2.8. Ensure adherence to all legal, regulatory and ethical standards applicable to the
University Hospitals and the clinical enterprise and shall review the UK HealthCare
Compliance Plan at least annually.
2.9. Serve, through its general grant of power by the University Board of Trustees as the
governing body of the University Hospitals and to exercise all the powers of a governing
body as required by and in accordance with the Conditions of Participation in the
Medicare Program promulgated by the Centers for Medicare and Medicaid Services of
the United States Department of Health and Human Services (the "Conditions of
Participation"), standards established by The Joint Commission (“TJC Standards"),
licensure requirements and other applicable federal and state law and to oversee the
University clinical enterprise.
2.10. Review and approve the annual, biennial, and other planned operating and capital budgets
for the University Hospitals and clinical enterprise presented by the Executive Vice
President for Health Affairs and recommend same to the University Board of Trustees
and monitor the implementation of such budgets.
2.11. Exercise oversight for, participate in and approve all short-term and long-term planning,
including the strategic plan for the University Hospitals and clinical enterprise.
2.12. Approve the written scope of services of the University Hospitals.
2.13. Review and evaluate annually the performance of the University Hospitals in relation to
the mission, vision and goals.
2.14. Manage conflict that may arise among leadership groups of the University Hospitals and
the University clinical enterprise, including the Committee, senior management and the
organized medical staff through the Joint Conference Committee established as a
committee of the Medical Staff under the UK HealthCare Medical Staff Bylaws.
2.15. Provide oversight for all matters involving quality and safety of patient care including,
but not limited to, patient flow, standard of treatment and services, provision of essential
services in a timely manner, use of outside services, quality, sufficiency of staffing,
adequacy of space, equipment and other resources, policies and procedures for care
treatment and services, patient education, quality measurement, assessment and
improvement, and development of clinical practice guidelines. The chairperson of the
Committee may appoint one Trustee member to serve as a member of the UK HealthCare
Quality and Safety Committee of the UK HealthCare Medical Staff.
III. COMPOSITION
The Committee shall be composed of five voting Trustee Members, seven non-voting Advisory
Members and up to seven non-voting Community Advisory Members.
3.1. Trustee Members: The Trustee Members shall be members of the University Board of
Trustees and shall be appointed by the Chair of the University Board of Trustees, upon
the recommendation of the University President. Annually, the Trustee Members shall
elect one of Trustee Members as the Chair of the Committee.
3.2. Advisog Members: The ex officio Advisory Members shall consist of the individuals Fcrmattew Posmow Horizcnm 62
holding the following positions: Executive Vice President for Health Affairs, Dean, j pt, Relative ee: pegeyyemeel: .g_8
/1 pt, Relative to: Paragraph
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