Utah Administrative Code
Topic - Health
Title R432 - Health Care Facility Licensing
Rule R432-100 - General Hospital Standards
Section R432-100-8 - Medical and Professional Staff

Universal Citation: UT Admin Code R 432-100-8

Current through Bulletin 2024-06, March 15, 2024

(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 Chapter 58-67, Utah Medical Practice Act or Chapter 58-68, the Utah Osteopathic Medical Licensing 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 two years.

(10) During an emergency or disaster situation, the licensee shall ensure that each temporary practitioner is oriented to their assigned area.

Disclaimer: These regulations may not be the most recent version. Utah may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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