Utah Admin. Code R432-100-8 - Medical and Professional Staff
(1)
Each licensee shall have an organized medical and professional staff that
operates under bylaws approved by the board.
(2) The medical and professional staff shall
advise and be accountable to the board for the quality of medical care provided
to patients.
(3) The medical and
professional staff shall adopt bylaws, and policies and procedures to establish
and maintain a qualified medical and professional staff including current
licensure, relevant training and experience, and competency to perform the
privileges requested. The bylaws shall address:
(a) the appointment and re-appointment
process;
(b) the necessary
qualifications for membership;
(c)
the delineation of privileges;
(d)
the participation and documentation of continuing education;
(e) temporary credentialing and privileging
of staff in emergency or disaster situations; and
(f) a fair hearing and appeals
process.
(4) A fully
qualified physician who is licensed by the Department of Commerce shall
supervise and direct the medical care of each person admitted to the hospital.
During an emergency or disaster situation, a member of the credentialed and
privileged staff shall supervise temporary credentialed
practitioners.
(5) The licensee may
not deny an applicant that is a podiatrist or psychologist solely on the
grounds that they are not licensed to practice medicine under Title 58, Chapter
67, Utah Medical Practice Act or Title 58, Chapter 68, Utah Osteopathic Medical
Practice Act.
(6) Membership and
privileges may not be denied on any ground that is otherwise prohibited by
law.
(7) The licensee shall orient
each applicant for medical and professional staff membership to the bylaws and
ensure they agree, in writing, to abide by each condition.
(8) The medical and professional staff shall
review each applicant and grant privileges based on the scope of their license
and abilities.
(9) The medical and
professional staff shall review appointments and re-appointments to the medical
and professional staff at least every three years.
(10) During an emergency or disaster
situation, the licensee shall ensure that each temporary practitioner is
oriented to their assigned area.
Notes
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