R432-500-9. Medical Director

(1) Direction.

(a) The licensee of the surgical facility shall retain, by formal agreement, a qualified physician to serve as medical director.

(b) The medical director shall have freedom from other responsibilities to assume professional, organizational, and administrative responsibility.

(c) The medical director shall be accountable to the governing authority for the quality of services rendered.

(2) Qualifications.

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

(a) Be currently licensed to practice medicine in Utah;

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

(3) Responsibilities.

(a) The medical director shall have overall responsibility for surgery and anesthesia services delivered in the facility.

(b) Applicable laws relating to use of anesthesia, professional licensure acts and facility protocols shall govern both medical staff and employee performance.

(c) The medical director shall be responsible for at least:

(i) Review and update facility protocols;

(ii) Periodically conduct reappraisals of medical staff privileges and revise those privileges as appropriate;

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

(iv) Establish and maintain a quality assurance mechanism to review identified problems and take appropriate action;

(v) Coordinate, direct and evaluate all clinical operations of the facility;

(vi) Evaluate and recommend the type and amount of equipment needed in the facility;

(vii) Assure that a qualified physician available when patients are in the facility;

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

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