North Dakota Administrative Code › Title 33 - State Department of Health › Article 33-07 - Licensing Medical Hospitals › Chapter 33-07-01.1 - Hospitals › Section 33-07-01.1-09 - Governing body

Current through Supplement No. 393, July, 2024
The governing body is legally responsible for the quality of
				  patient care services, for patient safety and security, for the conduct,
				  operation, and obligations of the hospital as an institution, and for ensuring
				  compliance with all federal, state, and local laws.
1. General acute hospital. The hospital must
				have a governing body legally responsible for directing the operation of the
				hospital in accordance with its mission. Hospitals operated by governmental
				organizations, with the exception of those sponsored by the federal government,
				shall provide written notification to the department of their designated
				governing bodies and the legal authority establishing these designations. No
				contracts, arrangements, or other agreements may limit or diminish the
				responsibility of the governing body in any way.
a. The governing body, in order to achieve
				and maintain generally accepted standards of professional practice and patient
				care services in the hospital, shall establish, cause to implement, maintain,
				and, as necessary, revise its practices, policies, and procedures for the
				ongoing evaluation of the services operated or delivered by the hospital and
				for the identification, assessment, and resolution of problems that may develop
				in the conduct of the hospital.
b.
				The governing body shall receive orientation and continuing education
				addressing the mission of the hospital, their roles and responsibilities,
				patients' rights, and the organization, goals, and operation of the
				hospital.
c. The governing body
				shall adopt written bylaws reflecting its legal responsibility and
				accountability to the patients and its obligation to the community. The bylaws
				must specify at least the following:
(1) The
				role and purpose of the hospital.
(2) The duties and responsibilities of the
				governing body.
(3) The
				responsibilities of any governing body committees, including the requirement
				that minutes reflect all business conducted, including findings, conclusions,
				and recommendations.
(4) The
				relationships and responsibilities of the governing body, hospital
				administration, and medical staff, and the mechanism established by the
				governing body for holding such parties accountable.
(5) The mechanisms for adopting, reviewing,
				and revising governing body bylaws.
(6) The mechanisms for formal adoption of the
				organization, bylaws, rules, and regulations of the medical staff.
d. Meetings of the governing body
				must be held in order for the governing body to evaluate the conduct of the
				hospital, including the care and treatment of patients as well as its own
				performance. Based on these evaluations, the governing body shall take
				necessary actions sufficient to correct noted problems. A record of all
				governing body proceedings which reflects all business conducted, including
				findings, conclusions, and recommendations, must be maintained for
				review.
e. The governing body shall
				ensure the establishment and maintenance of a coordinated quality improvement
				program that integrates the review activities of all hospital services for the
				purpose of enhancing the quality of patient care.
f. The governing body shall ensure that
				policies and procedures are reviewed at a minimum of every three years and when
				changes in standards of practice occur and shall at a minimum include:
(1) Personnel records including application
				forms and verification of credentials where applicable.
(2) Periodic performance
				appraisals.
(3) Patient care needs
				and services as determined by the hospital.
(4) Patient rights to include at least the
				following and require that each patient admitted be notified of these rights.
(a) The right to considerate and respectful
				care.
(b) The right to treatment
				and services consistent with acceptable professional standards of
				practice.
(c) The right to make
				informed decisions involving care in collaboration with the licensed health
				care practitioner.
(d) The right to
				personal privacy and confidentiality of information.
(e) The right to review the patient's own
				medical record and to have information explained.
(f) The right to formulate advanced
				directives consistent with the federal Self Determination Act.
(g) The right to consent or decline to
				participate in proposed research studies.
(h) The right to expect reasonable continuity
				of care at the time when hospital care is no longer needed.
(i) The right to be informed of hospital
				policies and practices that relate to patient care, treatment, and
				responsibilities.
(j) The right to
				be free from abuse, neglect, and misappropriation of patient
				property.
(5) The
				orientation program for all new employees.
(6) The governing body shall ensure the
				establishment and maintenance of a risk management plan that includes a
				mechanism for reporting, investigating, acting on, and documenting incidents
				and identified risks.
(7) The
				transfer and discharge of patients, including discharge planning to meet the
				patients' needs.
(8) An effective
				procedure for reporting transfusion reactions and adverse drug reactions to the
				licensed health care practitioner. The governing body shall ensure that blood
				transfusions and intravenous medications are administered in accordance with
				state law.
(9) An effective
				disaster plan.
g. The
				governing body shall develop a procedure to ensure that all personnel for whom
				licensure or certification is required have a valid and current license or
				certificate.
h. The governing body
				shall take all appropriate and necessary actions to monitor and restore
				compliance when deficiencies with statutory or regulatory requirements are
				identified.
i. The governing body
				shall appoint a chief executive officer who is responsible to the governing
				body for the management of the hospital. The governing body shall assure the
				chief executive officer's effective performance through ongoing documented
				monitoring and evaluation of that performance against written criteria
				developed for the position. Criteria must include, at a minimum, the hospital's
				compliance with statutory and regulatory requirements, the corrective actions
				required and taken to achieve such compliance, and the maintenance of
				corrective actions to achieve continued compliance in previously deficient
				areas.
j. The governing body shall
				ensure that the medical staff comply with the following:
(1) Determine in accordance with state law
				which categories of licensed health care practitioners are eligible candidates
				for appointment to the medical staff.
(2) Appoint a physician as chief of staff who
				has been approved by the medical staff and is qualified for membership on the
				medical staff. The chief of staff is responsible for directing the medical
				staff organization and shall report to the governing body.
(3) Ensure the implementation of written
				criteria for selection, appointment, and reappointment of medical staff members
				and for the delineation of their medical privileges.
(4) Ensure that staff membership or
				professional privileges in the hospital are not dependent solely upon
				certification, fellowship, or membership in a specialty body or
				society.
(5) Appoint members of the
				medical staff after considering the recommendations of the existing members of
				the medical staff in accordance with written procedures.
(6) Ensure that actions taken on applications
				for medical staff appointments and reappointments including the delineation of
				privileges are put in writing.
(7)
				Approve and ensure that the medical staff has written bylaws, rules, and
				regulations.
(8) Require that
				members of the medical staff abide by the medical staff bylaws, rules, and
				regulations.
(9) Ensure that the
				medical staff is accountable to the governing body for the quality of care
				provided to patients.
(10) Require
				that members of the medical staff practice only within the scope of privileges
				granted by the governing body.
k. The governing body shall ensure that the
				following patient care practices are implemented and monitored and take
				corrective action as necessary to attain compliance:
(1) Every patient of the hospital, whether an
				inpatient, emergency service patient, or outpatient, must be provided care that
				meets generally acceptable standards of professional practice.
(2) Every patient must be under the care of a
				licensed health care practitioner who is credentialed by the medical
				staff.
(3) Patients must be
				admitted to the hospital only by a licensed health care practitioner with
				admitting privileges.
(4) Staff
				must be available at all times, sufficient to meet the patient care
				needs.
(5) A patient's licensed
				health care practitioner shall arrange for the care of the patient by an
				alternate licensed health care practitioner during their
				unavailability.
(6) One or more
				licensed health care practitioners must be on duty or call at all times and
				available to the hospital within thirty minutes to give necessary orders or
				medical care to patients in case of emergency.
(7) Every patient must receive effective
				discharge planning consistent with identified patient and family needs from the
				hospital. Discharge planning must be initiated in a timely manner. Patients,
				along with necessary medical information, must be transferred or referred to
				appropriate facilities, agencies, or outpatient services, as needed, for
				followup or ancillary care.
(8)
				That all medical orders must be in writing and signed and dated by a licensed
				health care practitioner.
l. The governing body is responsible for
				providing a physical plant equipped with the needed facilities and services for
				the care of patients in compliance with construction standards contained in
				chapter
				33-07-02.1.
m. The governing body is responsible for
				services furnished in the hospital whether or not they are furnished by outside
				entities under contracts. The governing body shall ensure that a contractor of
				services (including one for shared services and joint ventures) furnishes
				services that permit the hospital to comply with all applicable laws, codes,
				rules, and regulations.
(1) The governing
				body shall ensure that the services performed under a contract are provided in
				a safe and effective manner.
(2)
				The hospital shall maintain a list of all contracted services, including the
				scope and nature of the services provided.