PURPOSE: This rule specifies the requirements for the organization of the medical staff in a hospital.

1. (1) The medical staff shall be organized, shall develop and, with the approval of the governing body, shall adopt bylaws, rules and policies governing their professional activities in the hospital.
2. (2) Medical staff membership shall be limited to physicians, dentists, psychologists and podiatrists. They shall be currently licensed to practice their respective professions in Missouri. The bylaws of the medical staff shall include the procedure to be used in processing applications for medical staff membership and the criteria for granting initial or continuing medical staff appointments and for granting initial, renewed or revised clinical privileges.
3. (3) No application for membership on the medical staff shall be denied based solely upon the applicant’s professional degree or the school or health care facility in which the practitioner received medical, dental, psychology or podiatry schooling, postgraduate training or certification, if the schooling or postgraduate training for a physician was accredited by the American Medical Association or the American Osteopathic Association, for a dentist was accredited by the American Dental Association’s Commission on Dental Accreditation, for a psychologist was accredited with accordance to Chapter 337, RSMo and for a podiatrist was accredited by the American Podiatric Medical Association. Each application for staff membership shall be considered on an individual basis with objective criteria applied equally to each applicant.
4. (4) Each physician, dentist, psychologist or podiatrist requesting staff membership shall submit a complete written application to the chief executive officer of the hospital or his designee on a form approved by the governing body. Each application shall be accompanied by evidence of education, training, professional qualifications, license and and other information required by the medical staff bylaws or policies.
5. (5) Written criteria shall be developed for privileges extended to each member of the staff. A formal mechanism shall be established for recommending to the governing body delineation of privileges, curtailment, suspension or revocation of privileges and appointments and reappointments to the medical staff. The mechanism shall include an inquiry of the National Practitioner Data Bank. Bylaws of the medical staff shall provide for hearing and appeal procedures for the denial of reappointment and for the denial, revocation, curtailment, suspension, revocation, or other modification of clinical privileges of a member of the medical staff.
6. (6) Any applicant for medical staff membership who is denied membership or whose completed application is not acted upon in ninety (90) calendar days of completion of verification of credentials data or a medical staff member whose membership or privi- 19 CSR 30-20

leges are terminated, curtailed or diminished in any way shall be given in writing the reasons for the action or lack of action. The reasons shall relate to, but not be limited to, patient welfare, the objectives of the institution, the inability of the organization to provide the necessary equipment or trained staff, contractual agreements, or the conduct or competency of the applicant or medical staff member.

1. (7) Initial appointments to the medical staff shall not exceed two (2) years. Reappointments, which may be processed and approved at the discretion of the governing body on a monthly or other cyclical pattern, shall not exceed two (2) years.
2. (8) The medical staff bylaws shall provide for—an outline of the medical staff organization; designation of officers, their duties and qualifications and methods of selecting the officers; committee functions; and an appeal and hearing process.
3. (9) The medical staff bylaws shall provide for an active staff and other categories as may be designated in the governing body bylaws. The medical staff bylaws shall describe the voting rights, attendance requirements, eligibility for holding offices or committee appointments, and any limitations or restrictions identified with location of residence or office practice for each category.
4. (10) The organized medical staff shall meet at intervals necessary to accomplish its required functions. A mechanism shall be established for monthly decision-making by or on behalf of the medical staff.
5. (11) Written minutes of medical staff meetings shall be recorded. Minutes containing peer review information shall be retained on a confidential basis in the hospital. The medical staff determine retention guidelines and guidelines for release of minutes not containing peer review materials.
6. (12) The medical staff as a body or through committee shall review and evaluate the quality of clinical practice of the medical staff in the hospital in accordance with the medical staff’s peer review function and performance improvement plan and activities.
7. (13) The medical staff shall establish in its bylaws or rules criteria for the content of patients’ records provisions for their timely completion and disciplinary action for noncompliance.
8. (14) Bylaws of the medical staff shall require that at all times at least one (1) physician SENIOR SERVICES

member of the medical staff shall be on duty or available within a reasonable period of time for emergency service.

AUTHORITY: sections 192.006 and 197.080, RSMo 2000 and 197.154, RSMo Supp. 2007.* This rule previously filed as 19 CSR 30-20.021(2)(C). Original rule filed June 27, 2007, effective Feb. 29, 2008.

*Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; and 197.154, RSMo 2004.