Utah Admin. Code R432-500-8 - Medical Director

(1) The licensee shall retain, by formal agreement, a qualified physician to serve as medical director who is:

(a) free from other responsibilities to assume professional, organizational, and administrative responsibility; and

(b) accountable to the governing authority for the quality of services provided.

(2) The physician designated as the medical director shall have at least the following qualifications:

(a) current license to practice medicine in Utah; and

(b) training and expertise in the branches of surgery and anesthesia services offered to provide supervision at the facility.

(3) The medical director shall ensure applicable laws relating to use of anesthesia, professional licensure acts, and facility protocols govern both medical staff and employee performance.

(4) The licensee shall ensure the medical director is responsible for the following:

(a) surgery and anesthesia services delivered in the facility;

(b) reviewing and updating facility protocols;

(c) conduct periodic reappraisals of medical staff privileges and revising those privileges as appropriate;

(d) recommend to the governing authority, names of qualified health care practitioners to perform approved procedures, and to recommend privileges to be granted;

(e) establish and maintain quality assurance mechanisms to review and identify problems and take appropriate action;

(f) coordinate, direct, and evaluate any clinical operations of the facility;

(g) evaluate and recommend the equipment type and quantity needed in the facility;

(h) ensure that a qualified physician is available when patients are in the facility;

(i) ensure physician documentation is recorded immediately and reflects an accurate description of care given; and

(j) ensure that planned surgical procedures are within the scope of privileges granted to the physicians.

Notes

Utah Admin. Code R432-500-8

Amended by Utah State Bulletin Number 2023-17, effective 8/10/2023