New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-P - Former Division of Public Health Services
Chapter He-P 800 - RESIDENTIAL CARE AND HEALTH FACILITY RULES
Part He-P 802 - RULES FOR HOSPITALS
Section He-P 802.16 - Organization and Administration
Universal Citation: NH Admin Rules He-P 802.16
Current through Register No. 40, October 3, 2024
(a) Each licensee shall have a governing body whose duties shall include:
(1) Management and control of the operation
of the hospital;
(2) Assessment
and improvement of the quality of care and services;
(3) Appointment of the administrator;
(4) Adoption of hospital by-laws
defining responsibilities for the operation of the hospital, and establishment
of a medical staff;
(5) Approval
of medical staff by-laws as described in (e) (2) below, defining the medical
staff responsibilities;
(6)
Responsibility for management of the overall operation and fiscal viability of
the hospital;
(7) Responsibility
for determination of the qualifications for appointment for all personnel;
and
(8) Ensuring compliance with
all relevant health and safety requirements of federal, state, and local laws,
rules, and regulations.
(b) Each hospital shall have a full-time administrator who:
(1) Has a master's degree
from an accredited institution and at least 4 years of experience working in a
health-related field or has a bachelor's degree from an accredited institution
and at least 8 years of experience working in a health-related field;
and
(2) Shall be responsible to the
governing body for the daily management and operation of the hospital and any
special health care services offered by the hospital including:
a. Management and fiscal matters;
b. Implementing the by-laws adopted by the
governing body;
c. The employment
and termination of personnel necessary for the efficient operation of the
hospital;
d. The designation of an
alternate, in writing, who shall be responsible for the daily management and
operation of the hospital and any special health care services offered by the
hospital in the absence of the administrator;
e. Attendance at meetings of the governing
body, medical staff, and personnel, to serve as a liaison to the governing
body;
f. The planning, organizing,
and directing of such other activities as may be delegated by the governing
body;
g. The delegation of
responsibility to subordinates as appropriate; and
h. Ensuring development and implementation of
all policies and procedures on:
1. Patient's
rights as required by
RSA
151:19-21;
2. Advanced directives as required by RSA
137-J;
3. Discharge planning as
required by
RSA
151:26;
4. Organ and tissue donor identification and
procurement;
5. Withholding of
resuscitative services from patients pursuant to RSA 137-J; and
6. Adverse event reporting.
(c) Each hospital shall have a full-time medical director who is qualified to practice medicine in the state and has at least 5-years' experience as a physician in a hospital setting. This shall not apply to critical access hospitals.
(d) Each hospital shall have a medical staff in accordance with the by-laws adopted under (a) (4) above.
(e) The medical staff shall be responsible for:
(1) Appointment of an executive committee
made up of members of the medical staff which shall make recommendations
directly to the governing body with regard to:
a. The process by which physicians or other
licensed practitioners shall be admitted to practice for the
licensee;
b. Evaluation of
individuals seeking medical staff membership;
c. Delineation of what clinical privilege
includes;
d. The organization of
the quality assessment and improvement activities of the medical staff;
and
e. The appointment of a medical
director who meets the qualifications of (c) above;
(2) Development of medical staff by-laws and
policies in conjunction with the governing body which shall establish a
mechanism for self-governance by the medical staff and accountability to the
governing body;
(3) Monitoring and
evaluation of the quality of patient care and patient care services in the
hospital including:
a. Monitoring of
medication use and review of pharmacy activity in the hospital;
b. Review of patient record
quality;
c. Review of blood use in
the hospital; and
d. Review of
other functions such as risk management, infection control, disaster planning,
hospital safety, and utilization review; and
(4) Identifying and making available
education programs designed to maintain the medical staff's expertise in areas
related to the services provided in the hospital.
(f) There shall be a full-time director of nursing services who is currently licensed in the state of New Hampshire pursuant to RSA 326-B, or licensed pursuant to the multi-state compact, and:
(1) Is an RN with a bachelor's and a master's
degree from an accredited institution;
(2) Is an RN with a bachelor's degree and at
least 4 years of relevant experience; or
(3) Is an RN with a minimum of 8 years of
relevant experience.
(g) The director of nursing services shall be responsible for:
(1) Establishment of standards of nursing
practice used in the hospital;
(2)
Ensuring that the admission process and patient assessment process coordinates
patient requirements for nursing care with available nursing resources;
(3) Participating with the
governing body, administrator, and medical staff to improve the quality of
nursing care at the hospital;
(4)
Nursing care as authorized by the nurse practice act and according to RSA 326;
and
(5) Nutritional
monitoring.
#5846, eff 6-22-94, EXPIRED: 6-22-00
New. #9580, eff 10-24-09
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