OPERATION OF APPROVED HOSPITALS REGULATION

Transcription

1 Province of Alberta HOSPITALS ACT OPERATION OF APPROVED HOSPITALS REGULATION Alberta Regulation 247/1990 With amendments up to and including Alberta Regulation 170/2012 Office Consolidation Published by Alberta Queen s Printer Alberta Queen s Printer 7 th Floor, Park Plaza Avenue Edmonton, AB T5K 2P7 Phone: Fax: qp@gov.ab.ca Shop on-line at

2 Copyright and Permission Statement Alberta Queen's Printer holds copyright on behalf of the Government of Alberta in right of Her Majesty the Queen for all Government of Alberta legislation. Alberta Queen's Printer permits any person to reproduce Alberta s statutes and regulations without seeking permission and without charge, provided due diligence is exercised to ensure the accuracy of the materials produced, and Crown copyright is acknowledged in the following format: Alberta Queen's Printer, 20.* *The year of first publication of the legal materials is to be completed. Note All persons making use of this consolidation are reminded that it has no legislative sanction, that amendments have been embodied for convenience of reference only. The official Statutes and Regulations should be consulted for all purposes of interpreting and applying the law.

3 (Consolidated up to 170/2012) ALBERTA REGULATION 247/90 Hospitals Act OPERATION OF APPROVED HOSPITALS REGULATION Table of Contents 1 Interpretation 2 Application of Regulation 2.1 Review by regional health authority 3 Planning approval 4 Construction approval 5 Location and site approval 6 Standards approval 7 Fire prevention regulations 8 Changes in capacity 9 Treatment privileges and admission of patients 10 Admission responsibility 11 Salmonella reports 12 Minutes of board meeting 13 Medical records 14 Signature of attending physician and nurse 15 Retention of medical records 15.1 Health Care Protection Act records 16 Rules of the hospital 17 Health examinations 18 Surgical care 19 Anaesthetics 20 Assistance at major operations 22 Operating room 23 Tissues removed at operation 24 Obstetrical care 25 Autopsies 26 Removal of body 27 Nursing service 28 Approval of changes in services 29 Approval of changes in education programs 30 Expense payments to board members Medical staff 33.1 Notice to professional association

4 Section 1 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 34 Accreditation 35 Reimbursement 35.1 Offence 36 Repeal Interpretation 1(1) In this Regulation, (a) Act means the Hospitals Act; (b) graduate nurse means a person who has graduated from a recognized formal educational program and is eligible but is not registered pursuant to the Nursing Profession Act; (c) in-patient means a person admitted to and assigned a bed in a hospital by the order of a member of the medical or professional staff who has admitting privileges; (d) out-patient means a person who receives out-patient services; (e) professional staff means health practitioners, other than physicians, who are regulated under a health profession statute and have been granted by the board of a hospital the authority to admit, attend or treat patients at and utilize the resources of that hospital. (2) Other words have the same meaning as in the Act or in regulations under Part 1 and Part 3 of the Act. AR 247/90 s1;163/95;178/95;272/99 Application of Regulation 2 This Regulation applies to the boards of approved hospitals. AR 247/90 s2 Review by regional health authority 2.1 Where a provision of this Regulation requires that a board obtain the approval of the Minister in respect of a proposed activity, the Minister may, prior to giving approval, require that the proposed activity be reviewed and approved by the regional health authority of the health region or regions in which the board operates a hospital. AR 402/94 s2 2

5 Section 3 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 Planning approval 3 Any hospital or other board or joint planning board contemplating any change in its program of services or facilities shall obtain the approval of the Minister and recommendations from the district or regional planning council, if established, for the proposed change. AR 247/90 s3 Construction approval 4(1) No hospital or other board shall undertake or authorize any construction, alteration or renovation, other than emergency or normal repair work, without the prior approval of the Minister. (2) The upgrading of an existing hospital to meet minimum standards shall be subject to approval of the Minister based on utilization, the condition of the physical plant and the assessed need for a hospital facility. (3) All plans for the construction, expansion, renovation or alteration of any health care facilities under the jurisdiction of the Minister shall be submitted to the Minister in accordance with the procedures established by the Minister. (4) Subject to subsection (5), final plans, specifications and all contract documents, including tenders, must receive approval of the Minister before construction contracts can be awarded. (5) Subsection (4) does not apply to a project if (a) an agreement exists between the Minister and the board of the hospital setting forth the responsibilities of each party to that agreement with respect to the construction or renovation of the hospital or facility, and (b) the Minister has approved that board s use of the contract management system in respect of the construction or renovations of that hospital or facility. (6) No changes to any contract documents, or to the construction, may be made without the prior approval of the Minister. (7) Notwithstanding approval by the Minister, full compliance with all applicable Acts, regulations, codes and standards shall be the responsibility of the board of the facility concerned and of their professional consultants. (8) The official rated capacity of a hospital shall be as established by the Minister. AR 247/90 s4 3

6 Section 5 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 Location and site approval 5 No hospital or other board shall (a) purchase or otherwise acquire any building site for hospital purposes without the approval of both the general location and the specific site by the Minister, (b) sell, lease or otherwise dispose of any land, building or facilities except on approval of the Minister, or (c) dispose of any hospital equipment except within policy established by the Minister. AR 247/90 s5 5.1 Repealed AR 163/95 s3. Standards approval 6 All construction, alteration or renovation of any hospital or other health facility under the Minister s administration shall comply with all applicable building codes and regulations and with the minimum standards of basic construction and planning requirements as adopted by the Minister. AR 247/90 s6 Fire prevention regulations 7 All hospitals and other health facilities under the Minister s administration shall conform to the regulations under the Fire Prevention Act. AR 247/90 s7 Changes in capacity 8(1) No change involving a period of over 60 days in the rated bed capacity of any hospital or health facility under the Minister s administration shall be made without the prior approval of the Minister. (2) The Minister must be notified in all cases where the number of beds set up is less than the official rated capacity. AR 247/90 s8 Treatment privileges and admission of patients 9(1) Only (a) physicians who have been appointed to the medical staff of a hospital on a permanent or temporary basis, or 4

7 Section 9 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (b) health practitioners who have been appointed to the professional staff of a hospital on a permanent or temporary basis may attend patients or have treatment privileges in the hospital. (2) As part of the admitting procedure the health practitioner shall (a) for each emergency admission, as soon as possible and no later than 24 hours following the admission of the patient, and (b) for each admission other than an emergency admission of the patient, provide a history, a description of pertinent physical findings and a statement of the provisional diagnosis and treatment. (3) Notwithstanding subsection (2), in hospitals where interns, students or clinical clerks are appointed or employed and are under the direction of a member of the medical or professional staff, a history may be completed by one of them but in that case it shall be completed within 48 hours following admission of the patient. (4) If possible, a note on the results of pertinent investigations previously carried out should be provided. (5) Before a person is accepted for admission to an auxiliary hospital, a report shall be provided indicating a recent negative chest x-ray for tuberculosis. (6) Candidates for admission to auxiliary hospitals who are reported to have active tuberculosis shall be referred to the Minister for assessment. (7) Candidates for admission to auxiliary hospitals who are reported to have inactive tuberculosis and who do not possess documentation to substantiate that their disease is inactive shall be referred to the Minister for assessment before admission may be approved. (8) Control of admission and stay in hospital of persons not requiring hospital care is the responsibility of the hospital administration staff and the hospital services utilization committee. (9) The attending health practitioner should complete a copy of the Certificate as to the Clinical Necessity for Admission of a Person Not Requiring Hospital Care Accompanying a Sick Patient and forward it to the administrator who shall (a) ensure that the certificate is considered by the hospital services utilization committee or the member of the 5

8 Section 10 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 medical or professional staff responsible for this function, and (b) ensure that the certificate is filed on the patient s medical record. (10) If the hospital services utilization committee does not confirm that admission of the person not requiring hospital care was clinically necessary for the welfare of a sick in-patient, the person is deemed not to be in need of hospitalization and thereby ineligible for hospital insurance benefits, in which case the non-eligible rate established by regulations should be charged. AR 247/90 s9;272/99 Admission responsibility 10(1) The implementation of the mandatory conditions for admission of a patient pursuant to section 9 shall be the responsibility of the hospital board through its senior administrative officer. (2) If a central placement office has been established to regulate admission of patients to long-term care facilities, operators of such facilities shall adhere to admission policy established by this Regulation. AR 247/90 s10 Salmonella reports 11(1) If a hospital receives positive salmonella reports from the Provincial Laboratory on 3 or more patients admitted within a oneweek period, the administrator shall notify the Minister of the scope of infection and the factors which caused or contributed to spread of it. (2) Subsection (1) does not absolve the hospital administrator from notifying the medical officer of health of all cases of notifiable diseases listed under the Communicable Diseases Regulation (Alta. Reg. 238/85). AR 247/90 s11 Minutes of board meeting 12(1) Pursuant to section 25 of the Act, a copy of minutes of all deliberations and transactions at board meetings signed by the secetary of the board shall be sent to the Minister within 3 weeks of their approval by the board. 6

9 Section 13 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (2) Subsection (1) does not apply to business of a Council of Sisters not pertaining to a district or hospital affairs, which should be conducted separately. AR 247/90 s12;251/2001 Medical records 13(1) The board of each approved hospital shall cause to be kept by the attending health practitioner a record of the diagnostic and treatment services provided in respect of each in-patient and outpatient in order to assist in providing a high standard of patient care. (2) For each admission, a record of diagnostic and treatment services shall be maintained that shall (a) identify the patient, and (b) provide sufficient information to justify the diagnosis and warrant the treatment given, including (i) provisional and final diagnosis, (ii) reports of diagnostic and treatment procedures, (iii) reports of consultations, (iv) surgical reports, (v) progress notes, (vi) orders for treatment, (vii) discharge summary as applicable, and (viii) the signature of the attending health practitioner. (3) The original or a copy of out-of-hospital records originating from (a) another approved hospital, or (b) from facilities approved by the College of Physicians and Surgeons of Alberta, and being sufficiently recent to be relevant to the patient s current status should be included in the record of diagnostic and treatment services. (4) If the patient receives an out-patient service, the medical record portion of the record of diagnostic and treatment services required under this section shall be prepared by the attending health 7

10 Section 14 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 practitioner on the prescribed form within 24 hours after the services have been provided. (5) Repealed AR 158/98 s2. (6) Diagnostic and treatment service records shall be legible, accurate and complete. (7) In addition to routine surgical and anaesthetic records maintained on surgical patients, narrative summaries of surgical and anaesthetic events preceding demise shall be recorded on all patients dying during surgery or within 10 days of its completion. AR 247/90 s13;158/98;272/99 Signature of attending physician and nurse 14(1) All health practitioners orders for patients shall be in writing and shall be dated and signed by the attending health practitioner or a member of the house staff responsible to him, but an order shall be considered to be in writing if dictated to a nurse or other authorized person, signed by that person on behalf of the dictating health practitioner stating his name, and countersigned by the health practioner within 24 hours. (2) Because the interval between a health practitioner s visits to patients in auxiliary hospitals may exceed 24 hours, the practice of signing orders as they are given and written must be done in accordance with (a) the rules of the hospital, (b) the hospital by-laws, (c) the medical staff by-laws, and (d) service contracts, if any. AR 247/90 s14;272/99 Retention of medical records 15(1) Diagnostic and treatment service records shall be retained by the hospital for (a) a period of 10 years from date of discharge from hospital, and (b) in addition, in the case of the patient being a minor, for a period of at least 2 years following the date on which the patient reached the age of 18 years. 8

11 Section 15.1 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (2) Diagnostic and treatment service records may be retained by the hospital for an additional period as may be considered necessary by the board. (3) Notwithstanding subsection (1), (a) diagnostic and treatment service records may be microfilmed on discharge of the patient from hospital and the original records may then be destroyed after expiration of one year from the date of discharge of the patient, and (b) x-ray films may be destroyed after expiration of 5 years from date of discharge of the patient. AR 247/90 s15 Health Care Protection Act records 15.1(1) Subject to subsection (2), the board of an approved hospital shall keep a statement referred to in section 5(3) of the Health Care Protection Act for a period of at least 10 years from the date of discharge of the patient from the hospital. (2) Where the patient was a minor at the time the insured surgical service was provided, the board shall keep the statement for a period ending (a) 10 years after the date of discharge of the patient from the hospital, or (b) 2 years after the patient s 18th birthday, whichever is longer. (3) The board of an approved hospital shall keep for a period of 6 years after they are created all records, documents and books of account that are necessary in order to determine whether the Health Care Protection Act and the regulations under it have been complied with as they apply with respect to the provision of enhanced medical goods or services and non-medical goods or services (a) in connection with the provision of an insured surgical service, or (b) that arise out of a stay at the approved hospital. (4) The board of an approved hospital may store statements, records, documents and books of account referred to in this (section in any format that will provide a copy of the statement, records, document or book of account in a legible written form within a reasonable time. AR 209/2000 s2 9

12 Section 16 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 Rules of the hospital 16 Hospital by-laws or rules under them or service contracts, if any, must make provision for the following: (a) routine stop orders on antibiotics, narcotics, anticoagulants, sedatives and other potentially dangerous drugs; (b) emergency call rosters of health practitioners; (c) the regular attendance to patients by their health practitioner and for the naming of an alternate health practitioner who may be called when the attending health practitioner is not available; (d) the control of the time of admission of patients, excepting emergency admission; (e) the completion of diagnostic and treatment service records within a minimum period of time after the patient s discharge and the specific action to be taken when this procedure is not followed; (f) post mortem care; (g) posting of no smoking signs in rooms where oxygen is used; (h) procedure for notifying the medical officer of health of all cases of notifiable diseases listed under the Communicable Diseases Regulation (Alta. Reg. 238/85); (i) establishment and function of an infection control committee and procedure for handling infections in the hospital and the methods of isolation; (j) arrangement for pre-natal antibody screening and blood grouping; (k) any other matters that are considered necessary by the board. AR 247/90 s16;272/99 Health examinations 17(1) Every hospital shall develop and maintain a program of health examinations for its staff based on the minimum considered necessary by its medical staff for the protection of both staff and patients. 10

13 Section 18 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (2) Notwithstanding subsection (1), the provincial smallpox vaccination policy for at risk personnel shall be followed. AR 247/90 s17 Surgical care 18(1) Excepting in situations of emergency in which any delay might have serious consequences, the patient shall be accompanied to surgery by a record of diagnostic and treatment services that includes as a minimum (a) a history, (b) physical examination, (c) provisional diagnosis, and (d) reports made pursuant to the investigations referred to in subsection (2). (2) The board of an approved hospital shall ensure that the rules adopted for the governing of the day to day management of medical affairs in the hospital regarding patient surgery, made pursuant to the by-laws of the medical staff referred to in section 17(3) of the Act, include a list of investigations which the medical staff stipulate to be the minimum required for each category of patient and procedure. (3) The record shall be completed before surgery on all elective cases and as soon as possible after surgery in emergency cases. AR 247/90 s18;251/2001 Anaesthetics 19(1) Except in an emergency situation when no other physician is available within a reasonable time, all surgical anaesthetics shall be administered by a qualified physician. (2) In an emergency situation described in subsection (1), the surgeon requesting an unqualified person to give the anaesthetic shall accept full responsibility for the procedure. (3) Surgical anaesthetics shall not be commenced before the surgical team is available in the hospital. (4) When reasonably possible, physicians providing anaesthetic services shall have a minimum of 6 months training in an anaesthetic training program approved by the College of Physicians and Surgeons of Alberta. (5) The state of the patient prior to the operation and anaesthetic technique shall be critically reviewed with reference to the need for 11

14 Section 20 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 mechanical ventilatory support in the immediate postoperative period and if, under the circumstances, mechanical ventilation equipment and personnel trained for its use are not available at that time, the surgery should be deferred or done elsewhere. (6) Consideration should be given to transporting poor risk patients requiring major surgery, whether elective or emergency, to centres where adequate ancillary care is available. AR 247/90 s19 Assistance at major operations 20(1) In a hospital of more than 100 beds where a clinical department is established, the medical staff shall determine those procedures and circumstances in which the assistance of a second physician is required for surgery. (2) In a hospital of less than 100 beds, if the medical staff believes it has an acceptable organization it may apply to the Minister for approval to make the determination referred to in subsection (1). (3) In other hospitals, where clinical departments are not established, the assistance of a second physician is required (a) in operations within or on the contents of the following cavities: (i) the cranium, (ii) the thorax, and (iii) the abdomen, including the pelvis, and (b) in operations which, because of their locality, the conditions of the patient, their difficulty, or the length of time required to operate, may constitute a distinct hazard to life or health, and including those in the following list, which may be amended following consultations between the Minister and the Alberta Medical Association: (i) parotid gland, excision of, total, subtotal; (ii) thyroidectomy; (iii) thyroglossal duct cyst, sinus, excision of; (iv) branchial cleft, cyst, sinus, excision of; (v) hernia, inguinal, double inguinal, femoral, umbilical, strangulated, repair of; (vi) limbs, amputation of; 12

15 Section 22 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (vii) varicose veins, axis ligation, stripping, deep ligation; (viii) fistula in ano, complicated, repair of; (ix) foreign body, deep removal of; (x) lymph nodes, deep biopsy of; (xi) mastectomy, simple, total, radical; (xii) hand injuries, severe, operative treatment of; (xiii) fractures, reduction, open, long bones; (xiv) compound fractures, operative reduction of, excluding digits; (xv) acute osteomyelitis, acute suppurative arthritis, operative treatment of; (xvi) internal derangement of the knee, other joints, operative treatment of; (xvii) colporrhapy, anterior, posterior; (xviii) vaginal operation combined with laparotomy, any; (xix) atresia vaginae, plastic repair of; (xx) mastoidectomy, radical; (xxi) tracheostomy, elective; (xxii) caesarian section. AR 247/90 s20 21 Repealed AR 393/91 s2. Operating room 22(1) The person in charge of an operating room shall be a graduate nurse with special training in operating room management or equivalent experience. (2) Before closure of (a) the peritoneum in abdominal surgery; (b) the pleura in chest surgery; (c) the subcutaneous tissue in other surgery; 13

16 Section 23 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 adequate precaution should be instituted to prevent an undesirable foreign body being left at the site of operation. (3) The precaution taken should be recorded on the patient s record. AR 247/90 s22;163/95;178/95 Tissues removed at operation 23(1) All tissues removed at operation, with the exception of those listed in subsection (5), shall be forwarded for examination to a pathologist registered in that specialty in Alberta. (2) Hospitals not having staff pathologists may use the facilities of a Provincial Laboratory. (3) All tissues shall be accompanied by a report giving the essential details, including the patient s name, sex, age, a brief history and the circumstances under which the tissue was removed. (4) The hospital is responsible for preserving and delivering tissue to the pathologist. (5) Tissues exempt from this Regulation are as follows: (a) amputation stumps-secondary; (b) blood clots; (c) bone fragments and ligaments; (d) bony ossicles (ears); (e) cartilage, external ear (plastic); (f) fingers; (g) foreign bodies (including bone plates, nails and screws); (h) hernial sac; (i) hydrocele sac; (j) intervertebral discs; (k) meningocele sac; (l) nasal septa when removed for obstruction only; (m) optic lens; (n) prepuces; 14

17 Section 24 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (o) ribs removed incidental to chest surgery; (p) scar tissue; (q) semilunar cartilages; (r) teeth; (s) tendon segments removed incidental to orthopaedic procedures; (t) toes; (u) toe and fingernails; (v) tonsils and adenoids (patients under 40); (w) vaginal wall fragments (plastic repair); (x) varicocele; (y) vein strippings. (6) Pathology reports on tissues examined shall be distributed as follows: (a) one copy for the patient s medical record, and (b) one copy to the surgeon who removed the tissue. AR 247/90 s23 Obstetrical care 24 A sample of blood shall be taken from each newborn immediately after delivery and forwarded to a Provincial Laboratory for a serological test for syphilis. AR 247/90 s24;150/97 Autopsies 25(1) Autopsies shall be performed, wherever possible, provided facilities are available, in (a) all situations in which the cause of death is in doubt, and (b) all postoperative deaths within 72 hours of the operation. (2) An autopsy should be considered when it might add to the medical knowledge of the medical staff if permission has been received from the next-of-kin of the deceased or the executor of the estate or both. 15

18 Section 26 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (3) An autopsy may be requested by a medical examiner. AR 247/90 s25 Removal of body 26(1) A body shall not be removed from any hospital until (a) it has been examined by a physician and he has made a notation on the record of the time of death and has signed the notation, (b) proper authority has been received from the hospital administration for the removal, and (c) in the case where an autopsy has been performed, the person performing the autopsy or a hospital representative on that person s behalf has made and signed a notation on the record that the next of kin of the deceased person has been fully informed that an autopsy has been performed. (1.1) Subsection (1) does not apply to an auxiliary hospital. (2) When the body of a deceased person is not claimed by the immediate relatives or their legal representatives, hospital authorities shall take action in accordance with the Human Tissue Gift Act. (3) If death was caused by a communicable disease, the hospital shall notify the relevant funeral home of the cause of death on release of the body. AR 247/90 s26;158/98;13/2001 Nursing service 27(1) Every hospital shall (a) maintain written nursing policies and procedures, (b) review them at least once a year, and (c) ensure that current copies are available at each nursing station. (2) Every hospital should have a system of clearly identifying various classifications of staff in nursing care and other areas. (3) The nursing service staff shall meet as a whole or in categories or departments on a monthly basis for the purpose of reviewing and evaluating the nursing service of the hospital and minutes shall be kept of all the meetings and the minutes shall become part of the records of the hospital. 16

19 Section 28 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (4) Adequate graduate nurse coverage shall be provided at all times in the hospital. AR 247/90 s27;163/95;178/95 Approval of changes in services 28 Every hospital shall require prior approval of the Minister for (a) any proposed major change or termination of an existing service provided by the hospital, or (b) the introduction of a new service. AR 247/90 s28 Approval of changes in education programs 29(1) Every hospital shall notify in advance and receive approval from (a) the Minister, in the case of education and training programs other than those directly associated with hospital based nursing education programs, or (b) the Minister of Enterprise and Advanced Education, in the case of hospital based nursing education programs before commencing new education and training programs or making major changes to or terminating existing education and training programs. (2) Any hospital operating an approved program shall be eligible for grants from the Minister and the Minister of Enterprise and Advanced Education apart from their normal operating grants based on the additional costs incurred in the operation of the program. (3) In this section, education and training programs means programs offered by a hospital for the education and training of personnel or students but does not include on-the-job training for the staff of the hospital. AR 247/90 s29;163/95;206/2001;105/2005;35/2007;170/2012 Expense payments to board members 30(1) The board may, by resolution, establish (a) the attendance requirements, (b) the amount payable to members for attendance at board meetings considered necessary by the board for the proper conduct of the affairs of a hospital or the discharge of the board s responsibilities, and 17

20 Section 31 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 (c) the amount payable to board members for necessary travel and subsistence expenses incurred in the conduct of the affairs of a hospital. (2) If feasible, members proceeding to a common destination by automobile shall use one vehicle and mileage allowance shall be paid to the operator of the vehicle only. AR 247/90 s30 Medical staff 31 In carrying out the provisions of sections 32 and 33 the board and the medical staff shall follow the procedures set forth in the by-laws of the medical staff that are enacted pursuant to the Act. AR 247/90 s31 Medical staff 32(1) The board shall establish a hospital medical staff by appointing qualified physicians to the medical staff. (2) The board may make temporary appointments to the medical staff for specified terms. (3) The board may review, suspend or terminate the appointment of any member of the medical staff. (4) The medical staff of a hospital shall be involved in the procedures for the establishment of medical staff by-laws and appointments to medical staff. AR 247/90 s32;89/2011 Medical staff 33(1) The board shall delineate the privileges which it grants to each member of the medical staff taking into consideration the needs and facilities of the hospital and physicians training and ability and may extend or reduce the privileges. (2) In the delineation of privileges, the circumstances of practice, the capabilities of the hospital from the standpoint of its physical plant, diagnostic services, medical staff, hospital staff and location shall be taken into consideration. (3) The board may withdraw privileges that it has granted to a member of the medical staff. (4) A physician shall have no privileges in a hospital until duly appointed to the medical staff. (5) Except in an emergency a physician who is not a specialist radiologist shall not be granted privileges to carry out fluoroscopy 18

21 Section 33.1 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 unless approved by the College of Physicians and Surgeons of Alberta to do so. (6) Repealed AR 272/99 s7. AR 247/90 s33;272/99;89/2011 Notice to professional association 33.1 If a member of the medical or professional staff of a hospital (a) is suspended or whose authority to admit, attend or treat patients has been cancelled or significantly altered because of incompetence, negligence or misconduct, or (b) resigns when the member s competence, negligence or conduct is under investigation, the hospital shall so advise the regulatory body of the health profession to which the member belongs. AR 272/99 s8 Accreditation 34(1) Each hospital shall strive to meet the standards for accreditation of hospitals established by the Canadian Council on Hospital Accreditation. (2) The taking of blood for transfusion and crossmatching of blood in a hospital shall be carried out only by suitably qualified personnel or members of the medical staff. (3) Disposable needles and syringes shall be rendered useless prior to their disposal and shall be disposed in such a manner that their handling will not produce injury. AR 247/90 s34 Reimbursement 35(1) If the attending health practitioner recommends that a member of the hospital staff accompany a patient for continuing necessary care on transfer from a hospital to another approved facility, the hospital board may comply. (2) The hospital shall reimburse the hospital staff member so accompanying a patient or person for necessary expenditures incidental to the assignment. AR 247/90 s35;272/99 19

22 Section 35.1 OPERATION OF APPROVED HOSPITALS REGULATION AR 247/90 Offence 35.1 A person who contravenes section 3, 4(1), 5 or 28 is guilty of an offence and liable to a fine of not more than $2000 in the case of a first offence and $5000 in the case of a subsequent offence. AR 402/94 s4;163/95 Repeal 36 The Operation of Approved Hospitals Regulations (Alta. Reg. 146/71) are repealed. AR 247/90 s36 20

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