JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS

GOVERNANCE STANDARDS

The governance of a hospital or health system sets the organization policy that supports quality patient care. It does this by developing the mission, vision, policies, and bylaws that govern the hospital’s operations.

GO.1	The hospital identifies how it is governed and the key individuals involved.

The hospital has a document that shows how it is governed. This document includes lines of authority relative to key planning, management, operations, and evaluation of responsibilities at each level of governance.

GO.2	Those responsible for governance establish policy, promote performance improvement, and provide for organizational management and planning.

The hospital’s governing body or health system board ultimately is responsible for the quality of care the hospital provides. To carry out this responsibility, the governing body provides for the effective functioning of activities related to:

• Delivering quality patient care
• Performance improvement
• Risk management
• Medical staff credentialing
• Financial management

GO.2.1

The hospital’s governing body or health system board adopts bylaws addressing its legal accountabilities and responsibility to the patient population served.

The governing body or health system board provides coordination and integration among the organization leaders to:

• Establish policy
• Maintain quality patient care
• Provide for necessary resources
• Provide for organizational management and planning

At a minimum, the governing bylaws specify the:

• Organization’s role and purpose
• Governing body’s or authority’s duties and responsibilities
• Process and criteria for selecting its members
• Governing body’s or authority’s organizational structure
• Relationship of responsibilities among those responsible for governing, and any authority superior to the governing body or authority (if such exists) the chief executive officer, the medical staff, and other appropriate leaders
• Requirement for establishing a medical staff
• Requirement for establishing auxiliary organizations, if applicable
• Definition of "conflict of interest"

GO.2.2

The hospital’s governing body or health system board provides for appropriate medical staff participation in governance.

GO.2.2.1

The medical staff has the right to representation (through attendance and voice), by one or more medical staff members selected by the medical staff, at governing body meetings.

GO.2.2.2

Medical staff members are eligible for full membership in the hospital’s governing body, unless legally prohibited.

The medical staff contributes to the quality of care by coordinating their work with that of other leaders and those responsible for governing the organization. Through its participation in governance, the medical staff helps ensure that all medical staff members responsible for assessing, caring for, or treating patients are clinically competent and that clinical care rendered is appropriate. This participation also allows them the opportunity to contribute to the organization’s planning, budgeting, safety management, and overall performance-improvement activities. The medical staff executive committee makes specific recommendations to the governing body for its approval. These recommendations relate to:

• The medical staff’s structure
• The process designed for reviewing credentials and delineating individual clinical privileges
• Recommending individuals for medical staff membership
• Recommending delineated clinical privileges for each eligible individual
• The organization of the medical staff’s performance-improvement activities as well as the process designed for conducting, evaluating and revising such activities
• The process by which medical staff membership may be terminated
• The process designed for fair-hearing procedures

GO.2.3

The hospital’s governing body or health system board establishes a criteria-based process for selecting a qualified and competent chief executive officer.

The chief executive officer has the knowledge and skills necessary to perform the duties required of the hospital’s senior leader. Among other criteria, education and relevant experience are important qualifications. The chief executive officer may be selected by the governing body. Or, the governing body may approve a chief executive officer selected by corporate management or another group.

GO.2.4

The hospital’s governing body or health system board provides for compliance with applicable law and regulation.

The intent of this standard is self-evident.

GO.2.5

The hospital’s governing body provides for the collaboration of leaders in developing, reviewing, and revising policies and procedures.

Because most policies and procedures address cross-functional, interdisciplinary, multidepartmental activities, they need to be developed collaboratively to be effective. The governing body or health system board and other leaders collaborate to develop, review, and revise key policies and procedures. Such policies and procedures are written and appear in bylaws, rules, regulations, protocols, or other documents. Those affected by policies and procedures are aware of their content.

Policies and procedures address key items regarding:

• Nursing care based on nursing standards of patient care and nursing practice standards (for example, critical care protocols, discharge planning)
• The medical staff’s responsibility for developing, adopting, and periodically reviewing its bylaws and rules and regulations consistent with organization policy and applicable law and other requirements

GO.2.6

The hospital’s governing body or health system board provides for conflict resolution.

The hospital has a system for resolving conflicts among leaders and the individuals under their leadership. Leaders regularly review the system’s effectiveness, revising it as necessary.

Reprinted with permission from the Comprehensive Accreditation Manual for Hospitals: The Official Handbook, Refreshed Core, Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrrace, Illinois, January 1999.

GOVERNANCE

The purpose of the governance section is to provide organizational guidance and oversight and to ensure resources and staff to support safe and adequate patient care.

The governing authority will:

• Adopt and periodically review bylaws which address legal accountabilities and responsibilities. Bylaws will provide for medical staff communication and conflict resolution with the governing authority
• Establish and review governing authority policies, promote performance improvement, and provide for organizational management and planning
• Establish a process for selecting and periodically evaluating a chief executive officer
• Establish and appoint a medical staff

Approve bylaws, rules ,and regulations as adopted by the medial staff before they become effective