1. 
   (1) An REH shall have an effective governing authority that is legally responsible for the conduct of the REH as an institution and shall provide administrative oversight for the care and services of the REH. The governing body must:

   1. (a) Determine, in accordance with state law, which categories of practitioners are eligible candidates for appointment to the medical staff;
   2. (b) Appoint members of the medical staff after considering the recommendations of the existing members of the medical staff;
   3. (c) Ensure that the medical staff has bylaws;
   4. (d) Approve medical staff bylaws and other medical staff rules and regulations;
   5. (e) Ensure that the medical staff is accountable to the governing body for the quality of care provided to patients; and

   6. (f) Ensure the criteria for selection are individual character, competence, training, experience, and judgment.

      1. 1. Members of the medical staff must be legally and professionally qualified for the positions to which they are appointed and for the performance of privileges granted. The REH grants privileges in accordance with recommendations from qualified medical personnel.
      2. 2. Medical staff privileges must be periodically reappraised by the REH. The scope of procedures performed in the REH must be periodically reviewed and amended as appropriate.
      3. 3. If the REH assigns patient care responsibilities to practitioners other than physicians, it must have established policies and procedures, approved by the governing body, for overseeing and evaluating their clinical activities.
   7. (g) Ensure that under no circumstances is the accordance of staff membership or professional privileges in the REH dependent solely upon certification, fellowship, or membership in a specialty body or society.

2. (2) Contracted services. The governing authority shall be responsible for services furnished in the REH whether or not they are furnished under contracts. The governing authority shall ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the REH to maintain compliance with the requirements of these rules.

   1. (a) The governing authority shall ensure that the services performed under a contract are provided in a safe and effective manner.
   2. (b) The REH shall maintain a list of all contracted services, including the scope and nature of the services provided.

Author: Dana H. Billingsley

Statutory Authority: Code of Ala. 1975, §§22-21-20, et seq.

History: New Rule: Published August 31, 2023; effective October 15, 2023.