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Governing Board Orientation Manual

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CONTENTS

 

QUICK REFERENCE GUIDE

TRUSTEES AND GOVERNING BOARDS

 Health Care Trends
Washington Hospitals
The Governing Board
Trustee Selection and Recruitment
Functions of a Hospital/Health System Governing Board
Individual Trustee Responsibilities
The Fiduciary Role
Legal Protection for Trustees
      Responsible Governance
      Indemnification
      Directors’ and Officers’ Liability Insurance
      General and Other Liability Insurance
Mission
Bylaws
Organizational Chart
Board Organization and Operations
Trustee Orientation and Continuing Education
Checklist for Governing Board Excellence
Board Self-Evaluation
Example of Board Self-Evaluation
References

 

MY HOSPITAL

 

HOSPITAL MANAGEMENT AND ADMINISTRATION

 Hospital/Health System Organization
Selecting a CEO
Finding a CEO
The CEO Contract
CEO Job Description
Examples of Governing Board and Administrator Responsibilities
CEO Performance Evaluation
      The Evaluation Process
      CEO Evaluation in a Total Quality Management Environment
Termination
Summary
References

 

MEDICAL STAFF

 Medical Staff Organization
Functions of the Medical Staff
The Governing Board and the Medical Staff
Medical Staff Bylaws
Medical Staff Committee Structure
Appointment, Reappointment and Delineation of Clinical Privileges
      Initial Appointment to the Medical Staff
      National Practitioner Data Bank
      Reappointment
      Delineation of Privileges
Due Process
Recruitment and Retention
References

 

REGULATORY ENTITIES

 Joint Commission on Accreditation of Healthcare Organizations
Washington Hospital Licensing Standards
Medicare Conditions of Participation
Summary of Primary Hospital Regulatory and Accrediting Entities
Other State and Federal Regulations
Local Regulations
Summary
References

 

FINANCES

 Introduction
Budget
      The Board’s Responsibility
      Budget Preparation
Annual Audit
Financial Reports
      Balance Sheet
      Income Statement
Ratio Analysis
      Liquidity
      Accounts Receivable Position
      Capital Structure
Financial Monitoring and Assessment Process
Financial Planning
Investment Policy
Public Hospital Districts
      Tax Revenues
      Financing Methods
Payment
      Medicare
      Balanced Budget Act
      Medicaid
      Medicaid Managed Care
      Medicaid Disproportionate-Share Hospital Program
      Cost Report
Compliance
Managed Care
      Negotiating Rates
Summary
References

 

QUALITY

 Board Responsibilities
     Board Self-Assessment
Quality Improvement
     The Joint Commission on Accreditation of Healthcare Organizations
     Washington State Licensing Standards
     Medicare Conditions of Participation
Quality Indicators
Performance Improvement Processes
JCAHO’s ORYX Initiative
Washington Health Foundation Quality Activities
Performance Improvement Activities
     Hospital-Wide Activities
     Medical Staff Activities
     Patient-Focused Functions Department Review
     Compliance with External Accreditation and Regulatory Agencies
Summary
References

 

STRATEGIC PLANNING

 Importance of Strategic Planning
Roles and Responsibilities
      Governing Board
      Strategic Planning Committee
      Chief Executive Officer
      Medical Staff
      Department Heads
      Patients and Community
      Planner
      Consultants
The Steps of Strategic Planning
      Get Organized
      Perform an Environmental Assessment
            The Internal Assessment
            The External Assessment
      Develop a Vision
      Review the Mission Statement
      Develop Strategies
            Goal Approach
            Critical Issues Approach
            Scenario Approach
      Prepare the Strategic Plan
      Approve the Plan
      Implement the Plan
      Monitor and Evaluate the Plan
Summary
References

 

INTEGRATED DELIVERY SYSTEMS

 Integrated Delivery System Definition
Objectives of Integrated Delivery Systems
Essential Characteristics of Integrated Delivery Systems
Strengths of Integrated Delivery Systems
      Access to Capital
      Lower Costs
      Personnel Recruitment and Retention
Making the First Decisions
Role of the Governing Board
Organizational Models
      The Physician-Hospital Organization
      The Management Service Organization
      The Group Practice Without Walls
      The Integrated Provider
      The Health Maintenance Organization
Forming an Integrated Delivery System
      Partnerships
      Range of Partners
Essential Elements in Planning Integration
      Screening Criteria
Governance
Legal Issues
      Corporate Laws
      Tax Issues
      The Internal Revenue Code
      Insurance Regulations
      Antitrust Issues
      Fraud and Abuse Prohibitions
      Licensure and Accreditation
      Malpractice Liability
      Hospital Districts
Summary
References

 

APPENDICES

SECTION I
Washington State Hospitals
Standards
      Joint Commission on Accreditation of Healthcare Organizations
      Washington State Licensing Standards
Glossary
Acronyms
Tips for Becoming a Better Board Member
Resources

SECTION II
Public Hospital Distict Commissioner Guide



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