(a)

1. (1) All persons admitted and discharged to any institution governed by these standards shall be under the care of a person duly licensed to practice medicine in Arkansas, hereafter called physician or surgeon.
2. (2) In institutions where two (2) or more physicians are allowed to practice there shall be an organized medical staff.
3. (3) Members of the staff shall be qualified legally and professionally for the positions to which they are appointed.
4. (4) Individuals who are not hospital employees, who work in the hospital, shall be credentialed through the medical staff with approval from the governing body.
5. (5) Refer to 20 CAR § 41-135, specialized service — emergency services.
6. (6) Note. See Arkansas Code § 17-95-107 regarding requirements for healthcare organizations that credential physicians/authorized staff to use the Arkansas State Medical Board’s Centralized Credentials Verification Service (CCVS).

(b) Credential files of the medical staff and other authorized staff.

1. (1) An individual file shall:

   1. (A) Be maintained for each physician/other authorized staff practicing in the hospital; and
   2. (B) Include at least the following:

(d) (d) Statement of postgraduate or special training and experience;

1. (ii) Specific delineation of privileges requested and granted;

   1. (iii) A detailed application signed by:

(b) (b) The Chair of the Credentials Committee; and

1. (c) (c) An officer of the governing body;

   1. (iv) Documentation of the applicant’s agreement to abide by the:

(b) (b) Hospital requirements;

1. (v) Verification of current Arkansas license;

   1. (vi) Verification of each applicable physician’s United States Drug Enforcement Administration registration;

      1. (vii) Verification of at least three (3) references;
      2. (viii) Documentation of all actions taken by the medical staff and governing board indicating:

(b) (b) Approval of appointment/reappointment; and

1. (c) (c) Other related data;

   1. (ix) Evaluation of members’ professional activities at the time of reappointment; and

      1. (x)

(a) (a) Nonemployee practitioners may be screened through:

1. (1) (1) The human resources department; or
2. (2) (2) Another hospital designee.

(b) (b) The requested privileges and credentialing shall be approved by the medical staff.

1. (2) Note. Hospitals shall report to the appropriate professional licensing board the names of individuals whose hospital privileges have been terminated or revoked for cause.

   1. (c) Medical staff bylaws. The medical staff bylaws shall include at least the following information:

2. (1) A provision stating the medical staff shall be responsible to the governing body of the facility for the:

   1. (A) Quality of medical care provided for patients in the hospital; and
   2. (B) Ethical and professional practices of members;
3. (2) A provision stating the requirements for medical and other authorized staff membership including allied health professionals;
4. (3) A provision stating the division of the medical staff and clinical departments;

5. (4) A provision stating the:

   1. (A) Election of officers;
   2. (B) Responsibilities; and
   3. (C) Terms;

6. (5) A provision establishing:

   1. (A) Medical staff committees;
   2. (B) Functions;
   3. (C) Frequency of meetings; and
   4. (D) Composition (quorum);
7. (6) A provision establishing frequency of general medical staff meetings, specifying attendance requirements;

8. (7) A provision establishing:

   1. (A) Written minutes be maintained of all medical staff meetings; and
   2. (B) The minutes shall be signed by the physician chair;
9. (8) A provision for an appeals process that delineates the procedures for a physician or other authorized staff to follow in challenging staff, that if ratified by the governing body adversely affects his or her appointment or reappointment to the medical staff;
10. (9) A provision establishing the designation of a specific physician who shall direct each clinical/diagnostic service;

11. (10)

    1. (A) A provision delineating requirements for maintaining accurate and complete medical records.
    2. (B) See Health Information Services, 20 CAR § 41-113;
12. (11) A provision for selection and approval of nationally recognized protocols for use in the emergency department;
13. (12) A provision for approval of the bylaws and amendments by the medical staff and the governing body; and

14. (13) Documentation of appointments, reappointments, and approval of requested privileges to the medical and other authorized staff as specified in the bylaws, but at least every three (3) years.

    1. (d) Medical staff minutes. Medical staff minutes shall include at least the following:
15. (1) Documentation of review of committee reports, including quarterly quality assurance/performance improvement (QA/PI);
16. (2) Review, approval, and revision of the medical staff bylaws, rules, and regulations;
17. (3) Election of officers as specified by the bylaws; and
18. (4) Documentation of physicians designated as chairs of the committees to direct the services defined in the medical staff bylaws.

(e) Quality assurance/performance improvement (QA/PI).

1. (1)

   1. (A) The organization shall develop, implement, and maintain an ongoing program to assess and improve the quality of care and services provided.

   2. (B)

      1. (i) A multidisciplinary committee shall meet at least quarterly to provide oversight and direction for the program.
      2. (ii) The hospital shall maintain minutes of the meetings.
   3. (C) A quality assurance/performance improvement plan shall be developed and maintained to describe the manner in which QA/PI activities shall be conducted in the hospital.

   4. (D)

      1. (i) The QA/PI plan shall be reviewed and approved by the chief executive officer, medical staff, and governing body annually.
      2. (ii) All hospital and medical staff programs, services, departments, and functions, including contracted services related to patient care, shall participate in ongoing quality assurance/performance improvement activities.
      3. (iii) The hospital shall collect and assess data on the functional activities identified as priorities in the QA/PI plan.
      4. (iv) Data collected shall be benchmarked against:

(b) (b) National or local standards.

1. (v) Improvement strategies shall be developed for programs, services, departments, and functions identified with opportunities for improvement.

   1. (vi) The effectiveness of improvement strategies and actions taken shall be monitored and evaluated, with documentation of conclusions regarding effectiveness.

      1. (vii) Identify and reduce:

(b) (b) Adverse patient events.

1. (viii) Approved organizational abbreviation list.

2. (2) Scope of QA/PI program. The QA/PI program shall include, but not be limited to, ongoing assessment and improvement activities regarding the following:

   1. (A) Access to care, processes of care, outcomes of care, and hospital-specific clinical data, including applicable peer review organization (PRO)/quality assurance/performance improvement organization (QA/PIO) data;
   2. (B) Customer satisfaction (patients and families, physicians, and employees);
   3. (C) Staff performance as it relates to the staff as a whole when reviewing aspects of care;
   4. (D) Complaint resolution;
   5. (E) Utilization and discharge planning data; and
   6. (F) Organizational performance.

3. (3) Program responsibilities.

   1. (A) The governing body shall assume overall responsibility and accountability for the organization-wide QA/PI program.

   2. (B) The governing body, chief executive officer, and medical staff shall:

      1. (i) Ensure QA/PI activities;
      2. (ii) Address identified priorities; and
      3. (iii) Be responsible for the development, implementation, monitoring, and documentation of improvement activities.

4. (4) Reporting. QA/PI activities shall be:

   1. (A) Reported to the governing body on at least a quarterly basis; and
   2. (B) Documented in the governing body meeting minutes.

5. (5) Policies and procedures. Policies and procedures pertaining to the QA/PI program that are not contained within the QA/PI plan shall be:

   1. (A) Maintained in a manual; and
   2. (B) Reviewed and approved annually.

6. (6) Program evaluation.

   1. (A) An evaluation of the QA/PI program shall be:

      1. (i) Conducted by the hospital; and
      2. (ii) Reported to the governing body annually.

   2. (B) The evaluation shall be:

      1. (i) Based upon objective data; and
      2. (ii) Include programs, services, departments, and functions targeted by the hospital for improvement as well as those conducting ongoing QA/PI activities.
   3. (C) Changes in the QA/PI program and QA/PI plan shall be made in response to the evaluation.

(f) Discharge planning.

1. (1) There shall be a discharge plan for each patient.

2. (2) Discharge plans shall incorporate available community and hospital resources such as social, psychological, nutritional, and educational services to:

   1. (A) Meet the medically related needs of the patients; and
   2. (B) Facilitate the provision of follow-up care.

3. (3) There shall be policies and procedures developed for discharge planning that shall include:

   1. (A) Initiation of discharge planning at the time of the patient’s admission;
   2. (B) Reassessment of patient’s condition and needs prior to the patient’s discharge;

   3. (C) Patient and family education regarding the discharge plan that includes:

      1. (i) Follow-up care and treatment; and
      2. (ii) Available community and hospital resources; and
   4. (D) Transfers and referral processes to appropriate facilities, agencies, or outpatient services as needed for follow-up or ancillary care, including necessary medical information.

(g) Organ and tissue donation.

1. (1) The governing body of each acute care hospital shall cause to be developed appropriate policies, procedures, and protocols for identifying and referring potential organ and tissue donors.

2. (2) The written policies and procedures shall include but not be limited to the following subjects:

   1. (A) Determination and declaration of brain death;

   2. (B) Organ procurement procedures:

      1. (i) Identifying potential donors;
      2. (ii) Referring potential donors; and
      3. (iii) Obtaining consent;
   3. (C) Role of attending physician;
   4. (D) Role of the procurement coordinator (employee of procurement agencies);
   5. (E) Reimbursement for cost of donation;
   6. (F) Liabilities associated with donation;
   7. (G) Agreement with organ procurement agency designated by the Centers for Medicare & Medicaid Services;
   8. (H) A consent procedure that encourages reasonable discretion and sensitivity to the family circumstances in all decisions regarding organ and tissue donations;
   9. (I) Determination by the organ procurement agency personnel of the suitability of the organs and/or tissues for transplantation; and
   10. (J) Requirements for documentation in the patient’s medical record that the family of a potential organ donor has been advised of their right to donate or decline to donate.