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Governance refers to the structure by which the multiple operating units of the hospital or healthcare system are responsive to their stakeholders (or shareholders in for-profit systems). The stakeholders are those who ultimately have the responsibility for clinical quality, patient satisfaction, fiscal viability, patient safety, and strategic direction of the organization. Although hospital administration and management are responsible for the day-to-day operations and implementation of the strategic direction of the institution, the hospital governance structure is the entity to which the administrative leadership team reports. Although the specific structure and taxonomy of boards vary, all healthcare organizations have a well-defined process by which all operations of the institution and its medical staff report their collective findings and recommendations to their parent board.

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These well-defined processes include medical staff credentialing; quality improvement and patient safety activities; patient satisfaction; mission, vision, and strategy statements; and financial management. A careful reading of any set of medical staff bylaws, rules and regulations, and administrative policies makes it clear that the ultimate source for governance for modern healthcare institutions is the healthcare system's board of directors, trustees, or governors.1 Hospitals vary widely in actual governance structures, depending upon their status as not-for-profit versus for profit and private versus public institutions. However, all healthcare institutions share a common requirement to be responsive to their stakeholders through a formal process.

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For emergency physicians, the relationships to the hospital board usually are several of the 6 core strategic relationships listed in Box 5-1.

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Box 5-1 Strategic Board Relationships for Emergency Physicians
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Nash and colleagues noted, “Hospitals and healthcare systems continue to experience unprecedented demand for good governance—a demand that extends far beyond traditional notions of financial oversight.”2

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Patient safety and quality of care are chief among those emerging demands, both of which require substantial board oversight. Jha and Epstein found that boards that were engaged in quality and safety oversight had demonstrably better outcomes.3

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An understanding of the governance function of the board is a core foundation on which the successful long-term practice of emergency medicine should be built. This chapter discusses the composition, purpose, and goals and objectives of typical healthcare boards; the changing nature of boards; the role of physician leaders in interacting with the governance structure; and the specific nature of the interrelation of emergency physicians with the board.

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To begin to understand governance structures, it is necessary to ask the “Why,” “How,” “What,” and “Who” of such organizations. As Nietzsche notes, “He who has a strong enough ‘Why' can bear almost any ‘How.’”4

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The “Why” of Hospital Governance

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The “Why” of governance can be answered from ...

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