OAR 333-071-0390
Medical Staff

(1) The medical staff is responsible for reviewing the professional practices of the SICF for the purposes of improving patient safety and patient care, and is accountable to the governing body.
(2) The SICF’s medical staff organized pursuant to OAR 333-071-0360 (Governing Body Responsibility) shall include physicians and may include other licensed health care practitioners as permitted by the governing body.
(3) The medical staff shall adopt and enforce by-laws, medical staff policies, and medical staff rules and regulations to carry out its responsibilities. The by-laws, medical staff policies, and medical staff rules and regulations must be approved by the governing body.
(4) By-laws, medical staff policies and medical staff rules and regulations shall include, but are not limited to:
(a) The organization of the medical staff, including qualifications for serving on the medical staff, nominations, election, appointment or removal of officers, and periodic review of its members;
(b) Criteria for credentialing health care practitioners and the process for applying for credentials;
(c) Criteria for restricting or terminating facility privileges and the process for restricting or terminating facility privileges;
(d) A process for periodically reviewing the procedures for granting, restricting and terminating facility privileges to ensure that procedures are being followed; and
(e) Procedures for ensuring that licensed health care practitioners with facility privileges i are acting within their scope of practice and acting consistent with the privileges granted by the governing body;
(f) Procedures for the acceptance of verbal orders by those individuals authorized by law or their scope of practice to accept verbal orders;
(g) Procedures for responding to medical emergencies, including contacting at least one physician in the event of a medical emergency; and
(h) Procedures for notifying patients orally and in writing of any financial interest as required by ORS 441.098 (Health practitioner referral of patient to treatment or diagnostic testing facility).
(5) Amendments to medical staff by-laws shall be accomplished through a cooperative process involving both the medical staff and the governing body. Medical staff by-laws shall be adopted, repealed or amended when approved by the medical staff and the governing body. Approval shall not be unreasonably withheld by either. Neither the medical staff nor the governing body shall withhold approval if such repeal, amendment, or adoption is mandated by law, statute or regulation or is necessary to obtain or maintain accreditation or to comply with fiduciary responsibilities or if the failure to approve would subvert the stated moral or ethical purposes of the facility.
(6) All health care practitioners with individual admitting privileges are subject to applicable provisions of the medical staff by-laws and rules governing admission and staff privileges.

Source: Rule 333-071-0390 — Medical Staff, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-071-0390.

333‑071‑0200
Purpose and Applicability 333‑071‑0205
Definitions 333‑071‑0210
License Application and Fees 333‑071‑0215
Application Review 333‑071‑0220
Approval of License Application 333‑071‑0225
Fees for Complaint Investigations and Compliance Surveys 333‑071‑0230
Expiration and Renewal of License 333‑071‑0235
Denial of License Application 333‑071‑0240
Return of SICF License and SICF Closure 333‑071‑0245
Discontinuance and Recommencement of Operations 333‑071‑0250
Classification 333‑071‑0260
Waivers 333‑071‑0270
Complaints 333‑071‑0280
Investigations 333‑071‑0290
Surveys 333‑071‑0300
Nurse Staffing Audit and Complaint Investigation Procedures 333‑071‑0310
Violations 333‑071‑0315
Informal Enforcement 333‑071‑0320
Formal Enforcement 333‑071‑0330
Approval of Accrediting Organization 333‑071‑0340
Civil Penalties for Violations of Nurse Staffing Laws 333‑071‑0345
Civil Penalties for Violation of Smoking Prohibition 333‑071‑0350
Civil Penalties, Generally 333‑071‑0360
Governing Body Responsibility 333‑071‑0370
Health Care Practitioner Credentialing 333‑071‑0380
Administrator 333‑071‑0390
Medical Staff 333‑071‑0400
Organization Policies 333‑071‑0410
Patient Rights 333‑071‑0420
Personnel 333‑071‑0430
Medical Records 333‑071‑0440
Quality Assessment and Performance Improvement 333‑071‑0450
Infection Control 333‑071‑0470
Patient Admission and Treatment Orders 333‑071‑0480
Nursing Care Management 333‑071‑0485
Nursing Services 333‑071‑0490
Nurse Executive 333‑071‑0510
Dietary Services 333‑071‑0520
Laboratory Services 333‑071‑0530
Pharmacy Services 333‑071‑0535
Radiology Services 333‑071‑0550
Sanitary Precautions 333‑071‑0560
Safety and Emergency Preparedness 333‑071‑0570
Smoking Prohibition 333‑071‑0580
Physical Environment Requirements
Last Updated

Jun. 8, 2021

Rule 333-071-0390’s source at or​.us