This
rule was filed as MCMC 90-1.
TITLE 7 HEALTH
CHAPTER 7 HOSPITALS
PART 4 BOARD OF TRUSTEES OF MINERS' COLFAX MEDICAL CENTER
BY-LAWS
7.7.4.1 ISSUING AGENCY:
Miners' Colfax Medical Center
[Recompiled
10/31/01]
7.7.4.2 SCOPE:
[RESERVED]
[Recompiled
10/31/01]
7.7.4.3 STATUTORY AUTHORITY: Miners' Colfax medical center (hereinafter
medical center") is the miners' hospital for the state of New Mexico,
deriving its legal status and authority from the Enabling Act for New Mexico SS
7 and 12, the Constitution of the state of New Mexico, art. XIV, SS 1, 2 and 3,
and 23-3-1, et seq. NMSA 1978.
[Recompiled
10/31/01]
7.7.4.4 DURATION:
[RESERVED]
[Recompiled
10/31/01]
7.7.4.5 EFFECTIVE DATE:
[RESERVED]
[Recompiled
10/31/01]
7.7.4.6 OBJECTIVE: PURPOSE OF THE MINER’S HOSPITAL: The miners' hospital is a general hospital
and is intended and meant to be for the free treatment and care of resident
miners of the state of New Mexico who may become sick or injured in the line of
their occupation. The board of trustees may make provision for charges to
miners with sufficient means to pay for their care. The medical center also provides health care
services for non-miners and miners who do not meet the statutory requirements
for free treatment in a manner consistent with trust requirements.
[Recompiled
10/31/01]
7.7.4.7 DEFINITIONS:
[RESERVED]
[Recompiled
10/31/01]
7.7.4.8 GOVERNING BOARD:
A. The governing board is a board of
trustees, the members of which are appointed by the governor of the state of
New Mexico with the advice and consent of the senate. One member of the board
shall be a licensed physician, two members shall be miners or their
representatives and two members shall be representatives of the general public.
Members of the board shall be appointed for staggered terms of five years each.
B. The board of trustees is a body
corporate under the name of the "board of trustees of miners' hospital of
New Mexico" and has the power to sue and be sued, to contract, to acquire
land by purchase or donation, and to do all other things in furtherance of its
duties to provide for the operation of a medical center and to determine, set,
and execute medical center policy. The board of trustees shall supervise and
control all functions of the operation and management of the medical center.
The board of trustees has absolute discretion to take whatever action may be
necessary in the best interest of the medical center, including but not limited
to: full power and authority with regard to the medical staff; authority to
approve all medical staff by-laws, rules and regulations, to suggest amendments
of these to the medical staff and to amend them with due consideration to
medical staff recommendations; authority to oversee all aspects of the medical
staff operations to ensure compliance with applicable federal and state laws
and with standards proposed by the joint commission on accreditation of
healthcare organizations.
C. By duly-adopted medical staff
by-laws governing appointments to the medical staff of the hospital, the board
shall provide a system of continual review and evaluation of the quality of
health care being rendered at the hospital. The medical staff by-laws shall
assure the board of trustees that any patient treated by the medical center
shall receive quality care.
D. Members of the board of trustees owe
a fiduciary duty of care and loyalty to the bedical center. A trustee shall
avoid active participation in a transaction in which they or a corporation with
which they are associated has a significant interest. Members of the board of
trustees shall adhere to the Conflict of Interest Act, 10-16-1, et seq., NMSA
1978. Disclosures of financial interests shall be made to the secretary of
state during the month of January of each year pursuant to 10-16-10, supra. In
addition, the conflict of interest statements required by 10-16-10, NMSA 1978
shall be submitted to the chairperson of the board and to the medical center's
chief executive officer.
E. Trust eligibility
requirements shall be established by the board with due regard to the statutes
and trust requirements governing the medical center and its responsibilities as
the miners' hospital.
[Recompiled
10/31/01]
7.7.4.9 REGULAR AND SPECIAL MEETINGS OF THE BOARD OF
TRUSTEES: The board of trustees shall hold regular
meetings at such times and places as set by the board of trustees, with such
meetings to occur not less than 8 times per year. Special meetings of the board
of trustees may be called by the chair or upon the request of any two members
of the board. A quorum shall consist of three members. Meetings shall be open
to the public in accordance with the Open Meetings Act, 10-15-1, et seq. NMSA
1978, as amended. The board shall resolve annually, at the first
regularly-scheduled meeting of each new year, the procedure for providing
reasonable notice of meetings pursuant to 10-15-1(C), supra. The resolution
shall state the number of days in advance that notice shall precede a regular,
special or emergency meeting and how such notice will be given. Meetings of the
board of trustees shall be regularly attended.
[Recompiled
10/31/01]
7.7.4.10 OFFICERS OF THE BOARD OF TRUSTEES:
A. The officers of the board of trustees
shall be a chair, a vice-chair and a secretary-treasurer, all of whom shall be
elected by a majority vote at a regular board meeting. Elections shall be
conducted at an annual meeting to the held during the month of July, unless
necessitated by vacancies on the board. Should the term of appointment for a
member-officer expire and a new member be appointed; should a member-officer
resign his position as board member by tendering his resignation; or should a
member-officer be removed from office on the board, the board shall conduct an
election to fill the office of such member-officer for the remaining term of
his or her office.
B. The chair shall call and preside at all
meetings. The chair may approve the meeting agenda in consultation with the
chief executive officer of the medical center and shall be available for
consultation with the chief executive officer on request. The vice-chair shall
act as chair in the absence of the chair and, when so acting, shall have all
the powers and authority of such office. The secretary-treasurer shall act as
chair in the absence of both the chair and vice-chair and, when so acting,
shall have all the powers and authority of such office. The chair shall have
such additional powers and duties as may be prescribed elsewhere in the by-laws
or established by resolution or policy of the board. The secretary-treasurer
shall act as custodian of all records and reports of the board of trustees and
shall be responsible for the keeping and reporting of adequate records of all
transactions and the minutes of all meetings of the board of trustees.
[Recompiled
10/31/01]
7.7.4.11 ADMINISTRATION OF THE MEDICAL CENTER:
A. The board of trustrees may provide
for the management and administration of the medical center by contracting with
a corporation engaged in providing management services in conformity with
standards for an accredited hospital. The board of trustees may employ directly
a competent, experienced, professional hospital administrator. In either case,
a medical center administrator shall be secured and shall be the chief
executive officer responsible for the management of the medical center.
B. The chief executive officer of the
medical center shall have all authority and responsibility necessary to operate
the medical center in all its activities and departments, subject only to
policies issued by the board of trustees and to applicable federal and state
laws and regulations. He or she shall act as the duly authorized representative
to the board in all matters in which the board has not formally designated some
other person to act. He or she shall report as directed to the chair between
board meetings and to the board at each meeting.
C. The authority and duties of the
chief executive officer shall include, but not be limited to: to sign, together with
such other authorized board member, any deeds, mortgages, bonds, contracts or
other instruments which the board has authority to execute except in cases
where the execution shall have been expressly delegated by the board or by the
by-laws or by statute; to carry out all policies established by the board of
trustees; to conduct all activities of the medical center in compliance with
federal and state laws and regulations; to prepare an annual budget showing the
expected receipts and expenditures as required by the board and by departments
of state government; as head of the medical center, to select, employ, control,
and discharge all employees, consistent with the regulations of the state
personnel board, and to develop and maintain additional personnel policies and
practices approved by the board of trustees; to see that all physical
properties are accounted for, safeguarded, and kept in a good state of repair
and operating condition; to supervise all business affairs and to ensure that
all funds are collected and expended to the best possible advantage; to assist
the chief of staff, the medical staff, and all those concerned with the
rendering of professional services to the end that the best possible care may
be rendered to all patients; to submit regularly to the board of trustees, or
its authorized committees, periodic reports of medical center services,
statistics, and financial activities and to prepare and submit such special
reports as may be required by the board of trustees; to attend all meetings of
the board of trustees, of the committees on which he or she serves and other
committees as necessary or required, and the medical staff executive committee;
to perform any other duty that may be necessary or in the best interest of the
medical center; to serve as the liaison officer and channel of communications
for all official communications between the board of trustees and the medical
staff.
[Recompiled
10/31/01]
7.7.4.12 COMMITTEES OF THE BOARD OF TRUSTEES: There shall be two types of committees of the
board of trustees--permanent and special.
A. Permanent committees:
(1) Committee of the
whole: The general conduct of the board
of trustees' business shall be through the five-member body acting as a whole
on matters pertaining to the operation of the medical center, unless otherwise
specified in these by-laws or voted by the board of trustees. In acting as a
whole, the board should provide for effective means of liaison between the
governing body, the medical staff and the administration, and shall evaluate
annually the administrator's performance.
(2) Joint conference
committee: The joint conference
committee shall serve as a liaison between the board of trustees, the medical
staff, and the administration. The committee shall provide a forum for
effective communication regarding medical center policy and operation;
institutional/program planning and goal setting; accrediting and licensing
requirements and inspections; requests and recommendations from the medical
staff; quality assurance; matters related to the medical staff by-laws, rules
and regulations and other matters of mutual concern to the medical staff, the
administration, and the board, which may be referred to this committee by the
board of trustees. The committee shall consist of the chair and
secretary-treasurer of the board of trustees, the chief and vice-chief of the
medical staff, and the hospital administrator. The chair of the board of
trustees shall serve as chair of the joint conference committee. The committee
shall meet at least quarterly, and shall maintain a written record of its
attendance, proceedings, recommendations, and actions, which shall be forwarded
to the board and to the medical staff.
(3) Credentials
committee: The credentials committee
shall be composed of three licensed physicians appointed by the board of
trustees. The chief of the medical staff shall submit recommendations of
qualified individuals to the board of trustees for their review and
consideration. The committee shall review the professional credentials of all
physicians and health care professionals, except those allied health
professionals employed by the medical center, who apply to join or to continue
as medical center staff for the purpose of rendering patient care. The
committee shall, to the best of its ability, determine the competence of the
applicant, the need for the services which the applicant would offer, and the
availability of related support services which may be required for quality
patient care. After consideration of these factors, the committee shall make a
recommendation to the board of trustees regarding the granting, suspension, or
revocation of privileges and the appropriate scope of privileges. The board of
trustees will act to grant, suspend, or rescind privileges, with consideration
of the committee's recommendations.
B. Special committees: The chair of the board of trustees, with the
concurrence of the board, shall create and make appointments of such standing
and special committees as may be considered necessary or desirable. Such
committees may be for, but are not limited to, the purposes of budget and
finance, long-range planning, building and equipment, preliminary credentials
review, etc. Appointments shall be made during a regular or special business
meeting of the board of trustees; such appointments become effective
immediately. Reappointment to a committee, including reappointment as chair, is
authorized if the individual is otherwise eligible. Each committee so created
shall consist of at least two trustees and may include persons who are not
trustees. The chair of any such committee shall be a member of the board of
trustees. Members of committees who are not members of the board of trustees
are accorded full voting participation in the committees of which they are
members. Minutes shall be kept of all committee meetings and reports of
committee activities and recommendations shall be sent to the board.
C. Committee meetings shall be held on the
call of the committee chair: Meetings
will be held at a time and place to conserve travel and time of the members.
Committees shall have the power of making recommendations to the board of
trustees.
[Recompiled
10/31/01]
7.7.4.13 MEDICAL STAFF:
A. Appointment: Ultimate responsibility for medical staff
appointments rests with the board of trustees. Medical staff membership shall
be limited, unless otherwise provided by law, to individuals who are currently
licensed to practice medicine, osteopathy, and dentistry. These individuals may
be appointed to the medical staff in accordance with the by-laws of the medical
staff, and pursuant to the following criteria:
(1) Appointment to the medical
staff is a privilege which shall be extended only to professionally competent
individuals who continuously meet the qualifications, standards, and
requirements set forth in these By-laws and in the policies adopted by the
board. All individuals practicing medicine and oral surgery in the medical
center, unless by specific provisions of these by-laws, must first have been
appointed to the medical staff.
(2) Only physicians and oral
surgeons who:
(a) are currently licensed to practice in this
state;
(b) are located close enough to provide timely
care for their patients;
(c) possess current, valid professional
liability insurance coverage in amounts specified in Subsection B [now Subsection
B or 7.7.4.13 NMAC] of this Article;
(d) are certified by the appropriate specialty
board, unless such requirement is waived by the board after considering the
special competence and experience of the applicant, and
(e) can document their background, experience,
training and demonstrated competence, their adherence to the ethics of their
profession, their good reputation and character and their ability to work
harmoniously with others sufficiently so that all patients treated by them
shall receive quality care and that the hospital and the medical staff will be
able to operate in an orderly manner, shall be qualified for appointment to the
medical staff. The word "character" is intended to include the
applicant's mental and emotional stability.
(3) No individual shall be
entitled to appointment to the medical staff or to the exercise of particular
clinical privileges in the Medical Center merely by virtue of the fact that:
(a) he or she is licensed to practice any
profession in this or any other state;
(b) he or she is a member of any particular
professional organization; or
(c)
he or she had in the past, or currently has, medical staff appointment
or privileges in another hospital.
(4) No individual shall be
denied appointment on the basis of age, sex, race, creed, color or national
origin.
B. Malpractice insurance: Good management of the assets of the hospital
and legitimate protection of the patients of the hospital require that all
appointees to the medical staff and all applicants for appointment have and
maintain malpractice insurance in adequate amounts to cover claims or suits
arising from alleged malpractice. Qualification under the Medical Malpractice
Act of New Mexico 41-5-1 et. seq., NMSA 1978, or coverage under the Tort Claims
Act of New Mexico, 41-4-1 et. seq., NMSA 1978, in cases of physicians who are
"public employees" is sufficient. In all other cases, the adequacy of
insurance protection required may depend upon the scope of staff privileges to
be exercised and other considerations. Accordingly, the minimum policy limits
in each instance shall not be less than those approved by the board after it
has considered a recommendation in this regard from the medical staff executive
committee. Compliance with this policy by medical staff appointees shall be
evidenced by filing with the chief executive officer of the medical center a
certificate of insurance from the carrier, showing at least the minimum amount
required as aforesaid. Any lapse in insurance coverage or cancellation of
insurance coverage will result in suspension of privileges until insurance is
obtained.
C. By-laws, rules and regulations: The medical staff will develop, adopt, and
periodically review medical staff by-laws, rules and regulations which are
consistent with medical center policy and legal or other requirements. Such
medical staff by-laws, rules and regulations shall become effective only upon
approval by the board of trustees and when so approved, shall become a part of
the board's by-laws. The medical staff by-laws, rules and regulations shall
include at least the following principles and procedures by which the medical
staff shall govern itself; formal means for medical staff participation in the
development of medical center policy relative to both management and patient
care; procedure for processing and evaluating applications for appointment or
reappointment to the medical staff and for the granting of clinical privileges;
a requirement that no qualified applicant shall be denied appointment and/or
clinical privileges on the bases of sex, race, creed, or national origin; a
requirement that all applicants must sign a statement to the effect that they
have read and agree to be bound by the medical staff by-laws, rules and
regulations and by the current medical center policies that apply to their
activities; mechanisms designed to assure the achievement and maintenance of
quality medical practice and patient care to include board policy, the quality
assurance program, and other quality measures; a grievance procedure, triggered
by adverse recommendations for appointment, reappointment, addition or
modification of clinical privileges, that entitles the affected party to
notice, hearing, and appellate review.
D. Delegated authority:
(1) The board delegates to the
medical staff the authority and responsibility to: provide appropriate medical
care; to evaluate the quality of medical care; to organize itself by adopting
by-laws, rules and regulations for review and approval by the board of
trustees; and, to accept and process applications for initial appointment and
reappointment to the medical staff and delineation of privileges.
(2) In the exercise of its
overall responsibility the board shall assign to the medical staff executive
committee reasonable authority
(a) to ensure appropriate professional care to
patients so that all patients with the same health problems shall receive the
same level of care;
(b) to ensure the ongoing review and appraisal
of the quality of professional care rendered, and to report results and
findings to the board; and
(c) to ensure that:
(i) only medical staff
appointees with admitting privileges admit patients;
(ii) each medical staff
appointee practices only within the scope of privileges granted by the board;
(iii) all individuals who
provide patient care services but who are not subject to the medical staff
delineation process, are competent to provide such services and that their
competency is monitored;
(iv) each patient's general
medical condition is the responsibility of a qualified medical staff appointee.
The committee shall also report to the board the mechanisms for monitoring and
evaluating the quality of patient care, for identifying and resolving problems,
and for identifying opportunities to improve patient care.
(3) The medical staff
executive committee shall make recommendations directly to the board
concerning:
(a) the structure of the medical staff;
(b) all matters relating to professional
competency including the conduct, evaluation, and revision of quality assurance
mechanisms;
(c) disciplinary actions and the mechanism for
fair hearing procedures;
(d) such specific matters as the board may
refer to it.
E. Board-medical staff liaison: The official method of communication and
liaison between
the board of trustees and the medical staff shall take place with the chief of
staff or his designee attending regular meetings of the board of trustees.
[Recompiled
10/31/01]
7.7.4.14 VOLUNTEER AUXILIARY: The board may authorize an auxiliary
comprised of community-minded volunteers who are interested in serving patients
and furthering the purpose of the medical center. Such auxiliary shall be
organized in responsible administrative units with elected officers and shall
adopt by-laws and/or rules and regulations for the governance of their conduct
and service within the medical center, subject to prior approval by the board
of trustees.
[Recompiled
10/31/01]
7.7.4.15 AMENDMENTS: The board acting through the
committee-of-the-whole shall review these by-laws on a continuing basis and at
least once per year prior to the annual meeting and may amend them by an
affirmative vote of a majority of the members of the board of trustees,
provided that all members shall possess a full statement of such proposed
amendments prior to the meeting where amendment of the by-laws is discussed or
effected.
[Recompiled
10/31/01]
7.7.4.16 Adopted and
approved this eighth day of December, 1990, by the board of trustees of Miners'
Colfax Medical center.
A. Charles B. Gonzales, Chairman
B. James Mayer, M.D., Vice Chairman
C. Filed with State Records Center on
[Recompiled
10/31/01]
HISTORY
OF 7.7.4 NMAC:
Pre
NMAC History: The material in this Part
was derived from that previously filed with the State Records Center:
MH-83-1,
Board Of Trustees Of Miners’ Hospital Bylaws, 12/29/83.
MCMC
87-1, Board Of Trustees Of Miners’ Colfax Medical Center Bylaws, 7/30/87.
MCMC
90-1, Board Of Trustees Of Miners’ Colfax Medical Center Bylaws, 3/12/91.
History
of Repealed Material: [RESERVED]