Public Health Service Governance: Principles and Framework

Abstract

This chapter sets out a proposed public health service’s governance framework and describes the systems in place to ensure that the health service Board, Executive and all staff of the organisation are accountable for the clinical, corporate, financial and operational aspects of the organisation.

About This Chapter

This chapter sets out a proposed public health service’s governance framework and describes the systems in place to ensure that the health service Board, Executive and all staff of the organisation are accountable for the clinical, corporate, financial and operational aspects of the organisation.

Good Governance Provides the Foundation for High Performance

Good governance strengthens community confidence in public entities and helps ensure their reputations are maintained and enhanced. It should enable public entities to perform efficiently and effectively and to respond strategically to changing demands.

Governance encompasses the processes by which public entities are directed, controlled and held to account. It includes the processes whereby decisions important to the future of a public entity are taken, communicated, monitored and assessed.

Governance in the public sector is built on:

• constitutional, legal and government frameworks;

• government decision making and reporting;

• authorisations and delegations in decision-making;

• accountability, transparency, integrity, stewardship, efficiency and leadership;

• values and codes of conduct;

• effective risk management;

• the integrity bodies—protecting public entities against crime and misconduct.

A board with decision-making powers is formed to govern a public entity. Governance gives practical meaning to public sector accountability obligations. For such public entities, governance defines the relationships between the board, senior management, the minister, portfolio department, stakeholders and integrity bodies.

Victorian Public Sector Commissioner ¹

Case Study

The public health service in question is one of the largest public health services in Australia, which provided healthcare to one quarter of this state’s population, across the entire life-span from new-born and children, to adults, the elderly, their families and carers. The health service has more than 17,000 staff work at over 40 care locations, including six hospital campuses, and an extensive network of rehabilitation, aged care, community health and mental health facilities.

Each year, the health service provided more than 3.6 million episodes of care to its community, with more than 260,000 people admitted to its hospitals, more than 220,000 receiving care at its emergency departments, performing more than 48,000 surgical procedures, and delivering more than 10,000 babies.

The health service for many years did not have a consolidated governance framework that was clearly articulated in a single document located centrally that was easily accessible to its staff, patients and the community. As a result, there was confusion as to the role of the health service Board, its Executive team, the senior managers and the frontline staff. This led to a confused delegation of authority leading to unclear lines of accountability, a lack of discipline around financial management, poor procurement practices, uncoordinated and unrestricted staff appointments, and disjointed reporting lines, which resulted in an adverse budget outcome due to uncontrolled costs, uncapped staff increases and lack of contract management, as well as low staff morale from reactive actions taken by middle managers to attempt to compensate for the poor governance.

A review occurred with the appointment of new executives, including a new Chief Legal Officer, which led to a systematic review and the development of a new governance framework from the ground-up, which included clear delineation of roles and responsibilities of all levels of management and staff, that are evidence-based, compliant with legislation and accessible to all employees.

The result of this is an almost immediate improvement in staff morale and culture as there were now clearly lines of accountability and reporting, with a concomitant improvement in financial outcomes, procurement practices and overall better clinical, operational and budget performance. The case study shows the importance of starting with the foundation of the principles of good, robust governance, and how that forms the basis of effective health service provision that leads to great patient care and an excellent staff and patient experience.

This chapter provides a template for other public health services who may wish to embark on a similar journey of developing their own governance framework and includes a check-list that may be helpful as part of that process.

Health Service Clinical Governance

Clinical Governance is a systematic and integrated approach to assurance and review of clinical responsibility and accountability that improves quality and safety and patient outcomes.² Clinical Governance is linked to corporate governance, strategic risk and service planning, informatics, performance and business management. The Health Service Clinical Governance Framework is the system by which the Board, Executive, clinicians and staff share responsibility and accountability for the safety and quality of care. Clinicians and clinical teams are responsible and accountable for the quality of care provided. The Board and Executive are responsible and accountable for ensuring the systems, structures and processes are in place to support clinicians in providing safe, high quality care and for clinician engagement in improvement and risk management activities.

Compliance of clinical governance is measured through accreditation mechanisms and through the health service Quality Committee which provides leadership and advice to the Board through the continuous assessment and evaluation of the safety and quality of clinical services provided by health service.

Corporate and Financial Governance

The Board needs to meet a range of requirements under the relevant financial legislation; including keeping proper financial accounts , risk management, audit arrangements, financial reporting, annual reporting to Parliament and responding to Ministerial requests for information.

To comply with the obligations in the relevant financial legislation, the public health service must ensure that, inter alia:

• The CEO has designated a suitably qualified employee as the CFO.

• The CEO and CFO have systems in place to keep proper accounts and financial records generally, a system for promptly preparing and auditing the annual financial statements, an assets register, and a system for the timely preparation of its annual report.

• The CEO and CFO have effective systems in place to receive, record, implement and monitor directions issued by the relevant Minister.

• An audit committee is in place.

• The audit committee has approved an internal audit charter.

• The risk management program includes a financial risk management program.

• The finance delegations meet the requirements of legislation.

• The CEO and CFO have systems in place to receive and respond promptly to requests for financial and other information from the relevant Minister.

Risk Management and Compliance

The health service Board must ensure that the health service also complies with mandatory risk management requirements set out in the relevant mandatory risk management regimes.

This includes (inter alia) ensuring that health service:

• (a) has an Enterprise Risk Management Framework developed in accordance with ISO 31000:2009 Risk management—Principles and guidelines ³; and

• (b) arranges all its insurance with the relevant medical indemnity insurance authority.

Other Legal Obligations

The Board ensures that the health service complies with all relevant legislation , including:

• Legislation relating to financial management and reporting obligations.

• Legislation relating to the administration of employee and patient information.

• Legislation relating to accountability and transparency requirements.

• Legislation relating to the safety and rights of mental health patients, such as the complaints.

• Legislation to improve the safety and protect the rights of employees.

The Board receives reporting on legislative compliance on an annual basis via the Audit Committee.

Health Service Board

The role and duties of the health service Board include strategy, governance and risk management.

The health service Board sets the strategic direction of the health service and monitors that health service is meeting its objectives and performance targets outlined in its Strategic Plan.

The health service Board has established this governance framework and monitors compliance with the framework. This framework covers the clinical work of the organisation, as well as the corporate and financial aspects of its operation.

The Board also ensures that risk management is integrated into health service’s systems and reviews the effectiveness of operational risk management, compliance and reporting systems.

Board Functions

The Board must perform its functions and exercise its powers subject to any lawful direction given by the Minister and in accordance with the provisions of the relevant legislation. Additionally, the Board is responsible for the oversight of the implementation of government policy and guidelines issued from time to time from the Department of Health and other government agencies.

In brief, the role of the Board is to provide strategic direction for health service and effective oversight of management.

The functions of the Board are to:

• develop statements of priorities and strategic plans for the operation of health service and to monitor compliance with those statements and plans;

• develop financial and business plans, strategies and budgets to ensure the accountable and efficient provision of health services by the public health service and the long term financial viability of the public health service;

• establish and maintain effective systems to ensure that the health services provided meet the needs of the communities served by health service and that the views of users and providers of health services are taken into account;

• monitor the performance of health service to ensure that:

  • health service operates within its budget;

  • its audit and accounting systems accurately reflect the financial position and viability of health service;

  • health service adheres to its financial and business plans, strategic plans and statements of priorities;

  • effective and accountable risk management systems are in place;

  • effective and accountable systems are in place to monitor and improve the quality and effectiveness of health services provided by health service;

  • any problems identified with the quality or effectiveness of the health services provided are addressed in a timely manner;

  • health service continuously strives to improve the quality of the health services it provides and to foster innovation;

• Board sub-committees are established and operate effectively;

• appoint a chief executive officer of health service and to determine, subject to the government approval, his or her remuneration and the terms and conditions of appointment;

• monitor the performance of the chief executive officer of health service, each financial year, having regard to the objectives, priorities and key performance;

• establish the organisational structure, including the management structure, of health service;

• develop arrangements with other relevant agencies and service providers to enable effective and efficient service delivery and continuity of care;

• ensure that the relevant Minister and bureaucrat are advised about significant board decisions and are informed in a timely manner of any issues of public concern or risks that affect or may affect health service;

• establish a Finance Committee, an Audit Committee and a Quality Committee;

• facilitate health research and education;

• adopt a code of conduct for staff of health service;

• provide appropriate training for directors;

• any other functions conferred on the board by or under the relevant legislation;

• each year ensure that the Chief Executive Officer convenes an annual meeting during which the Board submits the report of operations and financial statements;

• appoint at least one community advisory committee and ensure that the persons appointed to the community advisory committee are persons who are able to represent the views of the communities served by health service;

• appoint a primary care and population health advisory committee and ensure that the persons appointed to the committee have the knowledge and expertise;

• include in its report of operations, a report on the activities of its advisory committees.

Board Obligations

Pursuant to its obligations set out in the relevant legislation, in performing its functions and exercising its powers, the health service Board must have regard to:

• the needs and views of patients and other users of the health services that health service provides and the community that health service serves;

• the need to ensure that health service uses its resources in an effective and efficient manner; and

• the need to ensure that resources of the public health sector generally are used effectively and efficiently.

Board Membership

The composition of the health services Board is usually set out in the relevant legislation.

The Board should include at least one person who is able to reflect the perspectives of users of health service and that women and men are adequately represented.

It is an expectation that Board members (inter alia):

• undertake identified and agreed training and development in order to fully discharge their responsibilities;

• bring to the attention of the Board chair any actual or perceived conflict of interest or potential conflict of interest;

• attend, at a minimum, 75% of Board meetings and any committee meeting they may be involved in during the year.

Board Chair

One of the directors must be appointed according to the relevant legislation to be the chairperson of the Board.

The position of Board chair is important because she or he is the major point of contact between the Chief Executive Officer and the Board, leads the Board and develops its members as an effective team. The chair has a particular role to play in relation to effective Board operation. This includes effective, efficient and constructive chairing of meetings and managing the evaluation of the CEO and Board. The Board chair is responsible for ensuring a Board evaluation, chair and individual director evaluations occur annually with an externally facilitated review at least every 3 years.

Board Selection

Board composition is important for board effectiveness. Appointments to the Board are usually made in consultation with the Board Chair. To maximise the Board’s capacity for effective governance the right mix of skills, expertise and personal attributes are required. It is also important to achieve a balance between new members and ideas and corporate memory. The Board Chair and Directors, through the Board self-evaluation process, determine a view on the most effective composition for the Board, including skills mix and gaps, and provide advice on this to the Minister, if required.

Board Member Resignation and Removal

A director of the Board may resign in writing, signed by that person, and the appropriate body or individual as outlined in the relevant legislation may remove a director from office, if it is satisfied that the person:

• is physically or mentally unable to fulfil the role of director; or

• has been convicted of an offence, the commission of which, in the opinion of the Minister, makes the person unsuitable to be a director; or

• has been absent, without leave of the Board of directors, from all meetings of the Board of directors held during a period of 6 months; or

• is an insolvent under administration.

Board Committees

The Board delegates some aspects of its work to its committees. The committees are able to carry out a more detailed analysis of certain issues and make recommendations for the Board to consider. The Board remains accountable for all decisions.

Health service’s Board committees are each established with:

• clear terms of reference;

• procedures for agendas, minutes and reporting to the Board; and

• appropriate membership.

On discharging their obligations, all committee members will ensure they take into consideration the health, safety and welfare of persons at health service in all decision making, including the promotion of a zero harm culture within the health service.

The Health service should establish the following committees:

• Audit Committee

• Quality Committee

• Remuneration Committee

• Finance Committee

• Consumer Advisory Committee

• Primary Care and Population Health Advisory Committee

Audit Committee

The Audit Committee is a Committee of the Board. The purpose of the Audit Committee is to assist health service and its Board by providing assurance in the key areas of statutory financial statements, internal control, legislative compliance and oversight of the activities of risk management, internal and external audit.

The role of the Audit Committee is as follows:

• (a) independently review and assess the effectiveness of the health service’s systems and controls for financial management, performance and sustainability, including risk management;

• (b) oversee the internal audit function, including to:

  • 1. review and approve the internal audit charter;

  • 2. review and approve the strategic internal audit plan;

  • 3. review and approve the annual audit work program;

  • 4. review the effectiveness and efficiency of the function;

  • 5. advise the agency on the appointment and performance of the internal auditors; and

  • 6. meet privately with internal auditors if necessary;

• (c) review annual financial statements and make a recommendation to the health service Board as to whether to authorise the statements;

• (d) review information in the report of operations on financial management, performance and sustainability;

• (e) review and monitor compliance with the relevant financial legislation, and advise the health service Board on the level of compliance attained;

• (f) review and monitor remedial actions taken to address compliance deficiencies;

• (g) maintain effective communication with external auditors, including by:

  • 1. understanding the external audit strategy and internal audit activities;

  • 2. considering the external auditor’s views on any issues, including accounting issues that may impact on the financial statements, financial management compliance issues and other relevant risks impacting the health service’s finances;

  • 3. considering external audit outcomes, including financial and performance audits;

  • 4. providing a standing invitation to the external auditor to attend Audit Committee meetings; and

  • 5. meeting privately at least once each year to ensure frank and open communication;

• (h) consider recommendations made by internal and external auditors relating to or impacting on financial management, performance and sustainability and the actions to be taken by the health service to resolve issues raised; and

• (i) regularly review implementation of actions in response to internal or external audits, including remedial actions to mitigate future instances of non-compliance.

The Audit Committee must be independent with:

• (j) at least three members who are non-executive directors of the health service Board;

• (k) an independent member as Chair (this must not be the Chair of the Board);

• (l) self-assess its performance annually and report this assessment to the health service Board; and

• (m) not include the following persons as members:

• (n) the Chief Executive;

• (o) Chief Financial Officer; or

• (p) the internal auditors.

Quality Committee

The Quality Committee is a Committee of the Board of Directors. The purpose of the Quality Committee is to support the Board’s function of providing strategic leadership in relation to the clinical governance of quality and safety at health service. It serves to ensure on behalf of the Board of Directors of health service, that the following broad objectives are fulfilled:

• Effective and accountable systems are in place to monitor and improve the quality and effectiveness of all health services provided by health service.

• Any problems identified with the quality or effectiveness of the health services provided are addressed in a timely manner.

• The health service continuously strives to improve the quality of all the health services it provides and to foster innovation.

Remuneration Committee

The principal role of the health service Remuneration Committee is to advise the Board of Directors on matters relating to the organisation’s remuneration policies and practices.

In addition, the health service Remuneration Committee will provide oversight with respect to succession planning for the Chief Executive and senior executive positions.

Within the parameters established by the Board, the Remuneration Committee is responsible for:

• Developing and reviewing the organisation’s executive remuneration policy and practices and ensuring that the strategies and performance of health service are taken into account.

• Advising the Board on “best practice” trends and practices in employment conditions and employee remuneration, including the changing legal requirements on executive and senior management remuneration.

• Recommending remuneration movements for the Chief Executive to the Board and for approving remuneration movements for senior executives and senior managers.

Finance Committee

The Finance Committee is a Committee of the Board of Directors. The purpose of the Finance Committee is to advise the Board of Directors on financial matters impacting health service and to establish and maintain effective financial governance, including:

• (a) an appropriate internal management structure and oversight arrangements for planning, managing and overseeing the financial operations, risks and opportunities of their health service to achieve performance and compliance;

• (b) appropriate levels of resourcing and capability (including succession planning) to deliver health service’s financial management, performance and sustainability obligations;

• (c) clear roles, responsibilities, accountabilities and delegations that are documented and communicated;

• (d) the development and implementation of policies and procedures to support the internal control system, in a way that is consistent with, and appropriate for, the sound financial management of health service’s business operations;

• (e) the effective management and oversight of health service’s financial management activities that are undertaken externally, including shared services arrangements and outsourcing to private sector providers;

• (f) effective relationships between stakeholders, committees of the Board and management;

• (g) cooperation with external parties, including other Agencies, to achieve common objectives; and

• (h) consideration of the effect of compliance burdens when developing and imposing requirements.

Specifically, the Finance Committee will review, monitor and report on the following:

• Financial strategy and direction;

• Financial performance and reporting;

• Financial risks;

• Capital planning, major projects, major tenders and business cases;

• Investments and cash flow;

• Balance sheet position; and

• Fundraising activities.

• Other matters specifically delegated to it by the Board.

Community Advisory Committee

The Community Advisory Committee is an advisory committee established by the Board of Directors. The Board must ensure that:

• (a) persons appointed to the Community Advisory Committee are persons who are able to represent the view of the communities served by health service and

• (b) In appointing persons to the Community Advisory Committee, preference is given to a person who is not a registered health practitioner, nor a person who is not currently or not recently been employed or engaged in the provision of health services.

The role of the Community Advisory Committee is to:

• Identify and advise the health service Board of Directors on priority areas and issues requiring a consumer, carer and/or community perspective.

• Advocate on behalf of consumers, carers and the community, including promoting greater attention and sensitivity to the needs of diverse, disadvantaged, isolated and marginalised consumers and communities.

• Provide direction on the development of a strategic Community Participation Plan for approval by the health service Board of Directors and monitor its implementation and effectiveness, including overseeing the preparation of an annual report to the Department of Health on progress against the Community Participation Plan.

• Provide direction and advice on the implementation of the accreditation standards relevant to consumers and patient experience, and monitor implementation and evaluation across health service.

• Participate in the health service strategic planning process and provide ongoing monitoring and input into the strategic priorities.

• Facilitate two-way communication between consumer, carer and community groups and health service.

• Participate in monitoring Quality and Safety measurements and Patient Centred Care key performance indicators for quality improvement.

• Assist in identifying development and training needs in relation to consumer, carer and community participation and make recommendation to the health service Board of Directors on how to meet these needs.

In undertaking these responsibilities, the Community Advisory Committee can seek information and briefings on health service core activities and programs.

Board Effectiveness and Evaluation

The Board evaluates its own performance annually, and undertakes an externally facilitated review at least every 3 years in order to identify areas of improvement and to provide development for the Directors’ and the Board.

The Board Committees review their performance annually and provide recommendations to the Board of any actions that should be taken to improve the Committee’s performance. Each Board Committee reviews its Charter annually.

Delegations to the Health Service Executive

The Board has delegated powers to the CEO and Executive. The delegations of authority provide a list of functions that have been delegated by the Board. The delegation manual includes a description of the delegated power and any conditions limiting the exercise of those powers (including financial limits).

The delegations are reviewed annually by the Finance Committee and approved by the Board.

Directors’ Ethical and Legal Obligations

Code of Conduct

The public health service directors’ are subject to the Directors’ code of conduct . The code of conduct expresses the public sector values in terms that are most relevant to the special role and duties of Directors. The Directors’ code of conduct is based on the same set of values (the public sector values) that apply to all public officials, including employees.

A health service director must:

• Act with honesty and integrity . Be open and transparent in their dealings; use power responsibly; not place oneself in a position of conflict of interest; strive to earn and sustain public trust of a high level.

• Act in good faith in the best interests of health service. Demonstrate accountability for their actions; accept responsibility for their decisions; not engage in activities that may bring themselves or health service into disrepute.

• Act fairly and impartially. Avoid bias, discrimination, caprice or self-interest; demonstrate respect for others by acting in a professional and courteous manner.

• Use information appropriately. Ensure information gained as a director is only applied to proper purposes and is kept confidential.

• Use their position appropriately. Not use their position as a director to seek an undue advantage for oneself, family members or associates, or to cause detriment to health service; decline gifts or favours that may cast doubt on their ability to apply independent judgment as a health service Board member.

• Act in a financially responsible manner. Understand financial reports, audit reports and other financial material that comes before the health service Board; actively inquire into this material.

• Exercise due care, diligence and skill. Ascertain all relevant information; make reasonable enquiries; understand the financial, strategic and other implications of decisions.

• Comply with the establishing legislation for the health service.

• Demonstrate leadership and stewardship. Promote and support the application of the Victorian public sector values; act in accordance with the Directors’ Code.

Conflicts of Interest

The Directors’ code of conduct requires Directors to act with honesty and integrity and to act in the best interests of health service. This means avoiding placing themselves in a position of conflict of interest. Obligations in relation to conflicts of interests are further articulated in the health service’s Conflict of Interest Policies.

Duties of Directors

Health service Directors must act honestly, in good faith in the best interests of health service, with integrity, in a financially responsible manner, with a reasonable degree of care, diligence and skill, and in compliance with relevant legislation.

Health service Directors must not give to any other person, directly or indirectly, any information acquired through being a director (apart from when carrying out functions authorised, permitted or required under an Act).

Health service Directors must not improperly use his or her position, or any information acquired through that position, to gain a personal advantage, or for the advantage of another person, or to cause detriment to health service.

Declaration of Private Interests

Health service Directors’ are required to complete an updated Declaration of Private Interests on an annual basis. Any perceived or actual conflict of interest which is declared by a director is to be managed in accordance with the health service Conflict of Interest Policy.

Health Service’s Executive Committee

The health service’s Executive Committee is responsible for the day to day running of health service, in accordance with the law, the decisions of the Board and government policies.

Chief Executive Officer

The Board appoints the Chief Executive Officer (CEO) of health service and determines, subject to the Secretary’s approval, the CEO’s remuneration and the terms and conditions of his or her appointment.

The CEO is subject to the direction of the Board in controlling and managing health service. The functions of the CEO are:

• to prepare material for consideration by the Board, including the Strategic Plan;

• to ensure that health service uses its resources effectively and efficiently;

• to implement service development and planning; and

• any other functions as specified by the Board.

The role of the CEO is to:

• manage the effective and efficient operations of health service in accordance with the strategy, business plans and policies of the Board;

• implement Board decisions;

• ensure health service’s organisational functions are effective, including financial management, human resource management, asset management and reporting;

• maintain effective communication and co-operation with stakeholders in collaboration with the Chair of the Board;

• oversee the employment and management of staff;

• provide advice and information to the Board on any material issues concerning strategy, finance, reporting obligations and significant events that require the Board to notify the Minister and Department of Health;

• prepare health service’s Annual Report;

• liaise with the Department of Health; and

• represent health service to external parties as an official spokesperson for health service, in consultation with the Chair of the Board.

The CEO is usually the accountable officer for health service the relevant legislation. As the accountable officer, the CEO must:

• designate an employee as the CFO, and designate other staff who receive money and make payments;

• ensure that proper accounts and records are kept;

• provide the Minister for Health or the Minister for Finance any financial information they request;

• prepare financial statements and report of operations;

• complete the annual Financial Management Compliance Framework as soon as possible after the end of each financial year;

• write off debts, losses or deficiency in health service accounts in accordance with the regulations; and

• organise investigations into the loss, deficiency or destruction of public money or property that may have been caused by a serving or former office of health service and decides whether to try to recover funds from that officer.

Chief Financial Officer (CFO)

The CFO is responsible for health service’s financial accounting and financial reporting, the effectiveness of health service’s audit arrangements and the efficient and effective use of resources. The CFO is responsible to the CEO for ensuring that proper accounting records and systems and other records are maintained in accordance with the relevant regulations.

The CFO may provide the Board with advice on:

• the financial statements;

• compliance with legislation;

• the internal control systems to avoid fraud and misappropriation;

• liaison with external auditors;

• the audit process;

• action taken on audit reports; and

• managing financial risk.

External Regulatory and Monitoring

The health service is subject to regulation and oversight from a number of external bodies.

The Government

The Department of Health and government agencies have a number of key clinical governance responsibilities including:

• setting expectations and requirements regarding health service accountability for quality and safety and continuous improvement;

• ensuring health services have the necessary data to fulfil their responsibilities, including benchmarked and trend data;

• providing leadership, support and direction to ensure safe, high-quality healthcare can be provided;

• ensuring board members have the required skills and knowledge to fulfil their responsibilities;

• proactively identifying and responding decisively to emerging clinical quality and safety trends;

• effectively monitoring the implementation and performance of clinical governance systems, ensuring the early identification of risks and flags; and

• monitoring clinical governance implementation and performance by continually reviewing key quality and safety indicators.

Accreditation of the Health Service

Accreditation is part of the regulatory framework that informs government and the community that systems are present in health services to protect the public from harm and improve the quality of health service provision.

The health service maintains accreditation through an independent, external accreditation body. The accreditation process is a formal process of external review based on a series of standards of care and processes. Health services are all required to be accredited by certain specified bodies. The health service is also accredited and monitored against the relevant mental health and aged care accreditation bodies as relevant.

Health Service Governance Framework Checklist

The following table is a summary of the actions taken by the health service Board to ensure it acts in accordance with its eight governance principles.

Principle		Action
Establish robust governance and oversight frameworks	☑	Members of the board, the Chief Executive and the senior management of health service are aware of the governance requirements for health service as set out in the health service Governance Framework
	☑	The governance structures required by the health service Board Charter, statutory instruments and government policy are established to provide effective oversight of clinical and corporate responsibilities
	☑	Accountabilities for health service delivery are clearly established at health service
	☑	The authorities reserved for the Monash health Board and those delegated to management are clearly documented and reviewed annually
	☑	The Board—OH&S—Code of Conduct
	☑	The Board and chief executive can demonstrate compliance with the eight corporate governance standards approved by the Board
Effective and accountable systems are in place to monitor and improve the quality of the health services provided	☑	The Board ensures that effective safety and quality systems and robust organisational structures are in place, that their performance is monitored and that health service responds appropriately to safety and quality problems
	☑	The health service Board are responsible and accountable for ensuring the systems and processes are in place to support clinicians in providing safe, high-quality care, and in ensuring clinicians participate in governance activities in accordance with the Safer Care Victoria Clinical Governance Framework
	☑	The responsibility for designing and implementing systems and monitoring the effectiveness of clinical care is appropriately delegated to managers and health care professionals with specific expertise. Clinicians and clinical teams are responsible and accountable for the safety and quality of care they provide
	☑	The Board ensures it receives systematic reports across the range of quality and safety assurance activities
	☑	The Board ensures that health service participates in regular assessments to maintain accreditation to ensure that it meets quality and safety standards in service delivery
Set the strategic direction for the organisation and its services	☑	The strategic plan is developed in accordance with Ministerial guidelines
	☑	Agree an annual Statement of Priorities with the Minister
	☑	Prepare an annual quality account report
	☑	Quarterly reporting under the Victorian Health Services Performance Monitoring Framework
	☑	Monitoring service delivery performance
	☑	Foster research and education by ensuring key partnerships are in place
	☑	Ensure progress towards integrated care by ensuring key partnerships
Monitor financial and service delivery performance	☑	Approve financial and operating plans and budges to ensure the accountable and efficient provision of health services and the viability of health service
	☑	Monitor financial performance monthly
	☑	Reviewing the capital plan
	☑	Approving the annual financial statements
	☑	Reviewing and approving investment strategies in accordance with government policy
Maintain high standards of professional and ethical conduct	☑	The Board complies with the Director’s Code of Conduct issued by the Public Sector Standards Commissioner
	☑	Health service Board members disclose any conflicts of interest and declare personal interests in accordance with government policy
	☑	The Board reviews and approves the health service Code of Conduct and ensures that its obligations are enforced
	☑	A Fraud and Corruption Policy is in place
	☑	A Gifts and Benefits Policy is in place and monitored
	☑	All instances of improper conduct are managed properly and reported externally where relevant
Involve stakeholders in decisions that affect them	☑	Information is published on the internet, including quality of care reports, annual reports and privacy information
	☑	An effective complaints management process is in place.
	☑	Health service has a Community Participation Plan which is embedded in the health service Strategic Plan
	☑	Ensure that health service has programs demonstrating a commitment to diversity
	☑	Aboriginal Liaison
	☑	health service is responsive to statutory agencies such as the Coroner, IBAC, Mental Health Complaints Commissioner, Health Care Complaints Commissioner and the Ombudsman
Establish sound audit and risk management practices	☑	A compliance program is in place to ensure the legal and policy obligations of health service are identified, understood and managed
	☑	Health service’s Enterprise Risk Management Framework has been developed in accordance with ISO 31000:2009 Risk management—Principles and guidelines
	☑	Health service complies with the Victorian Government Risk Framework, including the requirement to arrange for its insurance with the VMIA
	☑	An internal audit function is in place and accountable to the Board
	☑	The Board regularly reviews health service’s governance framework including policies and procedures
	☑	The Board approves and regularly reviews the Delegations of Authority
	☑	The Audit Committee reviews management controls and strategies associated with high and medium risks
	☑	The Board ensures that the Internal Auditors have access to the health service Board via the Audit committee and has sufficient information to perform its function
Ensure key partnerships to develop integrated care, research and education	☑	The health service Translation Precinct (MHTP) brings the research, education and clinical expertise of health service, Monash University and the Hudson Institute of Medical Research and health service together