What is the “Governing Body” of a Hospital in California? (CCR 22 § 70701)
The governance of a California hospital is a three legged stool. There is the Medical Staff, the Executive Team and the Governing Body e.g. the Board of Directors. In most hospitals the Board is a rubber stamp for the Executive team but California law actually requires greater engagement.
California Regulations (the “CCR’s”) contain the rules that govern hospitals and CCR 22 sectio 70701 sets out the requirements for the Governing Body. Many of the requirements address the need for rules that govern the conduct of medical staff. So it requires the existence of a medical staff and appropriate bylaws. It requires the appointment of an executive ( CCR 22 sectio 70701(2))
Overlooked but absolutely critical is subsection (4) which requires the Governing Body to:
“Provide appropriate physical resources and personnel required to meet the needs of the patients and shall participate in planning to meet the health needs of the community.”
Add to that subsections:
(5) which requires the Governing Body to “Take all reasonable steps to conform to all applicable federal, state and local laws and regulations, including those relating to licensure, fire inspection and other safety measures.”
(6) “Provide for the control and use of the physical and financial resources of the hospital.”
These two sections require the Board of Directors to ensure that the hospital meet community needs and have the physical assets necessary to properly perform services. The Board cannot allow procedures to go forward if the hospital lacks the personnel or equipment necessary to safely perform those procedures.
Surgical Site Infection compliance as required by the CDC and the Joint Commission are ultimately in the hands of the Governing Body.
In cases where new or experimental surgeries are performed it is the Governing Body that determines whether a procedure should go forward.
See subsection (7) which reads:
(7) Require that the medical staff establish controls that are designed to ensure the achievement and maintenance of high standards of professional ethical practices including provision that all members of the medical staff be required to demonstrate their ability to perform surgical and/or other procedures competently and to the satisfaction of an appropriate committee or committees of the staff, at the time of original application for appointment to the staff and at least every two years thereafter.
In terms of compliance with infection control and other measures related to surgery competence includes meeting current standards of care in the medical community. In cases where standards are ignored or poor results are covered up, the Board of Directors (Governing Board) has the ultimate Responsibility.