No. 27374 (Amendment): R432-100-7. Medical and Professional Staff

DAR File No.: 27374
Filed: 08/27/2004, 11:53
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

Mass casualty incidents are likely to overwhelm the capacity of individual hospitals and the availability of adequate numbers of credentialed staff required. This rule requires hospitals to establish policies and procedures to issue temporary credentialing when there is an emergency or disaster situation. This rulemaking updates the rule to what is currently in place in hospitals for emergency or disaster situations.

 

Summary of the rule or change:

This change amends the General Hospital standard to allow hospitals to establish policies on issuing a temporary credential or privilege to a staff member who is not an employee.

 

State statutory or constitutional authorization for this rule:

Title 26, Chapter 21

 

Anticipated cost or savings to:

the state budget:

The only state-owned and operated hospital already has the procedures in place to issue a temporary credential to a staff member in case of emergency or disaster situation. There is no anticipated cost.

 

local governments:

Local government-owned and operated hospitals already have procedures in place to issue a temporary credential to a staff member in case of an emergency or disaster situation. There is no anticipated cost.

 

other persons:

Privately-owned and operated hospitals already have the procedures in place to issue a temporary credential to a staff member in case of an emergency or disaster situation. There is no anticipated cost.

 

Compliance costs for affected persons:

There are no anticipated costs for persons, this rule change matches the community practice for disaster planning and preparedness.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule reflects current practice in regulated businesses. No fiscal impact on business is anticipated. Scott D. Williams, MD

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Systems Improvement, Licensing
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Debra Wynkoop at the above address, by phone at 801-538-6152, by FAX at 801-538-6325, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

10/15/2004

 

This rule may become effective on:

10/16/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R432. Health, Health Systems Improvement, Licensing.

R432-100. General Hospital Standards.

R432-100-7. Medical and Professional Staff.

(1) Each hospital 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 must 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

([e]f) a fair hearing and appeals process.

(4) The medical care of all persons admitted to the hospital shall be under the supervision and direction of a fully qualified physician who is licensed by the state. During an emergency or disaster situation a member of the credentialed and privileged staff must supervise temporary credentialed practitioners.

(5) An applicant for staff membership and privileges may not be denied solely on the ground that the applicant is a licensed podiatrist or licensed psychologist rather than licensed to practice medicine under the Utah Medical Practice Act or the Utah Osteopathic Medical Licensing Act.

(6) Membership and privileges may not be denied on any ground that is otherwise prohibited by law.

(7) Each applicant for medical and professional staff membership must be oriented to the bylaws and must agree in writing to abide by all conditions.

(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 hospital shall orient each temporary practitioner to the practioner's assigned area of the hospital.

 

KEY: health facilities

[January 9, ]2004

Notice of Continuation October 16, 2003

26-21-5

26-21-2.1

26-21-20