105 CMR, § 130.1801 - Policies and Procedures for Patient and Family Advisory Council

(A) A hospital shall develop and implement written policies and procedures for the Council, which shall address, at a minimum, the following:

(1) The Council's purposes and goals.

(2) Membership of the Council including qualifications, selection, retention, term of service, and duties and election of officers. The Department recommends that the chair or co-chairs be current or former patient(s) or family member(s), or a staff person and a patient or family member.

(3) Orientation, training and continuing education for members of the Council.

(4) Roles of members of the Council, which may include the following as examples:

(a) participation on hospital committees, task forces and/or advisory boards;

(b) review of publicly-reported quality information;

(c) participation on committees addressing patient safety issues;

(d) participation on search committees and in the hiring of new hospital staff;

(e) participation in reward and recognition programs;

(f) as co-trainers for clinical and nonclinical staff, in-service programs, and health professional trainees; and

(g) any other role in accordance with the hospital's policies and procedures.

(5) Responsibilities of members of the Council, including policies that address confidentiality of patient information.

(B) Required Policies and Procedures.

(1) The Council shall meet at least quarterly.

(2) Minutes of Council meetings shall be maintained for a minimum of five years.

(3) Minutes of Council meetings including Council accomplishments shall be transmitted to the hospital's governing body.

(4) At least 50% of the Council members shall be current or former patients and/or family members and should be representative of the community served by the hospital.

Notes

105 CMR, § 130.1801

Amended by Mass Register Issue 1276, eff. 12/19/2014. Amended by Mass Register Issue 1343, eff. 4/7/2017.