59A-3.272. Governing Board

(1) The licensee shall have a governing board responsible for the conduct of the hospital as a functioning institution.

(2) The governing board shall be organized under written bylaws, rules and regulations which it reviews at least every two years, dates to indicate time of last review, revises as necessary, and enforces. Governing board by-laws shall:

(a) State the role and purpose of the hospital, including an organizational chart defining the lines of authority. The description of the structure of the hospital shall include full disclosure in writing of the names and addresses of all owners and persons controlling 5 percent or more interest in the hospital. In the case of corporations, holding companies, partnerships, and similar organizations, the names and addresses of officers, directors, and stockholders, both beneficial and of record, when holding 5 percent or more interest, shall be disclosed.

(b) State the qualifications for governing board membership, and the method of selecting members as well as the terms of appointment or election of members, officers and chairmen of committees.

(c) Provide for the designation of officers, their duties, and for the organization of the governing board into essential committees with the number and type consistent with the size and scope of the hospital’s activities.

(d) Coordinate through an executive committee or the governing board as a whole, the policies and activities of the facility and special committees established by the governing board.

(e) Specify the frequency of meetings, at regularly stated intervals, the number or percentage of members constituting a quorum, and require that minutes be recorded and made available to all members of the governing board.

(3) The governing board shall establish the position of chief executive officer or other similarly titled position, and define in writing the responsibility, authority and accountability of the chief executive officer for operation and maintenance of the hospital.

(4) The governing board shall approve the by-laws, rules and regulations of the organized medical staff, provide for the appointment, reappointment, or dismissal of members of the organized medical staff, and provide a procedure for hearings and appeals on all actions concerning appointment, reappointment or dismissal. No action on appointment, reappointment, or dismissal of a member of the organized medical staff shall be taken without prior referral to the organized medical staff for their recommendation, except in emergency cases.

(a) The governing board shall provide that no qualified applicant is denied organized medical staff privileges or clinical privileges solely because the applicant is licensed as a physician, dentist or podiatrist, psychologist, advanced practice registered nurse, or physician assistant.

(b) The governing board shall set standards and procedures to be applied by the hospital and the organized medical staff in considering and acting upon applications for staff membership or professional privileges, including delineation of privileges. Such standards or procedures shall be available for public inspection, and shall not operate to deny staff privileges or clinical privileges in an arbitrary, unreasonable or capricious manner, or on the basis of sex, race, creed, or national origin.

(c) When the standards and procedures established by the governing board require, as a precondition to obtaining staff membership or professional clinical privileges, the completion of or eligibility in, a program established by the American Medical Association or the Liaison Committee on Graduate Medical Education, the governing board shall also make available staff membership or privileges to physicians who have obtained the completion of or eligibility in, any program which is in the same area of medical specialization established by the American Osteopathic Association.

(d) The governing board shall require a delineation of privileges for each member of the organized medical staff. The delineation of privileges shall not be stated simply as a specialty designation, such as “general surgery” or “general medicine” unless such terms are specifically defined elsewhere.

(e) The governing board shall require that eligibility for privileges, delineation of privileges, and reappointments, be based on the applicant’s background, experience, health, training, demonstrated current competence, adherence to applicable professional ethics, reputation, ability to work with others, ability of the hospital to provide adequate facilities and supportive services for the applicant and his patients, and such other elements as the governing board determines that are not inconsistent with this part.

(f) The governing board shall establish a procedure, within a time-limited period, for approving, approving in part, or denying an applicant’s request for privileges.

(g) The governing board shall establish a procedure for an applicant for privileges to appeal an adverse decision, and shall establish a time-limited period for rendering a final decision after the appeal.

(h) The governing board shall set standards and procedures which provide for reasonable access by licensed chiropractors to the reports of diagnostic x-rays and laboratory tests of the institutions licensed facilities, subject to the same standards and procedures as other licensed physicians. However, nothing contained in the provisions of this section shall require a licensed facility to grant staff privileges to a chiropractor.

(5) Within 30 days of receipt of a written request, either by an applicant for staff privileges, or by a member of the organized medical staff whose privileges have been suspended, denied, revoked or curtailed, whether in whole or in part, the licensed facility shall supply the reasons for such action in writing to the requesting applicant or staff member. A denial of staff membership or professional clinical privileges to any applicant shall be submitted, in writing, to the applicant’s respective licensing board.

(6) Nothing herein shall prohibit the licensee of the facility from acting as the governing board, provided that the articles of incorporation or other written organizational plan describe the manner in which the licensee executes the governing board’s responsibility.

Rulemaking Authority 395.1055 FS. Law Implemented 395.0191, 395.0193, 395.0195, 395.1055 FS. History–New 9-4-95, Formerly 59A-3.217, Amended 11-21-18.