The Board of Directors is responsible for the overall governance of the affairs of the hospital. Each director is responsible to act honestly, in good faith and in the best interests of the hospital and in so doing, to support the hospital in fulfilling its purpose and discharging its accountabilities.
Strategic Planning and Purpose, Vision and Values
- The board participates in the formulation and adoption of the hospital’s purpose, vision and values
- The board ensures that the hospital develops and adopts a strategic plan that is consistent with the hospital’s purpose and values and that enables the hospital to realize its vision
- The board participates in the development of the strategic plan and approves it
- The board oversees the hospital’s operations for consistency with the strategic plan and strategic priorities
- The board receives regular briefings or progress reports on implementation of strategic priorities and initiatives
- The board ensures that its decisions are consistent with the strategic plan and the hospital’s purpose vision and values
- The board conducts an annual review of the strategic plan as part of a regular annual planning cycle
Quality and Performance Measurement and Monitoring
The board is responsible for establishing a process and a schedule for monitoring and assessing performance in areas of board responsibility including:
- Fulfillment of the strategic directions in a manner consistent with the purpose, vision and values
- Oversight of management performance
- Quality of patient care and hospital services
- Financial performance
- External relations
- Board’s own effectiveness
- The board ensures that management has identified appropriate measures of performance
- The board monitors hospital and board performance against board-approved performance standards
and indicators - The board ensures that management has plans in place to address variances from performance
standards indicators, and the board directs and oversees implementation of remediation plans
Financial Oversight
- The board is responsible for stewardship of financial resources including ensuring availability of, and overseeing allocation of, financial resources
- The board approves policies for financial planning and approves the annual operating and capital budget
- The board monitors financial performance against budget
- The board approves investment policies and monitors compliance
- The board ensures the accuracy of financial information through oversight of management and
approval of annual audited financial statements - The board ensures management has put measures in place to ensure the integrity of internal controls
Oversight of Management Including Selection, Supervision and Succession Planning
- The board recruits and supervises the CEO by:
- Developing and approving the CEO job description
- Undertaking a recruitment and selection process for the CEO
- Reviewing and approving the CEO’s annual performance goals
- Reviewing CEO performance and determining CEO compensation
- The board ensures succession planning is in place for the CEO and senior management
- The board exercises oversight of the CEO’s supervision of senior management as part of the CEO’s annual review
- Professional Staff (Credentialing/Chair/Chief Selection)
- The board makes the final appointment, reappointment and privilege delineation decisions
- The board ensures the effectiveness and fairness of the credentialing process
- The board develops, implements and maintains a process for the selection of department chiefs and other medical leadership positions as required
Risk Identification and Oversight
- The board is responsible to be knowledgeable about risks inherent in hospital operations and ensures that appropriate risk analysis is performed as part of board decision-making
- The board oversees management’s risk management program
- The board ensures that appropriate programs and processes are in place to protect against risk
- The board is responsible for identifying unusual risks to the hospital and for ensuring that there are plans in place to prevent and manage such risks
Stakeholder Communication and Accountability
- The board identifies hospital stakeholders and understands stakeholder accountability
- The board ensures the hospital appropriately communicates with stakeholders in a manner consistent with accountability to stakeholders
- The board contributes to the maintenance of strong stakeholder relationships
- The board advocates on behalf of the hospital in support of the purpose, vision and values and strategic priorities of the hospital
Governance
- The board is responsible for the quality of its own governance
- The board establishes governance structures to facilitate the performance of the board’s role and enhance individual director performance
- The board is responsible for the recruitment of a skilled, experienced and qualified board
- The board ensures ongoing board training and education
- The board periodically assesses and reviews its governance through evaluating board processes and structures including board recruitment, board composition and size, number of committees and their Terms of References, appointment of committee chairs, appointment of board officers and other governance processes and structures
Legal Compliance
The board ensures that appropriate processes are in place to ensure compliance with legal requirements