2.13 Subject: HEALTH SCIENCES CENTER AND SERVICES
Adopted: December 12, 1996
Amended: June 9, 1998
Amended: August 11, 1998
Amended: November 9, 1999
Amended: September 12, 2000

Applicability

This policy applies to the academic and clinical programs, facilities and services operating under the University Health Sciences Center.

Policy

The Health Sciences Center (HSC), a component part of the University of New Mexico and subject to the governance of the Board of Regents, consists of the School of Medicine (including programs of Allied Health Sciences and Dental Programs), the College of Nursing, the College of Pharmacy; the Health Sciences Center Library; several research and public service programs related to health sciences; and HSC Clinical Facilities, including the University of New Mexico Hospital ("UNMH"), University of New Mexico Mental Health Center, Children's Psychiatric Hospital, Carrie Tingley Hospital, and University of New Mexico Cancer Research and Treatment Center. The HSC Clinical Facilities also include various outpatient clinics operated by the HSC components. The Veterans Regional Federal Medical Center is affiliated with the Health Sciences Center.

The HSC Clinical Facilities are accredited as a single organization by the Joint Commission on Accreditation of Healthcare Organizations, whose standards require a single governing body, a single medical staff, and approval of medical staff credentialing decisions and oversight of quality assurance matters by the governing body. The HSC Clinical Facilities are served by the unified HSC Medical Staff with unified Bylaws, Rules and Regulations, whose members are required to be employed by UNM or to have faculty appointments in the UNM School of Medicine.

The Regents Health Sciences Center Committee has been appointed for the purpose of review of matters related to the Health Sciences Center; provided, however, that if another Regents' committee or the HSC Clinical Operations Board is delegated primary responsibility for review of certain matters, then those matters may be presented to the Regents' Health Sciences Committee only for information. The primary focus of the Regents' Health Sciences Committee will be on HSC research and education and on matters not otherwise delegated to the HSC Clinical Operations Board (the "Board"), as described below.

Under a Lease Agreement between the Regents and the Board of County Commissioners, dated July 1, 1999, and approved by the New Mexico Board of Finance on August 12, 1999, the Regents are responsible for operation and maintenance of UNMH and the Mental Health Center. The Lease Agreement is effective on October 8, 1999, the effective date of the Agreement Regarding Consent to Lease Agreement entered into between the Regents and the Indian Health Service. The Lease Agreement provides that the University will have exclusive responsibility and authority to control and manage UNMH and the Mental Health Center in accordance with terms of the Lease Agreement. Consistent with the Regents' constitutional and statutory responsibilities, the Regents retain the right to consider, determine, and act upon any matter relating to the HSC Clinical Facilities. Consistent with provisions of the Lease Agreement and for purposes of compliance with federal and state laws and regulations and accreditation standards applicable to healthcare facilities, the Regents will be deemed to be the ultimate governing body of the HSC Clinical Facilities.

The Lease Agreement provides for appointment of a combined nine-member governing board, called the "HSC Clinical Operations Board" (hereinafter, the "Board"), for the non-research, non-educational clinical operations of the HSC Clinical Facilities, with such authority and powers as are delegated to the Board by Regents' policy and consistent with applicable federal and state laws and regulations and accreditation standards. The non-research, non-educational clinical operations of the HSC Clinical Facilities are essentially those operations related to the delivery of routine patient care, including medical and surgical care, diagnostic procedures, psychiatric and mental health care, substance abuse services, rehabilitation, cancer treatment, home health services, and hospice care, to HSC patients. The initial delegation of authority and powers of the Board is set forth in Exhibit A to this policy (corresponding to Exhibit F to the Lease Agreement). Neither the Regents nor the Board itself may change this delegation without prior notification to the County and consultation with the County if the County requests such consultation.

The Regents will have authority to appoint seven of the Board members, and the County Commissioners will have authority to appoint two of the Board members. At least one Regent-appointed member of the Board will be a Pueblo Indian, as required by the contract between the County and the federal government for provision of care to Native Americans. Voting Board members will not include County Commissioners or Regent members.

The University's Vice President for Health Sciences serves as the Chief Executive Officer of the HSC Clinical Facilities. The chief administrative and medical officers of the HSC Clinical Facilities are appointed, and may be removed by, the Vice President for Health Sciences or designee. The Associate Vice President for Clinical Operations/CEO, UNMH is responsible for administering and managing the business and administrative operations of, and the clinical operations in support of delivery of medical care by, the HSC Clinical Facilities. The Associate Vice President for Clinical Affairs/Dean, School of Medicine, is responsible for medical direction of the HSC Clinical Facilities, including, but not limited to, delivery of medical care by, and related activities of, the HSC Medical Staff. They are also charged with reporting to the Board regarding matters involving their respective authorities and responsibilities for the HSC Clinical Facilities. The Vice President shall have the authority to appoint such other directors or administrators as in his or her judgment are necessary to carry out the functions of the HSC Clinical Facilities.

The Vice President shall make regular reports to the HSC Committee regarding matters of importance to the HSC. Representatives of the Board, designated by the chairperson of the Board, shall make reports to the HSC Committee at least quarterly regarding matters of concern to the HSC Committee or the Board within their respective scopes of responsibility.

Implementation

The University President shall hire a Vice President for Health Sciences who shall provide leadership and have administrative responsibility for all activities, operations and programs of the Health Sciences Center, consistent with University policies, recognizing that teaching, research, service and patient care are the foundations of an academic health center.

References

Hospital Funding Act, § 4-48B-7, -12, NMSA 1978; statutes applicable to Regents' responsibility for operation of Carrie Tingley Hospital ( §§ 23-2-1 et seq. NMSA 1978) and Children's Psychiatric Hospital ( § 23-8-1 NMSA 1978); 1999 Lease Agreement between Regents and County Commissioners of Bernalillo County; and 1999 Agreement Regarding Consent to Lease Agreement between the Regents and the Indian Health Service, on behalf of the IHS and the All-Indian Pueblo Council. (Supersedes: 1996 Resolution Concerning Health Sciences Center; 1998 Supplemental Resolution Regarding the University of New Mexico Hospital Board of Trustees.) (Copies maintained by Office of Vice President for Health Sciences and University Counsel.)

 

EXHIBIT A

DELEGATION OF AUTHORITY AND POWERS BY REGENTS TO
HSC CLINICAL OPERATIONS BOARD

Delegation

The authority and powers listed below are delegated by the Regents to the Board, pursuant to Section V and Exhibit F of the Lease Agreement, beginning on the effective date of the Lease Agreement and continuing in effect unless revised as provided in Section V of the Lease Agreement. This delegation supersedes any conflicting or inconsistent provisions in Regents' policies existing on the effective date of the Lease Agreement or adopted thereafter, except for Regents' policies revising this delegation in accordance with the provisions of Section V of the Lease Agreement. Actions by the Board pursuant to this delegation are subject to approval or ratification by the Regents as required by applicable federal and state laws and regulations, accreditation standards, and provisions of the Lease Agreement. As provided in Section V of the Lease Agreement, consistent with the Regents' constitutional and statutory responsibilities, the Regents will retain the right to consider, determine, and act upon any matter relating to the HSC Clinical Facilities. However, the Regents will neither modify nor decline to ratify actions by the Board, within the scope of the authority and powers delegated by the Regents to the Board, except after consultation with one or more representatives of the Board designated by the Chairperson of the Board.

1. Oversight of the non-research, non-educational clinical operations of the HSC Clinical Facilities in a proper and responsible manner so as to enable the HSC Clinical Facilities to provide or arrange for provision of high quality healthcare services to HSC patients and to support the teaching and clinical research missions of the HSC.

2. Review and approval of the HSC Clinical Facilities' operating and capital budgets.

3. Review and approval of the HSC Clinical Facilities' operating plan and strategic plan.

4. Adoption and amendment of the labor-management relations policy for employees of the HSC Clinical Facilities who are assigned to the University of New Mexico Hospital personnel system.

5. Review and approval of collective bargaining agreements for the HSC Clinical Facilities.

6. Review and approval of policies of the HSC Clinical Facilities that require review and approval by the governing body under applicable laws, regulations or accreditation standards.

7. Review and approval of HSC Medical Staff Bylaws and HSC Medical Staff Rules and Regulations and amendments thereto.

8. Assurance that the HSC Medical Staff has reasonable policies regarding credentialing of physicians and ancillary providers who practice at the HSC Clinical Facilities.

9. Receipt of and action upon recommendations of the HSC Medical Staff related to appointment and reappointment of members of the HSC Medical Staff and the granting and revocation of privileges to physicians and ancillary providers who practice at the HSC Clinical Facilities or at other patient care facilities as assigned by the HSC.

10. Receipt of and action upon, as appropriate, periodic reports and recommendations of the HSC Medical Staff and administrators related to quality assurance for patient care delivered at the HSC Clinical Facilities.

11. Coordination with and oversight of any advisory/advocacy boards existing or created for HSC Clinical Facilities for other than research and education purposes, and establishment of reporting mechanisms between those advisory/advocacy boards and the Board.

12. Review and approval of the bylaws of those advisory/advocacy boards and submission of the bylaws of those advisory/advocacy boards to the Regents for review and approval in accordance with Regents' policy.

Communication

Representatives of the Board designated by the Chairperson of the Board will make periodic reports to the Regents at least semi-annually regarding matters of concern to the Board within its scope of responsibility. The Regents may designate a member of the Regents to attend meetings of the Board or committee meetings of the Board, for liaison purposes, but not as a voting or ex officio member of the Board.

Comments should be sent to BRPM@UNM.edu

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