New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter A - Medical Facilities-minimum Standards › Article 2 - Hospitals › Part 405 - Hospitals-Minimum Standards › Section 405.2 - Governing body

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The established
					 operator shall be legally responsible for the quality of patient care services,
					 for the conduct and obligations of the hospital as an institution and for
					 ensuring compliance with all Federal, State and local laws.
(b)
Organization and operation.
(1) The hospital shall have a governing body
					 legally responsible for directing the operation of the hospital in accordance
					 with its mission. If a hospital does not have an organized governing body, then
					 the person or persons legally responsible for the conduct of the hospital shall
					 carry out the functions specified in this Part that pertain to the governing
					 body. Hospitals operated by governmental organizations, with the exception of
					 those sponsored by the Federal government, shall provide written notification
					 to the commissioner 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.
(2) 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.
(3) All officers, directors, trustees,
					 partners, or sole proprietors of the governing body shall participate in
					 orientation and continuing education programs addressing the mission of the
					 institution, their roles and responsibilities, patients' rights, and the
					 organization, goals and operation of the hospital's quality assurance
					 program.
(4) The governing body
					 shall adopt written bylaws reflecting its legal responsibility and
					 accountability to the patients and its obligation to the community it was
					 established to serve. The bylaws shall specify at least the following:
(i) the role and purpose of the
					 hospital;
(ii) the duties and
					 responsibilities of the governing body;
(iii) the responsibilities of any governing
					 body committees including the requirement that minutes reflect all business
					 conducted, including findings, conclusions and recommendations;
(iv) the relationships and responsibilities
					 of the governing body, hospital administration, and the medical staff, and the
					 mechanism established by the governing body for holding such parties
					 accountable;
(v) the mechanisms for
					 adopting, reviewing and revising governing body bylaws; and
(vi) the mechanisms for formal approval of
					 the organization, bylaws, rules and regulations of the medical staff and its
					 departments in the hospital.
(5) Meetings of the governing body shall 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, shall be maintained for review and
					 analysis.
(6) The governing body
					 shall establish and maintain a coordinated program which integrates the review
					 activities of all hospital services for the purpose of enhancing the quality of
					 patient care and identifying and preventing malpractice.