(a) A freestanding birthing center shall have an organized governing body that shall be legally responsible for:

1. (1) Maintaining patient care;
2. (2) Establishing policies for the facility; and
3. (3) The conduct of the center.

(b) Governing body bylaws.

1. (1) The governing body shall adopt written bylaws that shall be available to all members of the governing body.

2. (2) The bylaws shall ensure the following:

   1. (A) The governing body shall consist of three (3) or more individuals;
   2. (B) Maintenance of professional standards of practice;
   3. (C) Terms, responsibilities, and methods of selecting members and officers;
   4. (D) Selection of an administrator with responsibility for operation and maintenance of the facility;
   5. (E) Methods for establishing:

(i) Governing body committees; and

1. (ii) The duties of each committee;

   1. (F) Coordination of activities and general policies of the departments;
   2. (G) Liaison between the governing body and Professional Review Committee documented quarterly;
   3. (H) Quarterly governing body meetings with maintenance of minutes signed by an officer;
   4. (I) Provision for formal approval of the organization, bylaws, rules, regulations, and protocols of the freestanding birthing center staff and their services;
   5. (J) Method of credentialing or appointing members to the professional and other authorized staff;
   6. (K) Methods by which quality improvement (QI) is established;
   7. (L) Establishment of a quorum to be met in order to conduct business;
   8. (M) Annual approval of the operating budget by the governing body; and

   9. (N) Compliance with federal, state, and local laws.

      1. (c) Governing body minutes. The governing body minutes shall include at least the following information:

2. (1) Review, approval, and revision of the:

   1. (A) Governing body bylaws; and

   2. (B) Professional Review Committee:

      1. (i) Bylaws;
      2. (ii) Rules;
      3. (iii) Regulations; and
      4. (iv) Protocols;
3. (2) Election of officers as indicated in the bylaws;
4. (3) Documentation that the liaison between the governing body and Professional Review Committee is maintained;
5. (4) Appointment and reappointment of the Professional Review Committee and other credentialed staff as indicated in the bylaws;
6. (5) Review and approval of reports received from the Professional Review Committee and administration;
7. (6) Review and approval of the quality improvement plan of the facility at least annually; and

8. (7) Documentation of the quarterly quality improvement summaries.

   1. (d) Credential files. An individual file shall:
9. (1) Be maintained for each physician, certified nurse midwife, advanced practice nurse, and other allied health practitioners practicing in the freestanding birthing center; and

10. (2) Include at least the following:

    1. (A) Verification of:

       1. (i) Year and school of graduation;
       2. (ii) Date of licensure; and
       3. (iii) Postgraduate or special training and experience;
    2. (B) Specific delineation of privileges requested and granted;

    3. (C) Detailed application signed by:

       1. (i) The applicant;
       2. (ii) The chair of the Professional Review Committee; and
       3. (iii) An officer of the governing body;

    4. (D) Documentation of the applicant's agreement to abide by the freestanding birthing center:

       1. (i) Bylaws;
       2. (ii) Rules;
       3. (iii) Regulations; and
       4. (iv) Protocols;
    5. (E) Verification of current Arkansas license and certification as applicable;
    6. (F) Verification of each applicant's United States Drug Enforcement Administration permit;
    7. (G) Verification of at least three (3) professional references;

    8. (H) Documentation of all actions taken by the Professional Review Committee and governing body indicating:

       1. (i) The privileges granted;
       2. (ii) Approval of appointment/reappointment; and
       3. (iii) Other related data; and
    9. (I) Evaluation of professional performance at the time of reappointment.

(e) Professional Review Committee bylaws. The Professional Review Committee bylaws shall include at least the following provisions:

1. (1) Responsible to the governing body for the:

   1. (A) Quality of healthcare provided in the freestanding birthing center; and
   2. (B) Ethical and professional practices of its members;
2. (2) Requirements for membership;
3. (3) Election of officers, responsibilities, and terms;
4. (4) Functions, frequency of meetings, and composition (quorum) and attendance requirements;

5. (5) Written minutes shall be:

   1. (A) Maintained of all meetings; and
   2. (B) Signed by the chair;
6. (6) An appeals process if appointment/reappointment is not granted by the governing body;
7. (7) Delineation of maintaining accurate and complete medical records; and
8. (8) Approval of the bylaws and amendments by the Professional Review Committee and the governing body.

(f) Professional Review Committee minutes. Professional Review Committee minutes shall include at least the following:

1. (1) Documentation of review of committee reports including quarterly quality improvement (QI) summaries;
2. (2) Review, approval, and revision of the Professional Review Committee bylaws, rules, regulations, and protocols;
3. (3) Election of officers as specified by the bylaws;
4. (4) Documentation of a practitioner designated as chair of the committee to direct the services defined in the bylaws; and
5. (5) Documentation of appointments, reappointments, and approval of requested privileges to the freestanding birthing center staff as specified in the bylaws, but at least every two (2) years.

(g) Quality improvement (QI) program.

1. (1)

   1. (A) The freestanding birthing center shall develop, implement, and maintain a QI program.
   2. (B) The QI plan shall be reviewed and approved annually by the governing body.

   3. (C) The facility shall appoint a QI Committee with functions to include:

      1. (i) Quarterly meetings with maintenance of written minutes;
      2. (ii) Collection of data on the functional activities identified as priorities in QI and benchmark against past performance and national or local standards; and
      3. (iii) Development and implementation of improvement plans for identified issues, with monitoring, evaluation, and documentation of effectiveness.

2. (2) The scope of the QI program shall include but not be limited to activities regarding the following:

   1. (A) Assessment of processes and outcomes. Outcome data for morbidity, mortality, maternal and infant transfers and referrals, complications, Apgar scores, patients delivering outside the center, and other performance data shall be collected and analyzed on an ongoing basis;
   2. (B) Evaluation of customer satisfaction (patients, providers, patients’ families, employees);
   3. (C) Measurement of staff performance;
   4. (D) Complaint resolution;
   5. (E) Utilization data; and
   6. (F) Organizational/administrative performance.

3. (3) Reporting. QI activities shall be:

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

4. (4)

   1. (A) Policies and procedures covering all functions of the QI program shall be maintained.
   2. (B) All policies and procedures not contained within the QI plan shall be maintained in a manual.

   3. (C) The first page of the manual shall have the:

      1. (i) Annual review date; and
      2. (ii) Signatures of the persons conducting the review.