ORS 441.055 Health care facility medical staff and bylaws; rules

The governing body of each health care facility shall be responsible for the operation of the facility, the selection of the medical staff and the quality of care rendered in the facility. The governing body shall:

Ensure that all health care personnel for whom state licenses, registrations or certificates are required are currently licensed, registered or certified;

Ensure that physicians admitted to practice in the facility are granted privileges consistent with their individual training, experience and other qualifications;

Ensure that procedures for granting, restricting and terminating privileges exist and that such procedures are regularly reviewed to ensure their conformity to applicable law;

Ensure that physicians admitted to practice in the facility are organized into a medical staff in such a manner as to effectively review the professional practices of the facility for the purposes of reducing morbidity and mortality and for the improvement of patient care; and

Ensure that a physician is not denied medical staff membership or privileges at the facility solely on the basis that the physician holds medical staff membership or privileges at another health care facility.

The physicians organized into a medical staff pursuant to subsection (1) of this section shall propose medical staff bylaws to govern the medical staff. The bylaws shall include, but not be limited to the following:

Procedures for physicians admitted to practice in the facility to organize into a medical staff pursuant to subsection (1) of this section;

Procedures for ensuring that physicians admitted to practice in the facility are granted privileges consistent with their individual training, experience and other qualifications;

Provisions establishing a framework for the medical staff to nominate, elect, appoint or remove officers and other persons to carry out medical staff activities with accountability to the governing body;

Procedures for ensuring that physicians admitted to practice in the facility are currently licensed by the Oregon Medical Board;

Procedures for ensuring that the facility’s procedures for granting, restricting and terminating privileges are followed and that such procedures are regularly reviewed to assure their conformity to applicable law; and

Procedures for ensuring that physicians provide services within the scope of the privileges granted by the governing body.

Amendments to medical staff bylaws shall be accomplished through a cooperative process involving both the medical staff and the governing body. Medical staff bylaws 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 institution.

The Oregon Medical Board may appoint one or more physicians to conduct peer review for a health care facility upon request of such review by all of the following:

The physician whose practice is being reviewed.

The executive committee of the health care facility’s medical staff.

The governing body of the health care facility.

The physicians appointed pursuant to subsection (4) of this section shall be deemed agents of the Oregon Medical Board, subject to the provisions of ORS 30.310 to 30.400 and shall conduct peer review. Peer review shall be conducted pursuant to the bylaws of the requesting health care facility.

Any person serving on or communicating information to a peer review committee shall not be subject to an action for damages for action or communications or statements made in good faith.

All findings and conclusions, interviews, reports, studies, communications and statements procured by or furnished to the peer review committee in connection with a peer review are confidential pursuant to ORS 192.338, 192.345, 192.355 and 192.690 and all data is privileged pursuant to ORS 41.675.

Notwithstanding subsection (7) of this section, a written report of the findings and conclusions of the peer review shall be provided to the governing body of the health care facility who shall abide by the privileged and confidential provisions set forth in subsection (7) of this section.

Procedures for peer review established by subsections (4) to (8) of this section are exempt from ORS chapter 183.

The Oregon Health Authority shall adopt by rule standards for rural hospitals, as defined in ORS 442.470, that specifically address the provision of care to postpartum and newborn patients so long as patient care is not adversely affected.

For purposes of this section, “physician” has the meaning given the term in ORS 677.010.