481—51.26 (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.
	 51.26(1) Written policies and procedures shall be implemented governing surgical services that are consistent with the needs of the patient and the resources of the hospital. Policies and procedures shall be developed in consultation with and the approval of the hospital’s medical staff. At a minimum, the policies and procedures shall 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). The surgical service must maintain a roster of these individuals specifying the surgical privileges of each. Surgical privileges shall be reviewed and updated at least once every two years.
	  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.   	 Provisions for the pathological examination of tissue specimens either directly or through contractual arrangements.
	  l.   	 Appropriate preoperative teaching and discharge planning.
Reference sources to guide hospitals in the development of policies and procedures are: “Statement of Principles,” March 1994 Edition, American College of Surgeons; and “Standards and Recommended Practices,” 1995 Edition, Association of Operating Room Nurses.
	 51.26(2) Policies and procedures may be adjusted as appropriate to reflect the provision of surgical services in inpatient, outpatient or one-day surgical settings.
	 51.26(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.
	 51.26(4) An operative report must be written or dictated promptly following surgery and signed by the individual conducting the surgery.
	 51.26(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.
	 51.26(6) The surgical facilities shall be constructed in accordance with 481—51.50(135B).