PURPOSE: This rule defines governing body and establishes standards for the governing body of hospitals.

1. (1) The governing body is defined as an individual owner(s), partnership, corporate body, association or public agency having legal responsibility for the operation of a hospital subject to provisions of sections 197.020–197.120, RSMo.
2. (2) The governing body shall be the legal authority in the hospital and shall be responsible for the overall planning, directing, control and management of the activities and functions of the hospital.
3. (3) The governing body shall establish and adopt bylaws to provide for the appointment of a qualified chief executive officer and members of the medical staff and of the delegation of authority and responsibility to each. A copy of the governing body bylaws and of all amendments or revisions shall be submitted to the Department of Health for its records.
4. (4) Meetings of the governing body shall be held at regular, stated intervals and at other times necessary for proper operation of the hospital. Minutes of all meetings shall be kept as permanent records, signed and made available to members of the governing body.
5. (5) Bylaws of the governing body shall provide for the election of officers and for the appointment of standing and special committees necessary to effectively carry out its responsibilities. Written minutes of all committee meetings shall be maintained on a confidential basis.
6. (6) Bylaws of the governing body shall establish a direct and effective means of liaison among the governing body, the administration and the medical staff.
7. (7) The governing body shall select and employ a chief executive officer who should be qualified, by education and experience, in the field of hospital or health care administration.
8. (8) Bylaws of the governing body shall describe and convey authority to the chief executive officer for the administration of the hospital in all its activities. The chief executive officer shall be subject to special policies adopted or specific orders issued by the governing body in accordance with its bylaws.
9. (9) The Department of Health shall be notified of any change in the appointment of the chief executive officer.
10. (10) Bylaws of the governing body shall require that the medical staff, hospital personnel and all auxiliary organizations, directly or indirectly, shall be responsible to the governing body through the chief executive officer.
11. (11) Bylaws of the governing body shall require that a qualified individual be designated by the chief executive officer to act in his/her absence.
12. (12) Duly appointed representatives of the Department of Health shall be allowed to inspect the hospital as required in section 197.100, RSMo.
13. (13) Bylaws of the governing body shall provide for the selection and appointment of medical staff members based upon defined criteria and in accordance with an established procedure for processing and evaluating applications for membership. Applications for appointment and reappointment shall be in writing and shall signify agreement of the applicant to conform with bylaws of both the governing body and medical staff and to abide by professional ethical standards. Initial appointments to the medical staff shall not exceed two (2) years. Reappointments, which may be processed and approved at the discretion of the governing body on a monthly or other cyclical pattern, shall not exceed two
14. (2) years.
15. (14) Bylaws of the governing body shall require that the medical staff develop and adopt medical staff bylaws and rules which shall become effective when approved by the governing body.
16. (15) The governing body, acting upon recommendations of the medical staff, shall approve or disapprove appointments and on the basis of established requirements shall determine the privileges extended to each member of the staff.
17. (16) Bylaws of the governing body shall provide that notification of denial of appointment, reappointment, curtailment, suspension, revocation or modification of privileges shall be in writing and shall indicate the reason(s) for this action.
18. (17) The governing body shall establish mechanisms which assure the hospital’s compliance with mandatory federal, state and local laws, rules and standards.

19. (18) Although independent licensed practitioners are not authorized membership to the medical staff, the governing body may include provisions within its bylaws to grant licensed practitioners clinical privileges, on an outpatient basis, for diagnostic and therapeutic tests and treatment. The privileges shall be within the scope and authority of each practitioner’s current Missouri license and practice act.

    1. (A) The provisions shall include a mechanism to assure that independent practitioners who provide services have clinical privileges delineated by the governing body or designee.
    2. (B) The mechanism shall include criteria for a review of an independent practitioner’s credentials at least every two (2) years. At a minimum, the criteria shall include documentation of a current license, relevant training and experience, and competency.
20. (19) The governing body shall establish and implement a mechanism which assures compliance with the reporting requirements in section 383.133, RSMo.

AUTHORITY: sections 192.006 and 197.080, RSMo 2000.* This rule previously filed as 19 CSR 30-20.021(2)(A). Original rule filed June 27, 2007, effective Feb. 29, 2008. *Original authority: 192.006, RSMo 1993, amended 1995 and 197.080, RSMo 1953, amended 1993, 1995.