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Executing Effective Governance for Quality and Patient Safety


Understanding the Role of the Board in Quality and Safety

  • Sample Quality/Professional Affairs Committee Charter
  •  Accreditation Canada’s standards for Sustainable Governance help organizations and governing bodies meet the growing demand for excellence in governance practices in Canadian healthcare organizations. They are a response to system-wide changes in structures for healthcare delivery, and the increasing need for public accountability. They are built on five key functions of governance:
    • Developing the mission, vision and values
    • Collecting and using knowledge and information
    • Developing the organization
    • Building relationships with stakeholders
    • Demonstrating accountability
  •  Sample oversight questions that governing boards are encouraged to ask relating to their organizations’ performance in the area of quality improvement and patient safety: (Source: Health Association Nova Scotia, Risk Oversight Module 4)
      • How do we define quality?
      • How do our patients and their families define quality?
      • How does the medical staff define quality? What about nursing and other allied health professionals?
      • What should our specific aims be for improving quality and reducing harm over the coming year?
      • Who should be part of the process to set those aims?
      • How are physicians, nurses and other clinical leader involved in quality improvement projects?
      • How are patients and families involved in quality improvement efforts?
      • How are the CEO/Administrator and Chief Medical Officer personally involved in supporting quality and patient safety?
      • How can we improve the board’s capacity to provide effective quality and patient safety oversight?
      • How do we communicate in a transparent and evidence-based way to our patient safety record and our commitment to improve?
      • Are all of our policies and medical by-laws (human resources and others) aligned with our commitment to quality improvement and patient safety?
      • Are sufficient resources allocated to quality and patient safety initiatives?
      • How do we monitor our progress towards our quality and patient safety goals?
      • Do we survey our patients/residents to determine their satisfaction levels?
      • Do we survey our employees and medical staff to determine their satisfaction levels?
      • What are some national or international quality or patient safety initiatives in the health sector? How is our health organization connected to those initiatives?

Board Self Evaluation

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