Bill Text: OR SB205 | 2011 | Regular Session | Introduced
Bill Title: Relating to hospital credentialing.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Failed) 2011-06-30 - In committee upon adjournment. [SB205 Detail]
Download: Oregon-2011-SB205-Introduced.html
76th OREGON LEGISLATIVE ASSEMBLY--2011 Regular Session
NOTE: Matter within { + braces and plus signs + } in an
amended section is new. Matter within { - braces and minus
signs - } is existing law to be omitted. New sections are within
{ + braces and plus signs + } .
LC 2406
Senate Bill 205
Sponsored by Senator BATES (Presession filed.)
SUMMARY
The following summary is not prepared by the sponsors of the
measure and is not a part of the body thereof subject to
consideration by the Legislative Assembly. It is an editor's
brief statement of the essential features of the measure as
introduced.
Requires medical staff bylaws at health care facility to
provide for fair hearing process to challenge denial, revocation,
suspension or restriction of physician privileges. Specifies
requirements for process.
A BILL FOR AN ACT
Relating to hospital credentialing; amending ORS 441.055.
Be It Enacted by the People of the State of Oregon:
SECTION 1. ORS 441.055 is amended to read:
441.055. (1) 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:
(a) Ensure that all health care personnel for whom state
licenses, registrations or certificates are required are
currently licensed, registered or certified;
(b) Ensure that physicians admitted to practice in the facility
are granted privileges consistent with their individual training,
experience and other qualifications;
(c) Ensure that procedures for granting, restricting and
terminating privileges exist and that such procedures are
regularly reviewed to ensure their conformity to applicable law;
(d) 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 - }
(e) 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 { - . - } { + ; and
(f) Ensure that economic criteria, unrelated to quality of care
or professional competency, are not considered in determining a
physician's qualification for initial or continuing medical staff
membership or clinical privileges at the facility. + }
(2) 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:
(a) Procedures for physicians admitted to practice in the
facility to organize into a medical staff pursuant to subsection
(1) of this section { - ; - } { + . + }
(b) Procedures for ensuring that physicians admitted to
practice in the facility are granted privileges consistent with
their individual training, experience and other qualifications
{ - ; - } { + . + }
(c) 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 { - ; - } { + . + }
(d) Procedures for ensuring that physicians admitted to
practice in the facility are currently licensed by the Oregon
Medical Board { - ; - } { + . + }
(e) 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 - } { + . + }
(f) Procedures for ensuring that { - physicians provide - }
{ + a physician provides + } services within the scope of the
privileges granted by the governing body { - . - } { + and
ensuring that a physician is not required to provide call
coverage for clinical services for which the physician either is
not competent by training or experience to provide or has no
professional liability insurance coverage.
(g) Procedures ensuring a fair hearing process to challenge a
proposed action to deny, reduce, suspend or restrict a
physician's medical staff or clinical privileges that shall
include, but not be limited to, all of the following:
(A) A written notice to the physician stating the proposed
action and a detailed statement of the facts and reasoning that
form the basis of the action.
(B) The right of the physician to request a hearing before a
committee composed of noncompeting members of the facility's
medical staff. If the physician and the facility agree in
writing, another adjudicative body or person may be substituted
for the committee described in this subparagraph.
(C) The right of the physician to receive from the facility, no
less than 30 days prior to the scheduled date of the hearing,
notice of the date, time and place of the hearing, a summary of
the physician's rights at the hearing, a list of witnesses the
facility expects to call and a summary of each witness's expected
testimony.
(D) The right of the physician to:
(i) Call, examine and cross-examine witnesses;
(ii) Have a record of the hearing made at the expense of the
physician;
(iii) Present evidence determined by the committee or presiding
officer to be relevant regardless of whether such evidence would
be admissible in court;
(iv) Present a written statement at the close of the hearing;
(v) Receive a copy of the recommendation of the committee or
presiding officer;
(vi) Receive a written copy of the facility's written decision
that sets forth, in detail, the basis for the decision; and
(vii) Be represented by an attorney throughout the hearing
process.
(E) If the physician's initial application to become a member
of the facility's medical staff is denied or the application is
approved with limited or restricted privileges, a provision that
the burden of proof is on the physician to prove by clear and
convincing evidence that the physician's credentials meet or
exceed the written criteria of the facility for granting the
requested privileges. The facility has the burden of going
forward with clear and convincing evidence that the physician
should not be granted the privileges requested.
(F) If the facility proposes to revoke, suspend or restrict a
physician's existing medical staff or clinical privileges,
including requests for recredentialing, a provision that the
burden of proof is on the facility to prove by clear and
convincing evidence that the proposed action should be taken. The
physician has the burden of going forward with clear and
convincing evidence to prove that the proposed action should not
be taken.
(G) A provision that the parties to the fair hearing process
shall conduct discovery as provided in ORCP 36 to 46, and that if
any party refuses to conform the party's conduct or responses to
the requirements of the rules, the complaining party may petition
the circuit court in the county where the hearing is to take
place to impose such sanctions as the court deems proper.
(h) Provisions establishing that personal conduct, whether
verbal or physical, that affects or has the potential to affect
patient care negatively may constitute disruptive behavior and be
the basis for refusing to grant, restricting or terminating
privileges. A decision under this paragraph must be in writing,
furnished to the physician within 10 days of the decision, and
state the specific basis for the decision, which must be
supported by an objectively reasonable belief that the purported
disruptive behavior has or will negatively impact patient care.
As used in this paragraph, 'disruptive behavior' does not include
verbal or written criticism or expression offered in good faith
to improve patient care. + }
(3) 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.
(4) 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:
(a) The physician whose practice is being reviewed.
(b) The executive committee of the health care facility's
medical staff.
(c) The governing body of the health care facility.
(5) 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.
(6) 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.
(7) 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 192.501 to 192.505 and 192.690 and
all data is privileged pursuant to ORS 41.675.
(8) 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.
(9) Procedures for peer review established by subsections (4)
to (8) of this section are exempt from ORS chapter 183.
(10) 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.
(11) For purposes of this section, 'physician' has the meaning
given the term in ORS 677.010.
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