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8. Medical Staff

 
 
(Rev.56, Issued: 12-30-09, Effective/Implementation: 12-30-09)
 
§416.45 Condition for Coverage: Medical Staff
 
The medical staff of the ASC must be accountable to the governing body.
 
Interpretive Guidelines §416.45
 
The organization of the medical staff is left to the discretion of the governing body, but however the staff is organized, the ASC must have an explicit, written policy that indicates how the medical staff is held accountable by the governing body. The policy must address all requirements in this condition. Medical staff privileges may be granted both to physician and non-physician practitioners, consistent with their permitted scope of practice in the State, as well as their training and clinical experience.
 
It is possible for an ASC to be owned and operated by one physician, who could be both the sole member of the governing body and also the sole member of the ASC’s medical staff. In such cases the physician owner must nevertheless implement a formal process for complying with all medical staff regulatory requirements.
 
Survey Procedures §416.45
 
Ask the ASC’s leadership for its policy detailing how the governing body holds the medical staff accountable.
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