§ 103.4. Functions.
The governing body, with technical assistance and advice from the hospital staff, shall do the following:
(1) Provide appropriate physical resources and personnel required to meet the needs of the patients and participate in planning to meet the health needs of the patients and health needs of the community. A quality control mechanism should be established which includes as an integral part thereof a risk management component and an infection control program.
(2) Formulate short-range and long-range plans for the development of the hospital.
(3) Take all reasonable steps to conform to all applicable Federal, State, and local laws and regulations.
(4) Provide for the control and use of the physical and financial resources of the hospital.
(5) Review the annual audit of the financial operations of the hospital.
(6) Utilize the advice of the medical staff in granting and defining the scope of clinical privileges to individuals. When the governing body does not concur in the medical staff recommendation regarding the clinical privileges of an individual, there should be a review of the recommendation by a joint committee of the medical staff and governing body before a final decision is reached by the governing body.
(7) Require that applicants be informed of the disposition of their application for medical staff membership or clinical privileges, or both, within a reasonable period of time after their application has been submitted.
(8) Require that the medical staff bylaws, rules, and regulations be approved by the governing body. Such approval shall not be withheld unreasonably.
(9) Delegate to the medical staff the authority to evaluate the professional competence of staff members and applicants for staff privileges and hold the medical staff responsible for recommending initial staff appointments, reappointments, and assignments or curtailments of privileges.
(10) Require that resources be made available to address the emotional and spiritual needs of patients either directly or through appropriate referral or arrangement with community agencies.
(11) Maintain effective communication with the medical staff. This may be established, inter alia, through:
(i) a joint conference committee;
(ii) service by the president of the medical staff as a member of the governing body with or without a vote; or
(iii) appointment of individual medical staff members to governing body committees.
(12) Require the medical staff to establish controls that are designed to ensure the achievement and maintenance of high standards of ethical professional practices.
(13) Ensure that the medical staff is provided with the necessary administrative staff to facilitate utilization review and infection control within the hospital and to support any other medical staff functions required by this subpart or by the hospital bylaws.
(14) Require that each member of the medical staff act in an ethical manner.
(15) Ensure that the following public disclosure requirements are being met:
(i) The hospital provides to the appropriate Health Systems Agency (HSA) information that the HSA is required to collect pursuant to Section 1513(b) of the National Health Planning and Resources Development Act of 1974.
(ii) Information is to be made available to the public upon request regarding to the current daily cost reimbursement of the hospital under Blue Cross Medical Assistance and Medicare as well as the average daily charge to other insured and noninsured private pay patients.
(iii) The hospital provides for public disclosure of the persons owning 5.0% or more of the hospital as well as the officers of the hospital and members of the governing body.
(16) Establish a procedure for reporting the occurrence and disposition of any unusual incidents. The procedure shall insure that:
(i) Incident reports are analyzed and summarized and that the results and the summaries are kept available for the Department.
(ii) Corrective action is taken as indicated by the analysis of incident reports.
(17) Establish a procedure to ensure that special emergency reports to the Department under the provisions of § 151.48 (relating to report of emergencies causing interruption of service) are promptly and accurately reported.
Authority The provisions of this § 103.4 issued under act 67 Pa.C.S. § § 6101—6104; and Reorganization Plan No. 2 of 1973 (71 P. S. § 755-2).
Source The provisions of this § 103.4 amended September 19, 1980, effective September 20, 1980, 10 Pa.B. 3761. Immediately preceding text appears at serial pages (37776) to (37778).
Notes of Decisions Duty
Based upon this regulation and other Federal and State legislation and case law, the medical center had a duty to grant privileges only to those physicians determined to be competent to provide the medical services authorized by the privileges and to implement quality control procedures to ensure proper patient care. Gurevitz v. Piczon, 42 D. & C. 4th 308 (1999).
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