Leadership – Governance

Service: Risk Management
Subject: Leadership
Type: Risk Profiles

Governance risks in healthcare organizations can hinder the effective and efficient functioning of an organization and impact its strategic objectives including delivering high quality care. This risk relates to lack of effective structure and processes supporting good governance such as: inability to attract and/or retain board and committee members with the appropriate skillset, ineffective accountability processes, insufficient reporting for board oversight or decision making, lack of strategy alignment, poor management of stakeholder/partner relationships and lack of succession planning. This document contains information entered by HIROC Subscriber healthcare organizations (acute and non-acute) in the Risk Register application to help you in your assessment of this risk.

Key Controls/Mitigations Strategies

Governance Structure

  • Robust governance framework which includes: 
    • bylaws, 
    • governance manual, 
    • accountability framework,
    • committee’s terms of reference, 
    • compliance reporting, 
    • policies, 
    • board processes guidelines, 
    • board evaluation plan
  • Dedicated board liaison to support the board and committees 
  • Board and committees work-plan with priorities identified including key functions and policy review 
  • Special purpose committees developed as needed to reduce board structure risks 
  • Policy on delegation of authority to CEO reviewed annually
  • Collaboration and governance model structures iteration and development
  • Regular review for ensuring robust communications between board and committees

Reporting, Monitoring and Compliance  

  • Integrated risk management program including regular monitoring and reporting to committees/board
  • Information to the board to assist in their oversight function such as:
    • safety and quality indicators, 
    • aggregate data on complaints, 
    • corporate scorecard
    • financial update, controls, forecasting, funding agreements
    • procurement scorecard
    • outcomes of internal and external reviews and audits
    • policy and regulatory compliance reports 
  • Input from patients and families, such as:
    • safety walk rounds
    • patient representative
    • focus groups
    • patient stories
  • Whistleblower channels

Strategic Plan

  • Dedicated board retreats to develop, review, revise and/or extend strategic plan
  • Refresh strategic plans with focus on quality and safety

Board Recruitment and Retention

  • Active nominating committee 
  • Active board recruitment to fill in gaps in skills and experience
  • Refresh of skills matrix and governor succession planning
  • Succession planning – standing agenda item 
  • Board satisfaction survey

Board Education and Training

  • Orientation to new board members which is refreshed regularly
  • Board development plan and capacity building
  • Regular reviews of governance best practices with the board
  • Education on risk management in healthcare and board oversight role

Monitoring/Indicators

Organization Related

  • Quarterly reports on progress of strategic plan
  • Annual financial and internal control audit results
  • Organization balanced scorecard 
  • Financial indicators 
  • Quality improvement plan indicators 
  • Executive dashboard results
  • Big dot measures 
  • Satisfaction survey results (employee and patient)

Board Performance

  • Annual board evaluations
  • Performance evaluations of CEO and board members
  • Regular self-evaluations
  • Peer to peer evaluations
  • Regular feedback process on board meetings to determine its effectiveness 
  • Board and committee work-plan, annually reviewed and monitored for compliance
  • Committee assigned for board evaluation 
  • Accreditation – governance and leadership standards
Date last reviewed:
This is a resource for quality assurance and risk management purposes only, and is not intended to provide or replace legal or medical advice or reflect standards of care and/or standards of practice of a regulatory body. The information contained in this resource was deemed accurate at the time of publication, however, practices may change without notice.