Board policy manual & workplace conduct - Kingston General Hospital

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ISSUED BY:AUTHORIZED BY:CATEGORY:COMMITTEE:KGH Board of DirectorsKGH Board of DirectorsQuality and EffectivenessResourcesNUMBER: III-4ISSUE DATE: April 2010REVISION DATES:REVIEW DATE: April 2011PAGE: 1 of 1SUBJECT:RISK MANAGEMENTArticle 4.10 (c) (vii) and 4.10 (d) (iv) of the By-law provide for monitoring by the Board ofDirectors of organizational risk and risk mitigation plans.The Board of Directors must be knowledgeable about risks inherent in hospital operations andensure that appropriate risk analyses are performed as part of its decision-making. The Board ofDirectors is responsible for ensuring that appropriate risk management practices are in place inthe organization, and reviewing and approving the Hospital's variance and risk tolerance levels.In particular, the Board:i) Ensures that appropriate programs and processes are in place to protect againstrisk;ii) Expects management to identify and assesses the associated risks to theorganization when reviewing and approving resource allocation decisions;iii) Expects management to identify unusual risks to the organization and ensure thatthere are plans in place to prevent and manage such risks;iv) Works with the CEO to reduce risks to the organization and promote ongoing qualityimprovement.Each Board Standing Committee will review the risks related to its mandate at least annually.The Chief Executive Officer is accountable for: identifying the principal risks of the Hospital’sbusiness; determining the organization's exposure to risk; and developing and implementing arisk management framework.The Board of Directors of the Hospital will annually monitor and assess the Hospital’squantification of risks and how those risks are addressed.
ISSUED BY:AUTHORIZED BY:CATEGORY:COMMITTEE:KGH Board of DirectorsKGH Board of DirectorsQuality and EffectivenessQuality of Patient CareNUMBER: III-5ISSUE DATE: April 2010REVISION DATES: May 2011REVIEW DATE: March 2011PAGE: 1 of 1SUBJECT:ETHICSArticle 4.10 (c) (vii) of the By-law provides that the Board of Directors will have a policy thatensures a framework is in place for addressing ethical issues arising from care, education andresearch at the hospital. This policy supports the Accreditation Canada requirement thatorganizations develop and implement a written ethics framework that is adopted by thegoverning body and that defines formal processes for managing ethics related issues andconcerns.The CEO is responsible for putting an ethics framework in place and ensuring staff and serviceproviders know about the ethics framework and how to implement it.The CEO is also responsible for working with the Board of Directors to ensure the ethicalframework is applied in board decision making processes.
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SUBJECT:Policy # V-B-6Board Meeting
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Appendix ANamed Recognition - KGH A
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Board policy manual & workplace conduct - Kingston General Hospital

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