2.13.1 Subject: HEALTH SCIENCES CENTER QUALITY OF CARE
Adopted: August 14, 1997
Amended: November 9, 1999
Amended: September 9, 2008

Applicability

This policy applies to the quality of patient care delivered by the University of New Mexico Health Sciences Center (“HSC”), and supplements Regents' Policy 2.13.

Policy

Pursuant to that certain Lease between the Regents and the Board of County Commissioners of Bernalillo County, as described in Regents' Policy 2.13, (the “Lease”), the Regents have delegated to the University of New Mexico Hospital Board of Trustees (“UNMH BOT”) the authority to review, monitor and act upon issues related to quality assurance for patient care delivered by the UNM Hospital, as identified in Regents' Policy 2.13, subject to review and ratification by the Regents to the extent required by applicable laws, regulations and accreditation standards.

Consistent with the constitutional and statutory responsibilities of the Regents, the right is reserved unto the Regents to consider and determine, if in the exercise of sound discretion it is deemed necessary, any matter relating to quality of patient care delivered at UNM Hospital. The Regents and the UNMH BOT shall exercise their authority in accordance with the Lease; applicable state and federal laws and regulations; Regents' Policies 2.13 and 2.13.2 and other applicable policies and determinations of the Regents; applicable policies of the HSC; the HSC Medical Staff Bylaws, Rules and Regulations; and the standards of The Joint Commission or successor, the Liaison Committee for Medical Education of the American Medical Association and the American Association of Medical Colleges for so long as resources are reasonably available to make compliance with such standards possible.  

The Regents, through the authority delegated to the UNMH BOT, shall require the Executive Vice President of Health Sciences (the "Vice President") and designated HSC officials to conduct activities that contribute to the preservation and improvement of quality and efficiency of patient care provided at UNM Hospital, including, but not limited to: 

a. Prudent use of HSC resources as evaluated through a continuous utilization review process;

b. Continuous monitoring to assure that all individuals who provide patient care services, including those who are not required to have Medical Staff privileges, are qualified to provide such care;

c. Retrospective review and evaluation of the quality of patient care through valid and reliable patient care evaluation procedures; and

d. Such other measures as may be deemed to be necessary for the preservation and improvement of the quality and efficiency of patient care.  

Implementation

The Regents, through the UNMH BOT, shall exercise oversight and overall management of quality of care evaluation and improvement at the UNM Hospital by receiving and evaluating information provided to the UNMH BOT and providing policy guidance to the Executive Vice President and other HSC officials with respect to implementation of recommended improvements or corrective action. The UNMH BOT will receive information regarding quality of care from the Executive Vice President or designee, obtained by the Executive Vice President or designee through various quality committees, task forces, and teams charged with responsibility for assessing various measures of quality of care at UNM Hospital. When considering quality of care evaluation and improvement information concerning the UNM Hospital, the Regents and the UNMH BOT, whether acting jointly or severally, shall be considered a “review organization within the meaning of the New Mexico Review Organizations Immunity Act, N.M. STAT, ANN. § 41-9-1 et seq. (1978).

References

Regents' Policies 2.13 and 2.13.2; Review Organizations Immunity Act, N.M. STAT.ANN § 41-9-1 et seq. (1978).

Comments should be sent to BRPM@UNM.edu

Go to:
Table of Contents
Table of Contents - Section 2
Regents' Policy Manual Homepage

The University of New Mexico
Albuquerque, New Mexico