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Title: Section 407.4 - Governing body

Effective Date


407.4 Governing body.

(a) The entity or person established as operator of the PCH/CAH shall be legally responsible for the quality of patient care services; for the conduct and obligations of the hospital as an institution and for ensuring compliance with all federal, state and local laws. The operator's governing body, which shall mean the governing authority as defined in subdivision (a) of section 600.9 of this Title, shall operate in accordance with the provisions of section 405.2 of this Title except as provided for below. In addition, the governing body shall:

(1) ensure that all officers, directors, trustees, partners, or sole proprietors participate in orientation and continuing education programs addressing the mission, role and responsibilities of the hospital, the local EMS system and if appropriate, the network of which the PCH/CAH is a member in meeting the health care needs of patients and the community;

(2) adopt by-laws which reflect the role, purpose and responsibilities (3) establish and maintain a coordinated program, in conjunction with an affiliated full service hospital and other area providers as appropriate, which integrates the operational review activities of all hospital services for the purpose of enhancing the quality of patient care and identifying and preventing potential malpractice issues;

(4) sets policies that assure that a doctor of medicine or osteopathy and/or a registered physician's assistant under the general supervision of a physician or a nurse practitioner collaborating with a physician, is on duty at all times during regularly scheduled hours of operation of emergency care services, and other services at times determined appropriate by the governing body of the hospital and specified by hospital policies and procedures; and

(5) sets policies that ensure that a doctor of medicine or osteopathy is on call at all times.


VOLUME C (Title 10)