1. (1) The members of the REH medical staff shall conform to the medical staff bylaws and rules and regulations of the hospital, as approved by the governing authority, and shall be responsible for the quality of medical care provided to patients by the hospital.

2. (2) The medical staff must be composed of physicians. In accordance with state law, including scope-of-practice laws, the medical staff may also include other categories of physicians and non-physician practitioners who are determined to be eligible for appointment by the governing body.

   1. (a) The medical staff must periodically conduct appraisals of its members.
   2. (b) The medical staff must examine the credentials of all eligible candidates for medical staff membership and make recommendations to the governing body on the appointment of these candidates in accordance with state law, including scope-of-practice laws, and the medical staff bylaws, rules, and regulations. A candidate who has been recommended by the medical staff and who has been appointed by the governing body is subject to all medical staff bylaws, rules, and regulations, in addition to the requirements contained in this section.

3. (3) The medical staff must be organized in a manner approved by the governing body.

   1. (a) If the medical staff has an executive committee, a majority of the members of the committee must be physicians.
   2. (b) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: an individual physician; a doctor of dental surgery or dental medicine, when permitted by state law; or a doctor of podiatric medicine, when permitted by state law.

4. (4) If an REH is part of a system consisting of multiple separately certified hospitals, CAHs, and/or REHs, and the system elects to have a unified and integrated medical staff for its member hospitals, CAHs, and/or REHs after determining that such a decision is in accordance with all applicable state and local laws, each separately certified REH must demonstrate that:

   1. (a) The medical staff members of each separately certified REH in the system (that is, all medical staff members who hold specific privileges to practice at that REH) have voted by majority, in accordance with medical staff bylaws, either to accept a unified and integrated medical staff structure or to opt out of such a structure and to maintain a separate and distinct medical staff for their respective REH;
   2. (b) The unified and integrated medical staff has bylaws, rules, and requirements that describe its processes for self-governance, appointment, credentialing, privileging, and oversight, as well as its peer review policies and due process rights guarantees, and which include a process for the members of the medical staff of each separately certified REH (that is, all medical staff members who hold specific privileges to practice at that REH) to be advised of their rights to opt out of the unified and integrated medical staff structure after a majority vote by the members to maintain a separate and distinct medical staff for their REH;
   3. (c) The unified and integrated medical staff is established in a manner that takes into account each member REH's unique circumstances and any significant differences in patient populations and services offered in each hospital, CAH, and REH; and
   4. (d) The unified and integrated medical staff establishes and implements policies and procedures to ensure that the needs and concerns expressed by members of the medical staff, at each of its separately certified hospitals, CAHs, and REHs, regardless of practice or location, are given due consideration, and that the unified and integrated medical staff has mechanisms in place to ensure that issues localized to particular hospitals, CAHs, and REHs are duly considered and addressed.
5. (5) When telemedicine services are furnished to the REH's patients through an agreement with a distant-site hospital, the agreement must be written and specify that it is the responsibility of the governing body of the distant-site hospital to meet the requirements of this section with regard to the distant-site hospital's physicians and practitioners providing telemedicine services. The governing body of the REH whose patients are receiving the telemedicine services may, in accordance with CMS regulations, grant privileges based on its medical staff recommendations that rely on information provided by the distant-site hospital.
6. (6) When telemedicine services are furnished to the REH's patients through an agreement with a distant-site telemedicine entity, the written agreement must specify that the distant-site telemedicine entity is a contractor of services to the REH and as such, furnishes the contracted services in a manner that permits the REH to comply with all applicable conditions of participation for the contracted services, including, but not limited to, the requirements of this section with regard to the distant-site telemedicine entity's physicians and practitioners providing telemedicine services. The governing body of the REH whose patients are receiving the telemedicine services may, in accordance with CMS regulations, grant privileges to physicians and practitioners employed by the distant-site telemedicine entity based on such REH's medical staff recommendations; such staff recommendations may rely on information provided by the distant-site telemedicine entity.

7. (7) The governing body of the REH whose patients are receiving the telemedicine services may choose, in lieu of the requirements in paragraphs (2) and (3) of this section, to have its medical staff rely upon the credentialing and privileging decisions made by the distant-site hospital or telemedicine entity when making recommendations on privileges for the individual distant-site physicians and practitioners providing such services, if the REH's governing body ensures, through its written agreement, that all of the following provisions are met:

   1. (a) The distant-site hospital providing the telemedicine services is a Medicare participating hospital.
   2. (b) The medical staff of the distant-site telemedicine entity providing the telemedicine services meets all of the above-listed standards of this section.
   3. (c) The individual distant-site physician or practitioner is privileged at the distant-site hospital or telemedicine entity providing the telemedicine services, which provides a current list of the distant-site physician's or practitioner's privileges at the distant-site hospital or telemedicine entity.
   4. (d) The individual distant-site physician or practitioner holds a license issued or recognized by the state in which the REH whose patients are receiving the telemedicine services is located.
   5. (e) With respect to a distant-site physician or practitioner, who holds current privileges at the REH whose patients are receiving the telemedicine services, the REH has evidence of an internal review of the distant-site physician's or practitioner's performance of these privileges and sends the distant-site hospital or telemedicine entity such performance information for use in the periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include all adverse events that result from the telemedicine services provided by the distant-site physician or practitioner to the REH's patients and all complaints the REH has received about the distant-site physician or practitioner.
8. (8) The quality and appropriateness of the diagnosis and treatment furnished by NPs and PAs at the REH must be evaluated by a member of the REH staff who is a physician or by another physician under contract with the REH.

9. (9) The quality and appropriateness of the diagnosis and treatment furnished by physicians at the REH must be evaluated by one of the following:

   1. (a) One Quality Improvement Organization (QIO) or equivalent entity.
   2. (b) In the case of distant-site physicians and practitioners providing telemedicine services to the REH patients under an agreement between the REH and a distant-site hospital, the distant-site hospital; or
   3. (c) In the case of distant-site physicians and practitioners providing telemedicine services to the REH patients under a written agreement between the REH and a distant-site telemedicine entity, one QIO or equivalent entity.
10. (10) The REH staff will consider the findings of the evaluations and make any necessary changes.

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.