N.M. Code R. § 7.7.4.13 – Medical Staff

A. Appointment: Ultimate responsibility for medical staff appointments rests with the board of trustees. Medical staff membership shall be limited, unless otherwise provided by law, to individuals who are currently licensed to practice medicine, osteopathy, and dentistry. These individuals may be appointed to the medical staff in accordance with the by-laws of the medical staff, and pursuant to the following criteria:
(1) Appointment to the medical staff is a privilege which shall be extended only to professionally competent individuals who continuously meet the qualifications, standards, and requirements set forth in these By-laws and in the policies adopted by the board. All individuals practicing medicine and oral surgery in the medical center, unless by specific provisions of these by-laws, must first have been appointed to the medical staff.
(2) Only physicians and oral surgeons who:
(a) are currently licensed to practice in this state;
(b) are located close enough to provide timely care for their patients;
(c) possess current, valid professional liability insurance coverage in amounts specified in Subsection B [now Subsection B or 7.7.4.13 NMAC] of this Article;
(d) are certified by the appropriate specialty board, unless such requirement is waived by the board after considering the special competence and experience of the applicant, and
(e) can document their background, experience, training and demonstrated competence, their adherence to the ethics of their profession, their good reputation and character and their ability to work harmoniously with others sufficiently so that all patients treated by them shall receive quality care and that the hospital and the medical staff will be able to operate in an orderly manner, shall be qualified for appointment to the medical staff. The word "character" is intended to include the applicant's mental and emotional stability.
(3) No individual shall be entitled to appointment to the medical staff or to the exercise of particular clinical privileges in the Medical Center merely by virtue of the fact that:
(a) he or she is licensed to practice any profession in this or any other state;
(b) he or she is a member of any particular professional organization; or
(c) he or she had in the past, or currently has, medical staff appointment or privileges in another hospital.
(4) No individual shall be denied appointment on the basis of age, sex, race, creed, color or national origin.
B. Malpractice insurance: Good management of the assets of the hospital and legitimate protection of the patients of the hospital require that all appointees to the medical staff and all applicants for appointment have and maintain malpractice insurance in adequate amounts to cover claims or suits arising from alleged malpractice. Qualification under the Medical Malpractice Act of New Mexico 41-5-1 et. seq., NMSA 1978, or coverage under the Tort Claims Act of New Mexico, 41-4-1 et. seq., NMSA 1978, in cases of physicians who are "public employees" is sufficient. In all other cases, the adequacy of insurance protection required may depend upon the scope of staff privileges to be exercised and other considerations. Accordingly, the minimum policy limits in each instance shall not be less than those approved by the board after it has considered a recommendation in this regard from the medical staff executive committee. Compliance with this policy by medical staff appointees shall be evidenced by filing with the chief executive officer of the medical center a certificate of insurance from the carrier, showing at least the minimum amount required as aforesaid. Any lapse in insurance coverage or cancellation of insurance coverage will result in suspension of privileges until insurance is obtained.
C. By-laws, rules and regulations: The medical staff will develop, adopt, and periodically review medical staff by-laws, rules and regulations which are consistent with medical center policy and legal or other requirements. Such medical staff by-laws, rules and regulations shall become effective only upon approval by the board of trustees and when so approved, shall become a part of the board's by-laws. The medical staff by-laws, rules and regulations shall include at least the following principles and procedures by which the medical staff shall govern itself; formal means for medical staff participation in the development of medical center policy relative to both management and patient care; procedure for processing and evaluating applications for appointment or reappointment to the medical staff and for the granting of clinical privileges; a requirement that no qualified applicant shall be denied appointment and/or clinical privileges on the bases of sex, race, creed, or national origin; a requirement that all applicants must sign a statement to the effect that they have read and agree to be bound by the medical staff by-laws, rules and regulations and by the current medical center policies that apply to their activities; mechanisms designed to assure the achievement and maintenance of quality medical practice and patient care to include board policy, the quality assurance program, and other quality measures; a grievance procedure, triggered by adverse recommendations for appointment, reappointment, addition or modification of clinical privileges, that entitles the affected party to notice, hearing, and appellate review.
D. Delegated authority:
(1) The board delegates to the medical staff the authority and responsibility to: provide appropriate medical care; to evaluate the quality of medical care; to organize itself by adopting by-laws, rules and regulations for review and approval by the board of trustees; and, to accept and process applications for initial appointment and reappointment to the medical staff and delineation of privileges.
(2) In the exercise of its overall responsibility the board shall assign to the medical staff executive committee reasonable authority
(a) to ensure appropriate professional care to patients so that all patients with the same health problems shall receive the same level of care;
(b) to ensure the ongoing review and appraisal of the quality of professional care rendered, and to report results and findings to the board; and
(c) to ensure that:
(i) only medical staff appointees with admitting privileges admit patients;
(ii) each medical staff appointee practices only within the scope of privileges granted by the board;
(iii) all individuals who provide patient care services but who are not subject to the medical staff delineation process, are competent to provide such services and that their competency is monitored;
(iv) each patient's general medical condition is the responsibility of a qualified medical staff appointee. The committee shall also report to the board the mechanisms for monitoring and evaluating the quality of patient care, for identifying and resolving problems, and for identifying opportunities to improve patient care.
(3) The medical staff executive committee shall make recommendations directly to the board concerning:
(a) the structure of the medical staff;
(b) all matters relating to professional competency including the conduct, evaluation, and revision of quality assurance mechanisms;
(c) disciplinary actions and the mechanism for fair hearing procedures;
(d) such specific matters as the board may refer to it.
E. Board-medical staff liaison: The official method of communication and liaison between the board of trustees and the medical staff shall take place with the chief of staff or his designee attending regular meetings of the board of trustees.
[Recompiled 10/31/01]