Section 250.1210  Surgery

a)         Where a hospital provides surgical services, the service shall be provided in a manner sufficient to meet surgical needs of the patients.  The surgical department/service shall have a defined organization and shall be integrated with other departments and services of the hospital and shall be governed by written policies and procedures.

b)         The Director of Surgical Services or his designee shall design and implement an education program to orient new physicians, residents, physician assistants, and other employees and shall collaborate with the nursing administrator or his/her designee to establish orientation and continuing education programs for the nursing staff. The programs shall be planned, scheduled, documented by a written outline of its contents, and evaluated at least annually.

c)         The education program may be conducted using resources internal or external to the hospital.  Teaching material and suitable reference shall be supplied as needed for each patient care unit.

d)         The surgical services shall be directed by a member of the medical staff who is qualified by training and experience preferably certified by the American Board of Surgery and approved by the medical staff and board of the hospital.

(Source:  Amended at 5 ill. Reg. 507, effective December 29, 1980)