Kan. Admin. Regs. § 28-34-5a

Current through Register Vol. 43, No. 45, November 7, 2024

Section 28-34-5a - Governing authority

(a) Governing body. Each hospital shall have an organized governing body. The governing body shall be the ultimate authority in the hospital responsible for its organization and administration in a manner which is consistent with appropriate standards of patient care, environmental safety and institutional management.

(b) Bylaws. The governing body shall adopt its own set of bylaws. At a minimum, the bylaws shall contain the following provisions:

(1) A statement of the mission of the hospital;

(2) a description of the powers and duties of the governing body, officers and committees and of the responsibilities of the chief executive officer;

(3) a statement of the qualifications for governing body membership, the procedures for selecting members and the term for members, officers and committee chairpersons;

(4) a description of the authority delegated to the medical staff;

(5) a requirement that the governing body review and approve the bylaws of the medical staff organization;

(6) a requirement that the governing body approve or deny all applications for medical staff membership and for the granting of clinical and admitting privileges; and

(7) a description of the mechanism by which the governing body bylaws are adopted, reviewed and revised.

(c) Functions. At a minimum, the governing body shall:

(1) Provide adequate physical resources and personnel for appropriate patient care;

(2) participate in planning to define and help meet the health needs of the community;

(3) formulate short-term and long-term plans for the development of the hospital;

(4) review the annual audit of the financial operations of the hospital;

(5) maintain effective communication with the medical staff;

(6) require the medical staff to establish controls that are designed to achieve and maintain appropriate standards of ethical professional practice;

(7) establish a structure to effectively fulfill the governing body's responsibilities and to evaluate the implementation of programs and policies;

(8) maintain a written record of governing body proceedings; and

(9) implement and maintain a risk management program in accordance with K.S.A. 65-4291 et seq.

(d) Conflict of interest. Members of the governing body shall not maintain personal or business interests which conflict with those of the hospital to an extent deemed by the governing body to present a threat of injury to or loss of the hospital's reputation, assets or ability to provide patient care.

Kan. Admin. Regs. § 28-34-5a

Authorized by and implementing K.S.A. 1991 Supp. 65-431; effective June 28, 1993.