Code of Massachusetts Regulations
105 CMR - DEPARTMENT OF PUBLIC HEALTH
Title 105 CMR 130.000 - Hospital Licensure
Subpart D - SUPPLEMENTARY STANDARDS: PARTICULAR SERVICES
Section 130.1801 - Policies and Procedures for Patient and Family Advisory Council
Universal Citation: 105 CMR 130.000 MA Code of Regs 130.1801
Current through Register 1531, September 27, 2024
(A) A hospital shall develop and implement written policies and procedures for the Council, which shall address, at a minimum, the following:
(1) The Council's
purposes and goals.
(2) Membership
of the Council including qualifications, selection, retention, term of service,
and duties and election of officers. The Department recommends that the chair
or co-chairs be current or former patient(s) or family member(s), or a staff
person and a patient or family member.
(3) Orientation, training and continuing
education for members of the Council.
(4) Roles of members of the Council, which
may include the following as examples:
(a)
participation on hospital committees, task forces and/or advisory
boards;
(b) review of
publicly-reported quality information;
(c) participation on committees addressing
patient safety issues;
(d)
participation on search committees and in the hiring of new hospital
staff;
(e) participation in reward
and recognition programs;
(f) as
co-trainers for clinical and nonclinical staff, in-service programs, and health
professional trainees; and
(g) any
other role in accordance with the hospital's policies and procedures.
(5) Responsibilities of members of
the Council, including policies that address confidentiality of patient
information.
(B) Required Policies and Procedures.
(1) The Council shall meet at least
quarterly.
(2) Minutes of Council
meetings shall be maintained for a minimum of five years.
(3) Minutes of Council meetings including
Council accomplishments shall be transmitted to the hospital's governing
body.
(4) At least 50% of the
Council members shall be current or former patients and/or family members and
should be representative of the community served by the hospital.
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