Section 22-B2014. GOVERNING BODY AND ADMINISTRATION

 

2014.1Each hospital shall have a governing body which shall have the authority and responsibility for the direction and policy of the hospital.

 

2014.2The governing body's responsibilities shall include:

 

(a)Monitoring policies to assure appropriate administration and management of the facility;

 

(b)Maintaining the hospital's compliance with all applicable state and federal statutes, relevant state and federal rules and regulations, the hospital's policies and procedures as well as the hospital's plans of correction;

 

(c)Ensuring the quality of all services, care and treatment provided to patients whether those services, care or treatment are furnished by hospital staff or through contract with the hospital;

 

(d)Designating an administrator who is responsible for the day-to-day management of the hospital and defining the administrator's duties and responsibilities;

 

(e)Notifying the Department in writing within thirty (30) working days when a vacancy in the administrator position occurs, including who will be responsible for the position until another administrator is appointed;

 

(f)Notifying the Department in writing within thirty (30) working days when the administrator vacancy is filled indicating effective date and name of person appointed administrator;

 

(g)Appointment and reappointment of medical staff members who are credentialed in accordance with the District of Columbia Health Occupations Revision Act of 1985 (D.C. Law 6-99) and delineating their clinical privileges, according to the procedures for credentials review established by the medical staff and approved by the governing authority;

 

(h)In collaboration with the medical staff, establishing criteria for membership on the medical staff or clinical privileges;

 

(i)Rendering within a fixed period of time the final decision regarding medical staff recommendations for denial of staff appointments and reappointments, as well as for the denial, limitation, suspension or revocation of privileges. There shall be a mechanism provided in the medical staff bylaws, rules and regulations for review of decisions, including the right to be heard when requested by the practitioner;

 

(j)Ensuring the medical staff is accountable to the governing body for the quality of medical care and treatment;

 

(k)Ensuring a medical staff and a utilization review process is formed and operated for the purpose of reviewing the medical and hospital care provided and the use of hospital resources to assist individual physicians, administrators and nurses in maintaining and providing a high standard of medical and hospital care and efficient use of the hospital;

 

(l)At least once each year, reviewing reports and recommendations regarding all Quality Assurance/Performance Improvement activities and the Medical Staff and Utilization Review process. Reports shall be utilized to implement programs and policies to maintain and improve the quality of patient care and treatment;

 

(m)Establishing a means for liaison and communication between the governing authority, the medical staff and administration and promoting effective communication and coordination of services among the various hospital departments, administration and the medical staff;

 

(n)Requiring the medical staff to be organized with a chief of staff, president, or chairperson and approving the organization, bylaws, rules and regulations, and policies and procedures of the medical staff and the departments in the hospital;

 

(o)Establishing visitation policies which are in the best interest of patients, including, but not limited to, protection from communicable diseases, protection from exposure to deleterious substances and hazardous equipment and assurance of health and safety of patients; and

 

(p)In addition to the requirements of section 2032.1(d), establishing a written infection control program which includes a description of risks, strategies to address the risks, a statement of goals, a system to evaluate the program and applicable policies and procedures.

 

source

Notice of Final Rulemaking published at 55 DCR 8813 (August 15, 2008).