N.H. Admin. Code § He-P 802.16

Current through Register No. 50, December 12, 2024

Section He-P 802.16 - Organization and Administration

(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.

N.H. Admin. Code § He-P 802.16

#5846, eff 6-22-94, EXPIRED: 6-22-00

New. #9580, eff 10-24-09

Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12407, Effective 10/24/2017, Expires 4/22/2018.

Amended by Volume XLI Number 6, Filed February 11, 2021, Proposed by #13166, Effective 1/28/2021, Expires 1/28/2031.