The Office of Certificate of Need and Healthcare Facility Licensure in the Health Facilities Evaluation and Licensing Division of the Senior Services and Health Systems Branch of the Department of Health and Senior Services proposes to amend and adopt new administrative rules at N.J.A.C. 8:43G-5, which establishes hospital administration and hospital-wide policies.

     The amendments and new rules are intended to implement the requirements of N.J.S.A. 26:2H-12.34.  This law requires any person appointed to serve as a member of a general hospital board of trustees to complete a training program approved by the Commissioner of Health and Senior Services  that is designed to clarify the roles and duties of a hospital trustee, and that is at least one day in length.

The amendments proposed to N.J.A.C. 8:43G-5.1 would require that hospitals file with their applications for licensure or license renewal the names of the members of the hospital’s governing body.  Although most hospitals maintain a board of trustees, use of the term governing body in N.J.A.C 8:43G recognizes that some hospitals may maintain a different type of governing body or a differently named governing body.  The proposed amendments to this section would also require hospitals to file with their license or license renewal applications the term of office and the start and end date of the term of office for each of their governing body members.

Proposed new N.J.A.C. 8:43G-5.22 (a) would require general hospitals to ensure that the members of their governing bodies complete a training program, conducted by an approved training provider within six months of the member’s appointment or reappointment.  Proposed new N.J.A.C. 8:43G-5.22 (b) would require that the training program provide at least seven hours of instruction and address the following subjects: the ethical and fiduciary responsibilities of a member of a hospital governing body; the role of the governing body in improving health care quality and the mechanisms available for doing so; hospital financial management and understanding the financial statements of healthcare institutions and reimbursement and finance payment systems; hospital organization and governance; and legal and regulatory compliance issues.

       The notice of proposal appears in the June 16, 2008 issue of the New Jersey Register.

       The public has until August 15, 2008 to comment on the proposals.  Persons wishing to comment on the proposals must submit their comments in writing to Ruth Charbonneau, Director, Office of Legal and Regulatory Affairs, New Jersey Department of Health and Senior Services, PO Box 360, Trenton, NJ 08625.  Written comments on the proposals must be postmarked on or before August 15, 2008, which is the close of the 60-day public comment period for the proposals.