2015 ORS 441.055¹
Health care facility medical staff and bylaws
  • rules

(1) The governing body of each health care facility shall be responsible for the operation of the facility, the selection of the medical staff and the quality of care rendered in the facility. The governing body shall:

(a) Ensure that all health care personnel for whom state licenses, registrations or certificates are required are currently licensed, registered or certified;

(b) Ensure that physicians admitted to practice in the facility are granted privileges consistent with their individual training, experience and other qualifications;

(c) Ensure that procedures for granting, restricting and terminating privileges exist and that such procedures are regularly reviewed to ensure their conformity to applicable law;

(d) Ensure that physicians admitted to practice in the facility are organized into a medical staff in such a manner as to effectively review the professional practices of the facility for the purposes of reducing morbidity and mortality and for the improvement of patient care; and

(e) Ensure that a physician is not denied medical staff membership or privileges at the facility solely on the basis that the physician holds medical staff membership or privileges at another health care facility.

(2) The physicians organized into a medical staff pursuant to subsection (1) of this section shall propose medical staff bylaws to govern the medical staff. The bylaws shall include, but not be limited to the following:

(a) Procedures for physicians admitted to practice in the facility to organize into a medical staff pursuant to subsection (1) of this section;

(b) Procedures for ensuring that physicians admitted to practice in the facility are granted privileges consistent with their individual training, experience and other qualifications;

(c) Provisions establishing a framework for the medical staff to nominate, elect, appoint or remove officers and other persons to carry out medical staff activities with accountability to the governing body;

(d) Procedures for ensuring that physicians admitted to practice in the facility are currently licensed by the Oregon Medical Board;

(e) Procedures for ensuring that the facility’s procedures for granting, restricting and terminating privileges are followed and that such procedures are regularly reviewed to assure their conformity to applicable law; and

(f) Procedures for ensuring that physicians provide services within the scope of the privileges granted by the governing body.

(3) Amendments to medical staff bylaws shall be accomplished through a cooperative process involving both the medical staff and the governing body. Medical staff bylaws shall be adopted, repealed or amended when approved by the medical staff and the governing body. Approval shall not be unreasonably withheld by either. Neither the medical staff nor the governing body shall withhold approval if such repeal, amendment or adoption is mandated by law, statute or regulation or is necessary to obtain or maintain accreditation or to comply with fiduciary responsibilities or if the failure to approve would subvert the stated moral or ethical purposes of the institution.

(4) The Oregon Medical Board may appoint one or more physicians to conduct peer review for a health care facility upon request of such review by all of the following:

(a) The physician whose practice is being reviewed.

(b) The executive committee of the health care facility’s medical staff.

(c) The governing body of the health care facility.

(5) The physicians appointed pursuant to subsection (4) of this section shall be deemed agents of the Oregon Medical Board, subject to the provisions of ORS 30.310 (Actions and suits by governmental units) to 30.400 (Actions by and against public officers in official capacity) and shall conduct peer review. Peer review shall be conducted pursuant to the bylaws of the requesting health care facility.

(6) Any person serving on or communicating information to a peer review committee shall not be subject to an action for damages for action or communications or statements made in good faith.

(7) All findings and conclusions, interviews, reports, studies, communications and statements procured by or furnished to the peer review committee in connection with a peer review are confidential pursuant to ORS 192.501 (Public records conditionally exempt from disclosure) to 192.505 (Exempt and nonexempt public record to be separated) and 192.690 (Exceptions to ORS 192.610 to 192.690) and all data is privileged pursuant to ORS 41.675 (Inadmissibility of certain data provided to peer review body of health care providers and health care groups).

(8) Notwithstanding subsection (7) of this section, a written report of the findings and conclusions of the peer review shall be provided to the governing body of the health care facility who shall abide by the privileged and confidential provisions set forth in subsection (7) of this section.

(9) Procedures for peer review established by subsections (4) to (8) of this section are exempt from ORS chapter 183.

(10) The Oregon Health Authority shall adopt by rule standards for rural hospitals, as defined in ORS 442.470 (Definitions for ORS 442.470 to 442.507), that specifically address the provision of care to postpartum and newborn patients so long as patient care is not adversely affected.

(11) For purposes of this section, "physician" has the meaning given the term in ORS 677.010 (Definitions for chapter). [Amended by 1965 c.352 §1; 1971 c.730 §13; 1973 c.837 §14; 1973 c.840 §9; 1977 c.261 §4; 1977 c.448 §10; 1977 c.751 §23a; 1987 c.428 §9; 1987 c.850 §2; 1993 c.269 §1; 1995 c.727 §38; 1995 c.763 §1; 1999 c.542 §1; 2001 c.900 §167; 2009 c.595 §726; 2009 c.792 §58]

Notes of Decisions

This sec­tion does not require hospitals to admit chiropractors or naturopaths to practice or to adopt pro­ce­dures to allow these practi­tioners to apply for admission or, if admitted, to allow them staff privileges. Samuel v. Curry County, 55 Or App 653, 639 P2d 687 (1982) Sup Ct review denied

By compelling doctors to review their competitors, Oregon has expressed policy to replace pure competi­tion for purpose of determining whether peer-review ac­tivity is exempted from federal antitrust laws. Patrick v. Burget, 800 F2d 1498 (1986)

Chapter 441

Atty. Gen. Opinions

Licensing and phantom beds, (1970) Vol 40, p 171; a hospital's employing a licensed physical therapist as unauthorized practice, (1975) Vol 37, p 963


1 Legislative Counsel Committee, CHAPTER 441—Health Care Facilities, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ors441.­html (2015) (last ac­cessed Jul. 16, 2016).
 
2 Legislative Counsel Committee, Annotations to the Oregon Revised Stat­utes, Cumulative Supplement - 2015, Chapter 441, https://­www.­oregonlegislature.­gov/­bills_laws/­ors/­ano441.­html (2015) (last ac­cessed Jul. 16, 2016).
 
3 OregonLaws.org assembles these lists by analyzing references between Sections. Each listed item refers back to the current Section in its own text. The result reveals relationships in the code that may not have otherwise been apparent.