Section 107.4. Medical staff status

(a) Every hospital shall have an active medical staff to deliver the preponderance of medical services within the hospital. The active medical staff shall be responsible for its own organization and administration and should perform all significant duties pertaining thereto. Every member of the active medical staff shall be eligible to vote at staff meetings and to hold office.

(b) In addition to the active medical staff, the hospital may provide for additional kinds of medical staff privileges as delineated in subsection (c). The existence of additional staff categories shall in no way modify the privileges, duties, and responsibilities of the active medical staff.

(c) Additional staff categories may include the following:

(1) Associate medical staff. There may be an associate medical staff consisting of individuals who are being considered for advancement to the medical staff. Members of the associate medical staff shall be appointed and assigned to departments or services in the same manner as are members of the active medical staff. Although they may not hold office, they may serve on some medical staff hospital committees. The active medical staff should determine the extent of voting privileges to be granted to members of the associate medical staff.

(2) Courtesy medical staff. There may be a courtesy medical staff consisting of those medical practitioners eligible for staff membership who are given privileges to admit an occasional patient to the hospital. Courtesy staff members may neither vote nor hold office. Because admission of patients to the hospital is an exercise of a privilege and, therefore, is accompanied by a responsibility, admission of more than an occasional patient should require the practitioner to seek membership on the active medical staff.

(3) Temporary medical staff privileges. Temporary clinical privileges at the time of emergency or locum tenens may be granted to a medical practitioner for a limited and stated period on the recommendation of the chief of the applicable department/service or the president of the staff and with the concurrence of the chief executive officer.

(4) Consulting medical staff. There may be a consulting medical staff consisting of medical practitioners of recognized professional ability who are not members of another category of the medical staff and who have signified willingness to accept appointment to the consulting staff. Members of the consulting staff may neither vote nor hold office.

(5) Honorary medical staff. There may be an honorary medical staff consisting of former staff members, retired or emeritus, and of other practitioners of outstanding reputation whom the medical staff desires to honor. Those who are members of the honorary medical staff exclusively may neither vote nor hold office.

(d) Applicants approved for membership on the active, associate, or courtesy staff shall serve an initial provisional staff appointment. During this appointment, they must be assigned to departments services where their clinical competence and their ethical and moral conduct may be observed by a designated member of the active medical staff until such time as the probationary requirements established by the medical staff have been fulfilled.