§ 103.3. Governing body bylaws.
The governing body shall adopt bylaws in accordance with all requirements contained in this subpart and in accordance with the community responsibility of the hospital. As a minimum, the bylaws shall do the following:
(1) State the general and specific goals of the hospital.
(2) Be reviewed annually, be revised as necessary, and be dated to indicate when last reviewed or revised.
(3) Describe the powers and duties of the governing body officers and committees and the responsibilities of the chief executive officer.
(4) State the qualifications for governing body membership, the procedures for selecting members, and the terms of service for members, officers, and committee chairmen.
(5) Describe the authority delegated to the chief executive officer and to the medical staff. No assignment, referral or delegation of authority by the governing body shall relieve the governing body of its responsibility for the conduct of the hospital. The governing body shall retain the right to rescind any such delegation.
(6) Require the approval of the bylaws of any auxiliary organizations established by the hospital.
(7) Require the governing body to review and approve the bylaws of the medical staff organization.
(8) Establish a procedure for processing and evaluating the applications for medical staff membership and for the granting of clinical privileges.
(9) Establish a procedure for implementing, disseminating, and enforcing a Patient’s Bill of Rights in compliance with § § 103.21—103.24 (relating to Patient’s Bill of Rights).
(10) Require the governing body to institute procedures to ensure:
(i) orientation of newly elected board members to specific board functions and procedures;
(ii) periodic reexamination of the relationship of the board to the total hospital community.
(iii) an opportunity, at least annually, for the general public to attend a meeting of the governing body; this meeting shall be well publicized in advance of the meeting date and shall be held at a time convenient for attendance by the general public; and
(iv) the taking of minutes of all governing body and executive committee meetings and the dissemination of those minutes or summaries thereof on a regular basis to all members of the governing body.
Authority The provisions of this § 103.3 issued under 67 Pa.C.S. § § 6101—6104; and Reorganization Plan No. 2 of 1973 (71 P. S. § 755-2).
Source The provisions of this § 103.3 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial page (37776).
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