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Responsibilities of the Board

A) Strategic Planning:

  1. Approve a Strategic Plan that is consistent with the Hospital’s Mission, Core Values and will enable the organization to realise its Vision.
  2. Review the Strategic Plan as part of the planning cycle, and ensure it aligns with community needs, policies of the MOH and Ontario Health and promotes (where appropriate) integration with other health service providers.
  3. Monitor and measure corporate performance regularly against the approved Strategic Plan and Board-approved performance indicators.
  4. Ensure that Board decisions are consistent with the approved Strategic Plan, Mission, Vision and Core Values, unless there is a sound rationale to do otherwise.

B) Quality Oversight:

  1. Establish key quality objectives that support the Hospital’s strategic areas of focus and Mission.
  2. Receive assurance that the Hospital’s performance on the quality objectives are monitored on a regular basis.
  3. Receive assurance that the Hospital has adequate systems are in place to:
    1. review and disclose critical incidents to patients, the Quality Committee and the Medical Advisory Committee (“MAC”) on a timely basis;
    2. analyze critical incidents and put in place steps to avoid or reduce the risk of recurrence of similar incidents; and
    3. provide aggregated incident data to the Quality Committee at least twice a year.
  4. Receive confirmation that appropriate, effective and fair credentialing processes, criteria and timelines are in place.
  5. Approve appointments and re-appointments of physicians, dentists, midwives and extended class nurses to the professional staff of the Hospital.
  6. Through reports from the Chief of Staff (“COS”) and the MAC, monitor any professional staff performance issues and receive assurance they are addressed.
  7. Receive timely reporting from the Chief Executive Officer (“CEO”), the COS and the Internal Auditor (as appropriate) on plans to address variances from performance standards, and oversee the implementation of remediation plans.

C) Financial Performance:

Approve the annual operating and capital budget, ensuring that it supports the Hospital’s strategic areas of focus and Mission.

  1. Review resource utilization plans for alignment with strategic directions and that the Hospital operates within the Service Accountability Agreement (SAA).
  2. Validate that the Hospital’s performance on its financial objectives is monitored on a regular basis.
  3. Review the financial reporting process, management information systems and internal controls annually.
  4. Receive confirmation that policies are in place regarding asset protection, purchases, investments, contracts, leases, borrowing and signing authority.
  5. Review financial reports and approve the annual audited financial statements.

D) CEO and COS Goal Setting and Performance:

  1. Set performance objectives for the CEO and COS and annually review their performance, compensation and succession plans.
  2. Establish the process for the appointment or removal of the CEO and COS and appoint the CEO and COS in accordance with such process.
  3. Delegate and designate responsibility and authority to the CEO for the management and operation of the Hospital and require accountability to the Board.
  4. Delegate and designate responsibility and authority to the COS for the general clinical organization of the Hospital, the quality of patient care and the supervision of the practice of medicine, dentistry, midwifery and extended class nursing in the Hospital and require accountability to the Board.
  5. Appoint medical leadership positions on the recommendation of the MAC as required under TOH’s Medical, Dental, Midwifery and Nurses in the Extended Class By-law and the PHA.

E) Board Effectiveness:

  1. Recruit qualified Governors and non-Governor members of Committees (where appropriate) who are committed to the Hospital and plan for the succession of Governors and Officers.
  2. Establish Board goals and ensure that the Board receives timely and appropriate information to support informed policy formation, decision-making and monitoring.
  3. Evaluate Board performance on an annual basis in relation to its responsibilities.
  4. Periodically review and revise governance policies, processes and structures as appropriate to maximize the effective functioning of the Board.
  5. Comply with the Hospital’s obligations relative to the annual meetings of members.

F) Oversee Stakeholder Relationships:

  1. Identify key stakeholders and receive assurance on related accountabilities.
  2. Receive assurance that the Hospital communicates appropriately with stakeholders, in a manner consistent with respective accountabilities, and promotes engagement.
  3. Contribute to the maintenance of strong stakeholder relationships.
  4. Performs advocacy where required, in support of the Mission, Vision, Core Values and strategic areas of focus.

G) Enterprise Risk Management Program:

  1. Oversee the implementation of appropriate systems to manage these risks and regularly monitor principal risks to the Hospital’s business.
  2. Oversee Management’s procedures and policies for monitoring compliance with all applicable legislation, MOHLTC requirements, and all other applicable government ministry requirements.

H) Reporting:

  1. Receive periodic reports from Board Committee/Hospital representatives.

I) Legal Compliance:

  1. Receive assurance that appropriate processes are in place to ensure compliance with legal requirements.

Last updated on: July 12th, 2021