- (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)(a) 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.
(b) The bylaws shall address:
- (i) a fair hearing and appeal process;
- (ii) temporary credentialing and privileging of staff in emergency or disaster situations;
- (iii) the appointment and re-appointment process;
- (iv) the delineation of privileges;
- (v) the necessary qualifications for membership; and
- (vi) the participation and documentation of continuing education.
(4)(a) 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.
- (b) 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 the podiatrist or psychologist is 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 the applicant agrees, 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 the applicant's 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 the temporary practitioner assigned area.
KEY: health care facilities
Date of Last Change: June 5, 2026
Notice of Continuation: August 22, 2025
Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203