El Paso County Hospital Policy: C-1

EL PASO COUNTY HOSPITAL POLICY: C-1

DISTRICT POLICY EFFECTIVE DATE: 01/92

LAST REVISION DATE: 034/163

HOSPITAL DISTRICT COMMITTEES AND COUNCILS

POLICY

• The President and Chief Executive Officer (CEO) will appoint El Paso County Hospital District (EPCHD) committees/Councils to consider, investigate, make recommendations on, or report on a defined scope of responsibility.

• EPCHD Committees/Councils shall conduct their business consistent with the vision, values and strategic direction of the Hospital.

RESPONSIBLE

Board of Managers

Administrative Associates

President and Chief Executive Officer (CEO)

Hospital Committee Members

Chief Executive Office Coordinator

Administrative Assistant, Patient Care Services

Medical Staff Office Secretary

Hospital Associates

Risk Management Associates

DEFINITIONS

Committee: A group appointed by the CEO to consider, investigate, make recommendations on, or report on a defined scope of responsibility.

Council: An assembly of persons summoned or convened for consultation, deliberation, or advice.

Subcommittee: A subdivision of a Committee organized for a specific purpose.

Task force: A group organized to accomplish a specific objective of a limited scope.

POLICY REFERENCES

C-5Minutes of Hospital Meetings

CP-43Record Retention

Medical Staff Bylaws

PROCEDURE

1. Establishment

Issues that are multi-departmental or organization-wide should be communicated through established channels to the administrative Associate to determine the appropriateness of establishing a Committee, Council, subcommittee, task force, or performance improvement team, to address the issue.

1.Committee: Hospital Committees/Councils are designated by the CEO, who also has the authority to disband them

2.Subcommittee: Subcommittees are designated by the Committee/Council chairperson who also has the authority to disband them.

3.Task force:

a.Task forces are designated by the CEO who also has the authority to disband them.

b.Committee/Council task forces may be designated by the Committee/Council chairperson who also has the authority to disband them.

B.Appointments

1.Committee/Council

1. New hospital Committee/Council:

Chairpersons and members are appointed by the CEO. Should the chairperson leave employment, the CEO will appoint a replacement.

b.Established Hospital Committee/Council:

1)Committee/Council chairpersons and members serve from October 1st to September 30th and may be re-appointed annually, as designated by the CEO.

2)The CEO may designate that an Associate, by virtue of job position, be permanently appointed as a chairperson or member of a specific Committee/Council.

2.Subcommittee

a.The subcommittee chairperson and members are appointed by the Committee/ Council chairperson.

b.Should the subcommittee chairperson leave employment, the Committee/ Council chairperson will appoint a replacement.

3.Task Force

a.The task force chairperson and members are appointed by the CEO or the Committee/Council chairperson.

b.The task force serves until it has met its objectives or is disbanded by the appointing authority.

C.Operations

1.The responsibility of each Committee/Council will be clearly defined. Responsibilities and objectives will be reviewed annually. Recommended changes require CEO’s approval.

Each Hospital Committee/Council will develop and maintain a Hospital policy that describes the Committee's/Council’s responsibilities, operations, composition, meetings, and record keeping and reporting.

1. Authority

Hospital Committee/Council authority is delegated by the CEO. Committees/Councils may have administrative and/or advisory functions.

a.Actions that require change in Hospital policy require CEO’s approval.

b.Actions that require expenditure or Hospital funds shall be processed consistent with mechanisms established in the Hospital Procurement Manual.

c.When a Hospital Committee/Council proposes action that is beyond its delegated authority, recommendations shall be made to the appropriate administrative Associate and documented in a memorandum with the following information:

1)The background of the problem and why a decision should be made,

2)Alternatives considered, if applicable,

3)Recommendations with supporting information.

D.Committee Composition

1.The Hospital Committee/Council chairperson will define the ideal composition of the Committee and make recommendations to the CEO for approval concerning:

a.Number of members,

b.Expertise/discipline required for membership,

c.Replacements due to resignations.

2.Each Committee will have a vice-chairperson. The method for selecting the vice-chairperson is at the discretion of the chairperson (the vice-chairperson may be appointed by the chairperson or elected by the members).

3.A quorum consists of one half of the Committee/Council membership.

E. Meetings

1. Agenda

An agenda will be prepared by the chairperson to include approval of the minutes, unfinished business, and new business, and distributed in advance to provide time for members' preparation.

2.Committees/Councils will meet at least quarterly; meetings should be consistently scheduled to facilitate planning and attendance.

a.The chairperson will define attendance requirements for members and will approve all guests.

b.Failure of a member to meet attendance requirements will be reported to the CEO for recommended action.

c.The chairperson will determine if an alternate should attend a meeting if a member cannot attend.

1. Voting

1. Appointed members of the Committee/Council will be voting members.

1. Items passed by the Committee/Council normally must be approved by a 50% majority of the voting members present. Due to the critical nature of Committee/ Council work, the chairperson of the Committee/Council may establish the quorum based upon the number of Committee/Council members present at a specific meeting.

G.Record Keeping and Reporting

Hospital Committees/Councils will maintain records of operation, including agendas and minutes of all meetings, and as necessary, reports of activities, accomplishments, and recommendations in the following manner:

1.The chairperson is responsible for assuring that minutes are recorded for each meeting.

a.Minutes should be prepared according to C-5 and should include documentation of all decisions or recommendations.

b. The Chairperson will keep the minutes in his/her office and forward a copy of the minutes to the Risk Management Office for retention.

c.Agendas and minutes will be distributed to the CEO, Committee/Council members, and others as necessary and appropriate for dissemination of information and coordination. When the Committee/Council activities involve a Hospital department not represented on the Committee/Council, minutes must be distributed to that department.

1. Upon disbanding of a Committee/Council or task force, or separation of a chairperson, all appropriate documentation must be forwarded to the Chief Executive Office Coordinator and Risk Management Department.

1. The Risk Management Department is responsible for ensuring that record retention requirements are met.

2.Routine or special reports may be required as specified by the Committee/Council, or requested by the CEO.

3.Annually, each Hospital Committee/Council will prepare a report to the CEO detailing the following:

a.Summary of the status of the goals, objectives, and accomplishments of the preceding year,

b.Assessment of how successfully the mission was fulfilled,

c.Recommendations for continuing or discontinuing, or for changes in purpose or composition.

4.Other Hospital Committee/Council Duties:

a.The Medical Staff Office secretary maintains a calendar of Hospital Committee/ Council meeting dates;

b.The Chief Executive Office Coordinator maintains all minutes andCommittee/Council vice-chairs are responsible for maintaining committee/council documentation when a Committee/Council is disbanded or is waiting for the appointment of a new chairperson and for forwarding documentation when the new chairperson is appointed.

c.Committee/Council chairs are responsible for forwarding committee/council documentation to Risk Management when committees/councils areThe Chief Executive Office Coordinator forwards all minutes and documentation to the new chairperson when a new chairperson is appointed disbanded.

Review/Revision History:

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