2.13.2 Subject: HEALTH SCIENCES CENTER MEDICAL STAFF
Adopted: August 14, 1997
Amended: November 9, 1999

Applicability

This policy applies to the unified Medical Staff of the University Health Sciences Center (HSC), and supplements Regents' Policy 2.13.

Policy

Pursuant to a Lease Agreement between the Regents and the County Commissioners of Bernalillo County, as described in Regents' Policy 2.13, the Regents have delegated to the Health Sciences Center (HSC) Clinical Operations Board (the "Board") the authority to act upon issues related to the unified HSC Medical Staff, subject to review and ratification by the full Board of Regents to the extent required by applicable laws, regulations and accreditation standards.

The Regents hereby authorize the organization of the HSC Medical Staff to provide clinical services within the scope of their practice, as authorized by appropriate licensure boards of the State of New Mexico, and as authorized by the HSC, and to discharge those duties and responsibilities delegated to the HSC Medical Staff by the Regents.

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 the HSC Medical Staff. The Regents and the Board shall exercise their authority in accordance with the Lease Agreement; applicable state and federal laws and regulations; Regents' Policy 2.13 and 2.13.1 and other applicable policies and determinations of the Regents; and the standards of the Joint Commission on Accreditation of Healthcare Organizations 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 upon recommendation of the Board pursuant to recommendations of the HSC Medical Staff Executive Committee, consistent with qualifications for membership and privileges in accordance with HSC Medical Staff Bylaws, Rules and Regulations and procedures will appoint, reappoint and terminate appointment of members of the HSC Medical Staff. HSC Medical Staff members, as defined by the HSC Medical Staff bylaws, shall have appointments in the University's School of Medicine or other appropriate HSC academic unit. Medical Staff members whose duties are both administrative and clinical shall be subject to the same credentialing and privileging process as for other HSC Medical Staff members.

Only members of the active HSC Medical Staff with admitting privileges may admit patients to inpatient units of HSC Clinical Facilities. A physician member of the active HSC Medical Staff shall be on duty or on call at all inpatient HSC Clinical Facilities at all times.

The HSC Medical Staff shall be organized into a responsible administrative unit that is accountable to the Regents, through the Board. The HSC Medical Staff shall propose Bylaws and Rules and Regulations setting forth:

a. Its organization, including the appointment of committees and the selection of officers and chiefs of clinical services,

b. Quality of care protocols,

c. Procedures and qualifications for appointment to the HSC Medical Staff,

d. Procedures and qualifications for the granting of privileges to practice at HSC Clinical Facilities, and

e. Provisions for review and approval by the Regents, upon recommendation of the Board, of the HSC Medical Staff's recommendations with respect to appointment, reappointment or termination of appointment to the HSC Medical Staff and the granting or curtailment of HSC Medical Staff privileges.

The HSC Medical Staff Bylaws shall include the provision that the departmental organization of the HSC Medical Staff shall correspond to the departmental, and, if applicable, the divisional organization of the University's School of Medicine; that the department chairpersons or chiefs of divisions within the School of Medicine shall be the chairpersons of the corresponding department of the HSC Medical Staff; and that the Rules and Regulations of the HSC Medical Staff shall be organized within this framework. The HSC Medical Staff Bylaws and Rules and Regulations shall become effective when approved by the Regents, upon recommendation of the Board. The HSC Medical Staff Bylaws, and Rules and Regulations may not be amended unilaterally by the Regents, Board or the HSC Medical Staff.

Implementation

The Vice President for Health Sciences will designate a senior HSC official who is a physician member of the HSC Medical Staff (the Associate Vice President for Clinical Affairs/Dean, School of Medicine) with responsibility for medical direction of all the HSC Clinical Facilities, including, but not limited to, delivery of medical care by, and related activities of the HSC Medical Staff, as provided in Regents' Policy 2.13. This individual and the elected Chief of Staff of the HSC Medical Staff, or their designees, will attend meetings of the Board (and, when appropriate, meetings of the Regents' Health Sciences Center Committee and the full Board of Regents) to provide HSC Medical Staff perspective on issues addressed by the Board, and to serve as liaison between the Board and the HSC Medical Staff. If issues arise that require resolution by a joint conference committee of the Board and the HSC Medical Staff, then members of the Board shall meet with designated members of the HSC Medical Staff to resolve those issues, as provided in the HSC Medical Staff Bylaws.

References

Regents' Policies 2.13 and 2.13.1; 1996 Resolution Concerning Health Sciences Center. (Copies maintained by Office of Vice President for Health Sciences and University Counsel.)

Comments should be sent to BRPM@UNM.edu

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