10A NCAC 13B .3703      APPOINTMENT

(a)  The governing body may grant, deny, renew, modify, suspend, or terminate medical staff membership and clinical privileges after consideration of the recommendation made by the medical staff in accordance with the bylaws established by the medical staff and approved by the governing body for making such recommendations, and the facility bylaws established by the governing body for review and final determination of such recommendations.

(b)  Review of an applicant for medical staff membership and the granting of clinical privileges shall follow procedures set forth in the bylaws, rules, and regulations of the medical staff. These procedures shall require the following:

(1)           a signed application for medical staff membership, specifying date of birth, year and school of graduation, date of licensure, statement of postgraduate or special training and experience, and a statement of the scope of the clinical privileges sought by the applicant;

(2)           verification by the facility of the applicant's qualifications as stated in the application, including any required continuing education; and

(3)           written notice to the applicant from the governing body regarding appointment or reappointment, which specifies the approval or denial of clinical privileges and the scope of the privileges if granted.

(c)  Members of the medical staff and others granted clinical privileges in the facility shall hold current licenses to practice in North Carolina.

(d)  Medical staff appointments shall be reviewed at least once every two years by the medical staff in accordance with the bylaws established by the medical staff and approved by the governing body, and shall be followed with recommendations made to the governing body for review and a final determination.

(e)  The facility shall maintain a file containing performance information for each medical staff member. Representatives of the Division shall have access to these files in accordance with, and subject to the limitations and restrictions set forth in, G.S. 131E-80; however, to the extent that the same includes confidential medical review information, such information shall be reviewable and confidential in accordance with G.S. 131E-80(d) and other applicable law.

(f)  Minutes shall be taken and maintained of all meetings of the medical staff and governing body that concern the granting, denying, renewing, modifying, suspending or terminating of clinical privileges.


History Note:        Authority G.S. 131E-79; 42 CFR 482.12(a)(10); 42 CFR 482.22(a)(1);

Eff. January 1, 1996;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017;

Amended Eff. July 1, 2020.