N.J. Admin. Code § 8:43G-5.1

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:43G-5.1 - Administrative and hospital-wide structural organization

(a) There shall be an organizational chart of the hospital and each service that shows lines of authority, responsibility, and communication between and within services.

(b) The hospital shall have an established and functioning governing body responsible for establishing hospital-wide policy, adopting bylaws, maintaining quality of care, and providing institutional management and planning. The hospital shall file the following with its license application or license renewal application:

1. The name of each member of the hospital's governing body;

2. The name of the chairperson of the hospital's governing body;

3. The term of office of the chairperson and each member of the governing body; and

4. The start date and end date of the term of office of each member of the governing body.

(c) The governing body shall designate an administrator or chief executive officer for the hospital and develop criteria used to evaluate the performance of the administrator or chief executive officer.

(d) The hospital shall advise the Department's Licensing Office, in writing, within 15 days following any change in the designation of the administrator or chief executive officer of the hospital.

(e) The medical staff shall have the right of representation at governing body meetings.

(f) There shall be a formal mechanism for communication among the governing body, administration, and medical staff.

(g) Minutes of governing body meetings shall be recorded, signed, and retained in the hospital as a permanent record.

(h) The hospital shall have a multidisciplinary bioethics committee, and/or prognosis committee(s), or equivalent(s). The hospital shall assure participation by individuals with medical, nursing, legal, social work, and clergy backgrounds. The committee or committees shall have at least the following functions:

1. Participation in the formulation of hospital policy related to bio-ethical issues;

2. Participation in the formulation of hospital policy related to advance directives. Advance directive shall mean a written statement of the patient's instructions and directions for health care in the event of future decision making incapacity in accordance with the New Jersey Advance Directives for Health Care Act ( P.L. 1991, c.201). An "advance directive" may include a proxy directive or an instruction directive, or both.

3. Participation in the resolution of patient-specific bioethical issues, and responsibility for conflict resolution concerning the patient's decision-making capacity and in the interpretation and application of advance directives. The committee may partially delegate responsibility for this function to any individual or individuals who are qualified by their backgrounds and/or experience to make clinical and ethical judgments; and

4. Providing a forum for patients, families, and staff to discuss and reach decisions on ethical concerns relating to patients.

(i) The hospital shall establish a mechanism for involving consumers in the formulation of hospital policy related to bio-ethical issues.

(j) The hospital shall provide periodic community education programs, individually or in coordination with other area facilities or organizations, that provide information to consumers regarding advance directives and their rights under New Jersey law to execute advance directives.

(k) The hospital shall establish policies and procedures for the declaration of death of patients in accordance with N.J.S.A. 26:6 and the New Jersey Declaration of Death Act ( P.L. 1991, c.90). The policies and procedures shall accommodate a patient's religious beliefs with respect to declaration of death. Such policies shall also be in conformance with regulations and policies promulgated by the New Jersey Board of Medical Examiners which address declaration of death based on neurological criteria, including the qualifications of physicians authorized to declare death based on neurological criteria and the acceptable medical criteria, tests, and procedures which may be used.

(l) All hospitals are required to maintain an on-call list of appropriate primary care and sub-specialty physicians for all patients who require emergency department treatment or admission to the hospital for continuing care. All such patients being admitted to the hospital for continuing care shall be presumed to require routine care unless a clinical provider (physician, physician's assistant, advanced practice nurse, nurse practitioner, registered nurse) determines the patient's condition to be emergent. Routine and emergent cases shall be disposed as follows:

1. Consult requests designated as "routine" indicate that the requesting clinical provider wishes to present a patient to the on-call physician, but that the patient's condition does not require emergency consultation. The hospital shall have a by-law to determine the appropriate on-call physician response time to consult requests for routine cases.

2. Consult requests designated as "emergent" indicate that the requesting clinical provider wishes to present a patient to the on-call physician and that the patient's condition requires the on-call physician's prompt response. Since patient outcome in emergent cases may be directly related to care provided by the on-call physician, that physician shall respond by telephone within 20 minutes of receiving a call from hospital clinical staff. In addition, the treating physician present in the hospital and the on-call physician shall discuss and agree upon an appropriate in-person response time for the on-call physician. If the physicians are unable to reach an agreement as to an appropriate in-person response time for the on-call physician, then the opinion of the treating physician present in the hospital shall govern. However, with regard to patients aged 18 or under, the in-person response time shall not be longer than 60 minutes after the initial call to the on-call physician. The hospital shall note on the patient's medical record the events occurring during the patient's stay in the emergency department. The hospital shall monitor that information and the hospital quality improvement staff shall review that information at least annually.

N.J. Admin. Code § 8:43G-5.1

Amended by 50 N.J.R. 552(b), effective 1/16/2018