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UNM Policy Office

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Regents' Policy Manual - Section 3.6: UNM Hospital Board of Trustees

Adopted Date: 12-14-2010
Amended: 03-14-2016
Amended: 12-09-2020

(replaces portions of RPM 2.13)

Applicability

This policy applies to the oversight and governance of the clinical, operational and financial affairs of the UNM Hospital.

Policy

Under that certain Lease Agreement for Operation and Lease of County Healthcare Facilities between the Regents and the Board of County Commissioners of the County of Bernalillo (the “County” or the “County Commissioners”), dated as of July 1, 1999, and approved by the New Mexico Board of Finance on August 12, 1999, as amended by that certain First Amendment to Lease Agreement for Operation and Lease of County Healthcare Facilities dated as of November 18, 2004 (as amended, the “Lease”), the Regents are responsible for operation and maintenance of UNMH and the Mental Health Center. The Lease is effective as of October 8, 1999, the effective date of the Agreement Regarding Consent to Lease Agreement entered into between the Regents and the Indian Health Service which was amended by that certain First Amended Agreement Regarding Consent to Lease Agreement dated as of November 18, 2004 (as amended, the “Consent”).  The Lease provides for appointment of a combined nine‑member governing board, which shall be known as the “UNM Hospital’s Board of Trustees” (hereinafter, the “UNMH BOT”) for the non-research, non-educational operations of the UNM Hospital, with such authority and powers as are delegated to the UNMH BOT by Regents’ policy and consistent with applicable federal and state laws and regulations and accreditation standards.  The current delegation of authority and powers by the Regents to the UNMH BOT is set forth in Exhibit A to this policy (corresponding to Exhibit F to the Lease).

The Regents will have authority to appoint seven of the UNMH BOT members, and the County Commissioners will have authority to appoint two of the UNMH BOT members.  At least one Regent‑appointed member of the UNMH BOT 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 either County Commissioners or Regent members.

Relationship to the Board of Regents and to the UNM Health Sciences Center Committee

The Regents may, but are not obligated to, by and through the HSC Committee, designate a member of the Regents to attend meetings of the UNMH BOT and/or committee meetings of delegated committees of the UNMH BOT, for liaison purposes, but not as a voting member of the UNMH BOT.

Representatives of the UNMH BOT, as designated by the Chairperson of the UNMH BOT, will make periodic reports to the HSC Committee, at least semi-annually, on matters within the UNMH BOT’s delegated responsibility and will report for ratification, all matters required to be ratified and approved by the governing body under applicable laws, regulations, or accreditation standards and Regents’ policies.

Actions by the UNMH BOT pursuant to this delegation are subject to approval or ratification by the HSC Committee and the Board of Regents as required by applicable federal and state laws and regulations, accreditation standards, and provisions of the Lease.  As provided in Section V of the Lease, 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 UNM Hospital in a manner consistent with this Policy.  However, neither the HSC Committee nor the Regents will modify nor decline to ratify actions by the UNMH BOT, within the scope of the authority and powers delegated by the Regents to the UNMH BOT, except after consultation, with one or more representatives of the UNMH BOT designated by the Chairperson of the UNMH BOT. 

References

Hospital Funding Act, N.M.STAT.ANN. §§4-48B-7 and -12 (1978); statutes applicable to Regents’ responsibility for the operation of Carrie Tingley Hospital, N.M.STAT.ANN. §§ 23‑2‑1 et seq (1978), and the Children’s Psychiatric Hospital N.M.STAT.ANN. § 23‑8‑1 (1978); 1999 Lease Agreement between Regents and County Commissioners of Bernalillo County as amended by the 2004 First Amendment to Lease Agreement; and the 1999 Agreement Regarding Consent to Lease Agreement between the Regents and the Indian Health Service, and the All‑Indian Pueblo Council as amended by the 2004 First Amendment to the 1999 Agreement Regarding Consent to Lease Agreement. (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 the Executive Vice President for Health Sciences and Chief Executive Officer of the UNM Health System, and the Office of University Counsel.);  RPM 3.4 “Health Sciences Center and Services” RPM 3.5 “Health Sciences Center Committee.”

EXHIBIT A

AMENDED AND RESTATED
DELEGATION OF AUTHORITY AND POWERS BY REGENTS TO
THE UNIVERSITY OF NEW MEXICO HOSPITAL BOARD OF TRUSTEES

Delegation

The authority and powers listed below are delegated by the Regents of the University of New Mexico (the “Regents”) to the University of New Mexico Hospital Board of Trustees, (the “UNMH BOT”), pursuant to Section V of that certain Lease Agreement for Operation and Lease of County Healthcare Facilities dated as of July 1, 1999, as amended by that certain First Amendment  to Lease Agreement for Operation and Lease of County Healthcare Facilities dated as of  November 18, 2004 (as amended, the “Lease”), effective as of January 1, 2011 (the “Delegation Effective Date”).  This delegation shall continue in effect unless revised as provided in Section V of the Lease.  This delegation amends, restates, and supersedes any and all previous delegations and/or conflicting or inconsistent provisions in Regents' policies existing on the Delegation Effective Date, except for Regents’ policies revising this delegation in accordance with the provisions of Section V of the Lease.[1]  As provided in Section V of the Lease, 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 UNM Hospital and, subject thereto, the Regents hereby delegate the following authority and responsibility to the UNMH BOT it being the intention of the Regents to designate, for licensure, accreditation, and governance purposes, the UNMH BOT as the “governing body” for the UNM Hospital:

  1. Oversight and management of the non-research, non-educational operations of the UNM Hospital in a proper and responsible manner so as to enable the UNM Hospital to provide or arrange for provision of high quality healthcare services to patients of the UNM Hospital and to support the teaching and clinical research missions of the HSC; provided, however, that nothing contained in this delegation shall be construed to be a delegation of authority to the UNMH BOT of any matter covered and addressed by the University of New Mexico Labor Management Relations Resolution adopted by the Regents on May 9, 2006 (the “Labor Resolution”).

  2. Review and recommend for approval to the UNM Health Sciences Center Committee (“HSC Committee”) in accordance with applicable Regent or University policy, the UNM Hospital’s operating and capital budgets.

  3. Review and approve, or in appropriate circumstances recommend for approval in accordance with applicable Regent or University policy, the following:

    1. the procurement by the UNM Hospital of equipment (whether by purchase, lease, or other forms of acquisition[s]);

    2. execution by the UNM Hospital of contracts for services with third parties; or

    3. lease by the UNM Hospital of real estate.

    In this connection, the HSC Committee shall establish by resolution, the level of approval authority for the UNMH BOT with respect to Vendor Contracts, leases of real property, Trade Transactions, Third Party Payor Contracts and/or Strategic Transactions within the parameters of what are Approvable Transactions as set forth in RPM 3.4. 

  4. Review and approval, in coordination with the HSC Committee, of the UNM Hospital’s operating plan and strategic plan. 

  5. Review and approval of policies of the UNM Hospital that require review and approval by the governing body under applicable laws, regulations or accreditation standards; subject to ratification by the HSC Committee and the Board of Regents, other than policies that are covered by the Labor Resolution.

  6. Review and approval, in accordance with applicable Regent or University policy and/or applicable accreditation standards, the Medical Staff Bylaws and the HSC Medical Staff Rules and Regulations and amendments thereto.

  7. Assurance that the Medical Staff has reasonable policies and procedures in place regarding credentialing of physicians and ancillary providers who practice at the UNM Hospital.

  8. Receipt of and action upon recommendations of the Medical Staff related to appointment and reappointment of members of the Medical Staff and the granting of privileges to physicians and ancillary providers who practice at the UNM Hospital or at other patient care facilities as assigned by the HSC. In this connection, all action by the UNMH BOT related to the appointment and reappointment of members of the Medical Staff shall be fully effective at the time of such action, even if the affected medical staff member may have the ability to appeal the same to the Regents under Regents’ Policy 1.5.  With respect to “Professional Review Actions” as defined in the Medical Staff Bylaws and related manuals and in applicable federal and state laws, rules, regulations, and accreditation standards, the affected member or members of the Medical Staff shall have such appellate rights as are specified in the Medical Staff Bylaws and related manuals.

  9. Receipt of and action upon, as appropriate, periodic reports and recommendations of the Medical Staff and administrators of the UNM Hospital related to quality assurance for patient care delivered at the UNM Hospital.

  10. Coordination with and oversight of any advisory/advocacy boards existing or created for UNM Hospital for other than research and education purposes, and establishment of reporting mechanisms between those advisory/advocacy boards and the UNMH BOT.

  11. Review and recommendation as to the bylaws of advisory/advocacy boards of UNM Hospital and submission of the bylaws of those advisory/advocacy boards to the Regents for review and approval in accordance with applicable Regents’ policy.

  12. Subject to RPM 7.8 (with respect to financial settlements) oversight of claims and/or lawsuits involving the UNM Hospital and, in coordination with the HSC Committee, the development of a loss control program with respect thereto.

  13. Oversight of, and action upon, issues involving compliance by the UNM Hospital and the employees thereof with applicable federal and state health care regulatory requirements including, without limitation, billing issues, anti-kickback statute issues, Stark law issues, and other regulatory requirements and with the HSC Institutional Compliance Program as contemplated in RPM 3.7.

  14. Oversight of, and action upon, issues involving compliance by the UNM Hospital and the employees thereof with applicable federal and state health care regulatory requirements including, without limitation, compliance with HIPAA, HITECH and the regulations and with the University’s HIPAA compliance program as contemplated in RPM 3.7.

[1] Capitalized terms not otherwise defined in this Exhibit A shall have the meanings ascribed to such terms in Regents’ Policy 3.4.