6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 6

Current through Register Vol. 47, No. 20, October 25, 2024

Part 6 - GOVERNANCE AND LEADERSHIP

6.1 Governing Body

(A) Each hospital shall have a governing body that is legally responsible for the conduct of the hospital.

(B) Organization and responsibilities of the governing body

(1) The governing body shall:

(a) Be formally organized with a written constitution or articles of incorporation and bylaws.

(b) Hold meetings at regularly stated intervals, but at least quarterly, and maintain records of these meetings.

(c) Appoint an administrative officer who is qualified by education, training, competency, and experience in hospital administration, and delegate to them the executive authority and responsibility for the administration of the hospital. The administrative officer shall:

(i) Act as the liaison between the governing body and the medical staff.

(ii) Develop and implement a written organizational plan defining the authority, responsibility, and functions of each category of personnel.

(iii) Develop written policies and procedures for employee and medical staff use.

(iv) Ensure policies and procedures are reviewed and, if necessary, updated every three (3) years, or more often as appropriate.

(2) The governing body shall be responsible for all the functions performed within the hospital through the approval and implementation of written policies and procedures.

(3) With respect to patient care and services provided, the governing body shall:

(a) Provide services and hospital departments necessary for the welfare and safety of patients.

(b) Ensure that the patients receive care in a safe setting, including providing the equipment, supplies, and facilities necessary for the welfare and safety of patients.

(c) Ensure that each hospital department or service has written organizational policies and procedures that identify the scope of care and services provided, the lines of authority and accountability, and the qualifications of the personnel performing the services.

(d) Ensure services are provided in accordance with current standards of practice.

(e) Ensure hospital policies and procedures are available to employees at all times.

(f) Ensure that each service or department provides, at minimum, twelve (12) hours of training annually regarding the direct patient care and services provided by the service or department.

(g) Provide professional staff and auxiliary personnel in sufficient numbers, types, and qualifications necessary to protect the health, safety, and welfare of patients commensurate with the scope and type of services provided.

(h) Ensure that services performed under a contract are provided in a safe and effective manner.

(i) Ensure there is medical staff coverage twenty-four (24) hours per day, seven (7) days per week.

(4) With respect to the oversight of off-campus locations, the governing body shall ensure that each off-campus location:

(a) Has an administrator that reports to an identified administrator of the hospital campus.

(b) Operates under the applicable policies and procedures of the hospital campus, as well as specific policies and procedures that address the services provided at the off-campus location.

(c) Provides care and services by qualified personnel in accordance with recognized standards of practice.

(d) Has a health information management system that is integrated with that of the hospital campus.

(e) Has onsite supervision of services that is appropriate to the scope of services offered and supervisory staff are available to furnish assistance and direction during the performance of a procedure, if needed.

(f) Has professional staff who has clinical privileges at the hospital campus.

(g) Is held out to the public as part of the hospital, so patients know they are entering the hospital and will be billed accordingly.

(h) Has exterior building signage containing the main hospital's name, but does not have an emergency department in conformance with Part 21 of this chapter, Emergency Services, and that the off-campus location:

(i) posts signage on or near the front entrance indicating the hours of operation, services provided, and instructions to call 911 in an emergency when the location is closed;

(ii) has a staff member onsite during operating hours with current certification in first aid and CPR; and

(iii) staff trained to respond to acute care emergencies and emergency transfer protocols, as appropriate to their responsibilities.

(5) With respect to the oversight of the Medical Staff, the governing body shall:

(a) Determine which categories of practitioners are eligible candidates for appointment to the medical staff.

(b) Appoint members to the medical staff after consideration of medical staff recommendations.

(c) Approve medical staff bylaws and other medical staff policies and procedures.

(d) Consult directly with the appointed or elected medical staff leader or their designee.

(e) Ensure any disciplinary action that results in a suspension, revocation, or limitation of the privileges of a member of the medical staff is reported to the appropriate licensing or certification authority.

6.2 Medical Staff

(A) All hospitals shall have an organized medical staff that is responsible for the quality of medical care provided to patients by the hospital.

(B) Organization and responsibilities of the medical staff (1) The medical staff shall:

(a) Be organized in a manner approved by the governing body.

(b) Adopt written bylaws, which address at a minimum:

(i) Application and appointment to the medical staff;

(ii) Privileges and duties of each category of medical staff member, in accordance with the requirements of Section 25-3-103.5, C.R.S.;

(iii) Professional conduct in the hospital;

(iv) Discipline of medical staff members;

(v) The right to appeal medical staff decisions;

(vi) Attendance requirements for medical staff meetings; and

(vii) The formation of committees.

(c) Ensure the governing body approves the bylaws.

(d) Appoint or elect a physician from the organized medical staff as the medical staff leader.

(e) Meet regularly and maintain written records of these meetings. (2) The Medical Staff shall be responsible for the following:

(1) Exercising oversight of all medical staff members or licensed independent practitioners in the hospital through processes such as peer review and making recommendations concerning privileging and re-privileging.

(2) Ensuring all persons admitted as patients to a hospital shall have the benefit of continuing daily care of a medical staff member or a licensed independent practitioner.

(3) Developing and implementing policies and procedures for coordinating and designating responsibility when more than one member of the medical staff or licensed independent practitioner is treating a patient.

6 CCR 1011-1 Chapter 04, pt. 6