Ga. Comp. R. & Regs. R. 111-8-40-.09 - Governing Body and Hospital Administration
The 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; and
3. 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;
and
3. 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.
Notes
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