Current through Register Vol. 35, No. 18, September 24, 2024
A.
General requirements: The hospital shall have an effective
governing body, which is legally responsible for the management and provision
of all hospital services, maintenance of the hospital services and the quality
thereof.
B.
Responsibilities.
by-laws: The governing body shall adopt by-laws. The by-laws shall be in
writing and shall be available to all members of the governing body as well as
the public. The by-laws shall:
(1) stipulate
the basis upon which members are selected, their terms of office and their
duties and requirements;
(2)
specify to whom responsibilities for operation and maintenance of the hospital,
including evaluation of hospital practices, may be delegated, and the methods
established by the governing body for holding these individuals
responsible;
(3) require a
physician owner or other provider to disclose to the patient or the patient's
representative and document for the patient's medical record a financial
interest in the hospital before referring a patient to the hospital;
(4) provide for the designation of officers,
if any, their terms of office and their duties, and for the organization of the
governing body;
(5) specify the
frequency with which meetings shall be held;
(6) allow for the organization of committees,
either standing or ad hoc, to assist the board in carrying out their
responsibilities;
(7) provide for
the appointment of members of the medical staff; during periods of routine
operation, and during disaster and emergency; and
(8) provide mechanisms for the formal
approval of the organization, by-laws and rules of the medical staff.
C.
Meetings:
(1) The governing body shall meet at regular
intervals as stated in its by-laws.
(2) Meetings shall be held frequently enough
for the governing body to carry on necessary planning for growth and
development and to evaluate the performance of the hospital, including the care
utilization of physical and financial assets and the delegation to the
CEO/administrator for the hiring and direction of personnel.
(3) Minutes of meetings shall reflect
pertinent business conducted.
D.
Committees:
(1) The governing body shall appoint
committees. There shall be an executive committee and others as allowed by
bylaws.
(2) The number and types of
committees shall be consistent with the size and scope of activities of the
hospital
(3) The executive
committee or the governing body as a whole shall establish operating guidelines
for the activities and general policies of the various hospital services and
committees established by the governing body.
(4) Written minutes, or reports, which
reflect business conducted by the executive committee shall be maintained for
review by the governing body.
(5)
Other committees, which may include finance, joint conference, quality
improvement and plant and safety management committees, shall function in a
manner consistent with their duties assigned by the governing body and shall
maintain written minutes or reports which reflect the performance of these
duties. If the governing body does not appoint a committee for a particular
area, a member or members of the governing body shall assure the performance of
the duties normally assigned to a committee for that area.
E.
Medical staff liaison: The
governing body shall establish a formal means of liaison with the medical staff
by a joint conference committee or by other means as follows:
(1) a direct and effective method of
communication with the medical staff shall be established on a formal, regular
basis, and shall be documented in written minutes or reports which are
distributed to designated members of the governing body and the active medical
staff; and
(2) liaison shall be a
responsibility of the joint conference committee or its equivalent and the
executive committee for designated members of the governing body.
F.
Medical staff
appointments: The governing body shall appoint members of the medical
staff in accordance with the approved medical staff by-laws.
(1) A formal procedure shall be established,
governed by written rules covering application for medical staff membership and
the method of processing applications during periods of routine operation, and
during disaster and emergency.
(2)
The procedure related to the submission and processing of applications shall
involve the chief executive officer/administrator, the credentials committee of
the medical staff or its equivalent, and the governing body.
(3) Action taken by the governing body on
applications for medical staff appointments shall be in writing; and available
to the licensing authority during surveys or complaint
investigations.
(4) Written
notification of applicants shall be made by either the governing body or its
designated representative.
(5)
Applicants selected for medical staff appointment shall sign an agreement to
abide by the medical staff rules and by-laws.
(6) The governing body shall establish a
procedure for appeal and hearing by the governing body or a designated
committee if the applicant or the medical staff wishes to contest the decision
on an application for medical staff appointments.
G.
Appointment of chief executive
officer/administrator; The governing body shall appoint an administrator
or a chief executive officer/administrator for the hospital. The governing body
shall review the performance of the chief executive officer/administrator at
least annually.
H.
Patient
care: The governing body shall establish a policy, which requires that
every patient be under the care of a licensed, independent practitioner as
determined by the medical staff and governmental body.
I.
Physical plant requirements:
The governing body shall be responsible for providing a physical plant equipped
and staffed to maintain the needed facilities and services for
patients.
J.
Risk
management: The facility shall have a risk management program. State,
county or city facilities must have a risk management plan in accordance with
the general services department rules.
K.
Discharge planning.
(1) The governing body shall assure that the
hospital maintains an effective, ongoing program coordinated with community
resources to facilitate the provision of appropriate follow-up care to patients
who are discharged.
(2) The
hospital shall have current information on community resources available for
continuing care of discharged patients.
(3) The discharge planning program shall:
(a) have a mechanism to identify patients who
require discharge planning to provide continuity of medical care to meet their
identified needs;
(b) initiate
discharge planning in a timely manner;
(c) identify the role of the patient's
provider, nursing staff, social work staff, other appropriate staff, the
patient, and the patient's family or representative in the initiation and
implementation of the discharge planning process;
(d) assure documentation in the medical
record of the discharge plan;
(e)
allow for the timely and effective transmittal of all medical, social, economic
information concerning the patient to persons responsible for subsequent care
of the patient;
(f) provide that
every patient, or their legal representatives, receive relevant information
concerning their health needs and is involved in his or her own discharge
planning; and
(g) be reviewed at
least once a year to evaluate effectiveness.
