical examinations and to prescribe treatment. The authorizations shall be given only to those with appropriate licenses or clinical privileges, or both. Specific attention shall be given to the clinical responsibilities and authority of house-staff officers and other physicians in training.

(12) Medical records. Requirements shall be established regarding completion of medical records, including a system for disciplinary actions for those who do not complete records in a timely manner.

(13) Liaison with governing body. A mechanism shall be provided by which the medical staff shall consult with and report to the governing body. Because the governing body of the hospital, acting through the chief executive officer, has the overall responsibility for the conduct of the hospital and because the medical staff has the overall responsibility for the provision of medical care to patients, there shall be full communication between the two bodies. Both shall be adequately informed regarding hospital activities. Further, representatives of the medical staff shall participate in hospital deliberations which affect the discharge of medical staff responsibilities.

(14) Specified professional personnel. Specified professional personnel are individuals who are duly licensed practitioners, members of the house staff, or persons otherwise qualified to render direct medical care under the supervision of a member of the medical staff and who are capable of effectively communicating with patients, the medical staff and hospital personnel. The bylaws shall state the rules and regulations, qualifications, status, clinical duties and responsibilities of specified professional personnel whose services require that they be processed through usual medical staff channels. The training, experience and demonstrated current competence of specified professional personnel shall be sufficient to permit their performance of the following functions:

(i) The exercise of judgment within their areas of competence; provided that a member of the medical staff shall have the ultimate responsibility for patient care.

(ii) Direct participation in the management of patients under the supervision or direction of a member of the medical staff.

(iii) The writing of orders and the recording of reports and progress notes in medical records of patients, within the limits established by the medical staff and consistent with the provisions of the Medical Practice Act of 1974 (63 P. S. § § 421.1—421.18) (Repealed).

(15) Acceptance of medical staff bylaws. Mechanisms shall be provided whereby there is evidence that each medical staff member has read and understands the bylaws and agrees to abide by the current medical staff bylaws and rules and regulations and by the hospital bylaws. As evidence of having read and understood the bylaws, each member of the medical staff should sign, on application to the medical staff and as the bylaws are amended, an agreement to abide by the current medical staff bylaws and rules and regulations and hospital bylaws.

(16) Consultations. Consultations, when requested by staff physicians, should be provided where possible by Board Certified or Board Eligible physicians for the particular specialty required.

The provisions of this § 107.12 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761; amended December 3, 1982, effective December 4, 1982, 12 Pa.B. 4129. Immediately preceding text appears at serial pages (52760) and (52762).

Notation

Authority

The provisions of this § 107.12 issued under section 2102(g) of The Administrative Code of 1929 (71 P. S. § 532(g)); and section 803 of the Health Care Facilities Act (35 P. S. § 448.803).

Notes of Decisions

Determination of the appropriate method of judicial review of a hospital’s revocation of a physician’s staff privileges should be determined on basis of procedural safeguards and there is no distinction between public, private and quasi-public hospitals. Allison v. Centre Community Hospital, 604 A.2d 294 (Pa. Cmwlth. 1992).

Cross References

This section cited in 28 Pa. Code § 107.12a (relating to specified professional personnel—statement of policy); 28 Pa. Code § 107.61 (relating to written orders); and 28 Pa. Code § 117.43 (relating to medical records).