481—51.18(135B) Surgical services. All hospitals providing surgical services shall be properly organized and equipped to provide for the safe and aseptic treatment of surgical patients.
	51.18(1) Written policies and procedures governing surgical services shall be developed and implemented in consultation with the hospital’s medical staff and, at a minimum, provide for:
	a. 	Surgical services under the direction of a qualified doctor of medicine or osteopathy.
	b. 	Delineation of the privileges and qualifications of individuals authorized to provide surgical services as set forth in the hospital’s medical staff bylaws and in accordance with subrule 51.5(4), including a periodic review and update of surgical privileges not to exceed every three years or other term permitted by an accrediting organization approved by CMS for federal certification, whichever is longer. The surgical service must maintain a roster of these individuals specifying the surgical privileges of each.
	c. 	Immediate availability of at least one registered nurse for the operating room suites to respond to emergencies.
	d. 	The qualifications and job descriptions of nursing personnel, surgical technicians, and other support personnel and continuing education required.
	e. 	Appropriate staffing for surgical services, including physician and anesthesia coverage and other support personnel.
	f. 	Availability of ancillary services for surgical patients, including but not limited to blood banking, laboratory, radiology, and anesthesia.
	g. 	Infection control and disease prevention, including aseptic surveillance and practice, identification of infected and noninfected cases, sterilization and disinfection procedures, and ongoing monitoring of infections and infection rates.
	h. 	Housekeeping requirements.
	i. 	Safety practices.
	j. 	Ongoing quality assessment, performance improvement, and process improvement.
	k. 	The pathological examination of tissue specimens either directly or through contractual arrangements.
	l. 	Appropriate preoperative teaching and discharge planning.
	51.18(2) Policies and procedures may be adjusted as appropriate to reflect the provision of surgical services in inpatient, outpatient or one-day surgical settings.
	51.18(3) There must be an appropriate history and physical workup documented and a properly executed consent form in the chart of each patient prior to surgery, except in the event of an emergency.
	51.18(4) A full operative report must be written or dictated within 24 hours following surgery and signed by the individual conducting the surgery.
	51.18(5) Equipment available in the operating room, recovery room, outpatient surgical areas, and for postsurgical care must be consistent with the needs of the patient.
[ARC 7573C, IAB 2/7/24, effective 1/18/24]