Laws and Rules for Hospital Medical Staff Committees

What laws and rules apply to hospital medical staff?

The following are the rules the medical staff committees must follow:

Hospital Bylaws - The hospitals are also required to follow their own medical staff bylaws, such that the credentialing, peer review and disciplinary action is taken in a fair and just manner.

Florida Statute - Under Florida statute it is Chapter 395 Section 0191 (395.0191), that establishes rules and procedures for hospital medical staff membership and clinical privileges.

Federal Law - Under Code of Federal Regulations - 42 CFR Section 482.22, a hospital mush have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospitals. 

JACO or TJC - The hospitals are required to follow The Joint Commission's policies and procedures to medial staff membership and clinical privileges.  

The hospitals are required to provide formal notices to the physician with sufficient information so they understand what is about to take place.  

Here are some pointers on how to prepare for such precarious meetings. See how to prepare for meeting.

Before you apply for any hospital privileges, get called into a disciplinary or peer reviewing meeting, or have a formal hearing with the Credentialing Committee, or the Medical Executive Committee, consult your attorney.    

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