Rule 111-8-40-.09 - Governing Body and Hospital AdministrationThe hospital shall have an established and functioning governing body that is responsible for the conduct of the hospital as an institution and that provides for effective hospital governance, management, and budget planning.
(a) The governing body shall be organized under bylaws and shall be responsible for ensuring the hospital functions within the classification for which it is permitted by the Department.(b) The governing body shall appoint members of the medical staff within a reasonable period of time after considering the recommendations of the medical staff, if any, and shall ensure the following:1. That every inpatient is under the care of a qualified member of the medical staff;2. That the medical staff is organized and operates under medical staff bylaws and medical staff rules and regulations, which shall become effective when approved by the governing body; and3. That the medical staff is responsible to the governing body for the quality of all medical care provided to patients in the hospital and for the ethical and professional practices of its members while exercising their hospital privileges.(c) If the hospital does not provide emergency services as an organized service, the governing body shall ensure that the hospital has written policies and procedures approved by the medical staff for the appraisal of emergencies, the initial treatment of emergencies, and the referral for emergency patients as appropriate.(d) The governing body shall identify an administrator or chief executive officer who is responsible for the overall management of the hospital. The administrator or chief executive officer shall: 1. Ensure that there are effective mechanisms in the hospital's organization to facilitate communication between the governing body, the medical staff, the nursing staff, and other departments of the hospital;2. Ensure that patients receive the same quality of care throughout the hospital; and3. Be responsible for reporting to the appropriate licensing board any member of the medical staff whose privileges at the hospital have been denied, restricted, or revoked, or who has resigned from practice at the hospital, to the extent required by state law.(e) The hospital shall advise the Department immediately and in writing of a change in the designation of the administrator or chief executive officer.(f) The governing body shall ensure that the hospital is staffed and equipped adequately to provide the services it offers to patients, whether the services are provided within the facility or under contract. All organized services providing patient care shall be under the supervision of qualified practitioners.(g) The governing body shall be responsible for compliance with all applicable laws and regulations pertaining to the hospital.Ga. Comp. R. & Regs. R. 111-8-40-.09
O.C.G.A. § 31-7-2.1.
Original Rule entitled "Governing Body and Hospital Administration" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.