(a)  Each department or service providing surgical services shall be directed by members of the medical staff whose clinical and administrative privileges have been approved by the governing body.

(b)  The medical staff shall establish and maintain a system for monitoring and evaluating the quality and appropriateness of the care and treatment of surgical patients, and for monitoring the clinical performance of all individuals with clinical privileges.

(c)  In facilities where there is no anesthesiologist on staff the facility shall:

(1)           with review of the medical staff, establish a consultation agreement with a board-certified or board-eligible anesthesiologist for the purpose of establishing policies and procedures that relate to the safe administration of anesthesia in all departments or services of the facility;

(2)           assume the responsibility for establishing general policies for anesthesia services; and

(3)           establish a line of communication and supervision for staff.


History Note:        Authority G.S. 131E-79;

Eff. January 1, 1996;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.