Standard 2: Governance and Accountability (Version 11)

Why it matters. A facility with no clearly accountable governing body has no one answerable for safety and quality when things go wrong. Named members with documented authority make that accountability real.

Sample. Review the governing body's records for the last 12 months, and its terms of reference.

1. A governing body with named members and defined terms exists.

Method. Check the terms of reference and the membership register for named members and their terms of office.

Evidence to show. GOV-POL-001 Governing Body Terms of Reference; GOV-REG-001 Register of Governing Body Members.

Pass when. Every member is named and has a defined term.

2. The body meets on a fixed schedule, with minutes kept.

Method. Compare the meeting dates in the minutes with the schedule set in the procedure.

Evidence to show. GOV-FRM-003 Governing Body Minutes Template, completed for each meeting.

Pass when. Meetings take place on the scheduled dates, and minutes exist for each one.

3. Quality, safety and financial oversight are assigned to the board.

Method. Read the minutes for a quality and safety review at each meeting, and check that clinical governance and financial stewardship are named board responsibilities.

Evidence to show. GOV-SOP-001 Governing Body Meetings and Decisions on Safety and Quality; minutes.

Pass when. Each meeting records a quality and safety review, and both responsibilities are named in the procedure.

Immediate fail (any one means the criterion is not met)

• The governing body does not exist, or has no minutes for the last 12 months.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Hospital Safety Index: Guide for Evaluators, 2nd ed. Used for: Board oversight of safety and quality (2.1). https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/

Why it matters. A facility without a written plan drifts, and its resources follow whichever problem is loudest that week. A written plan with a mission, values and code of conduct sets the direction that staff and the board can be held to.

Sample. Review the plan and the code of conduct currently in force, and the decisions made in the last year.

1. A written strategic plan covers at least several years.

Method. Check the plan's period, its approval record and its mission statement.

Evidence to show. GOV-PLN-001 Strategic Plan (template and approval).

Pass when. The plan is approved, covers a multi-year period and states a mission.

2. A resourcing decision can be traced to the plan.

Method. Select one budget or staffing decision from the last year and trace its link to a plan objective.

Evidence to show. The budget or staffing decision record, and the plan.

Pass when. The decision refers to a plan objective.

3. Values and a code of conduct guide staff behaviour.

Method. Ask staff to describe the code of conduct, and check that it is separate from the mission statement.

Evidence to show. GOV-POL-002 Code of Conduct for Staff.

Pass when. The code of conduct is approved, separate from the mission, and staff can describe its main points.

Immediate fail (any one means the criterion is not met)

• The facility has no written strategic plan, or no code of conduct for staff.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Hospital Safety Index: Guide for Evaluators, 2nd ed. Used for: Strategic direction and safety priorities (2.2). https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/

Why it matters. Many facilities have a complete set of policies that nobody follows. A policy that staff cannot explain in practice is a document, not a control.

Sample. Select three policies at random and check them against practice in the last 12 months.

1. Staff can describe how a named policy is applied.

Method. Ask staff in two areas to describe how one selected policy is applied in their daily work.

Evidence to show. GOV-FRM-002 Policy Application Audit Form, completed for each selected policy.

Pass when. Staff describe the policy as it is written.

2. Adherence is checked and gaps have a defined response.

Method. Read the audit records and check that each gap has an action recorded.

Evidence to show. GOV-REG-002 Policy Register; GOV-FRM-002 audit records.

Pass when. Every gap found has a recorded action.

3. The quality improvement plan is complete, authorised and reviewed.

Method. Check the plan for all five areas, its named owners and indicators, and its approval and review dates.

Evidence to show. GOV-PLN-002 Quality Improvement Plan; GOV-POL-003 Policy Development, Approval, Review and Application.

Pass when. The plan covers all areas, each has a named owner and an indicator, and approval and review are dated.

Immediate fail (any one means the criterion is not met)

• A policy is in use with no adherence check, and no response when a policy-practice gap is found.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Hospital Safety Index: Guide for Evaluators, 2nd ed. Used for: Policy application and quality improvement (2.3). https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/

Why it matters. Patient health information is sensitive, and a breach can harm patients and families. Defined access controls and a breach response plan keep it protected, even in a temporary setting.

Sample. Review the access controls and the breach response plan currently in force.

1. Access to patient data is restricted by role.

Method. Check the access list against staff roles for a sample of systems and paper records.

Evidence to show. DIG-POL-001 Information Security and Access Control Policy.

Pass when. Every person with access has a role that needs it.

2. A breach response plan exists and is actionable.

Method. Read the procedure and check that it names the steps, the responsible person and the reporting route.

Evidence to show. DIG-SOP-001 Patient Data Breach Response Procedure.

Pass when. The procedure names who acts, what they do and how it is reported.

3. Access controls and the breach plan have been tested.

Method. Check the date and result of the most recent test or review.

Evidence to show. DIG-FRM-001 Breach Response Test Record.

Pass when. A test or review is recorded within the last 12 months, with actions closed.

Immediate fail (any one means the criterion is not met)

• Patient records can be accessed by staff with no role-based need, and no breach response plan exists.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. WHO SMART Trust. Ethical Considerations and Data Protection Principles. Used for: confidentiality, access restriction and security of health data (2.4). https://smart.who.int/trust/ethical_principles.html
2. ISO 27799:2016. Health informatics: Information security management in health using ISO/IEC 27002. Used for: information security controls for patient data (2.4). https://www.iso.org/standard/62777.html
3. International Agency for Research on Cancer (WHO). Confidentiality of medical records, section 3: Access to and storage of data. Used for: written list of authorised staff, lockable storage and confidential handling of records (2.4). https://gicr.iarc.who.int/static/public/docs/Confidentiality%20IACR-IARC%20(Tech%20Rep%202004-3).pdf

Why it matters. Keeping records forever is costly and risky, and destroying them too early can break the law and remove evidence a patient needs. A retention policy sets the period for each record type, and the disposal is recorded.

Sample. Review the retention policy and the disposal records for the last 12 months.

1. A written retention policy sets periods for each record type.

Method. Check that the policy lists each record type with its retention period.

Evidence to show. The retention policy and the record register.

Pass when. Each record type has a stated period.

2. The periods match the national requirement.

Method. Compare the periods with the legal requirement for the country where the facility operates.

Evidence to show. The national requirement cited in the policy.

Pass when. Each period is at least the national requirement.

3. Disposal is secure and documented.

Method. Select disposal records and check the date, method and authoriser.

Evidence to show. REC-FRM-003 Records Disposal Record.

Pass when. Each disposal is recorded with its date, method and authoriser.

Immediate fail (any one means the criterion is not met)

• Records are disposed of with no retention policy, or are destroyed before the retention period ends.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. International Agency for Research on Cancer (WHO). Confidentiality of medical records, section 3: Access to and storage of data. Used for: retention of records for a stated period, secure disposal by shredding, and confidential waste (2.5). https://gicr.iarc.who.int/static/public/docs/Confidentiality%20IACR-IARC%20(Tech%20Rep%202004-3).pdf

Why it matters. Root cause analysis finds why an incident happened, not who was involved. A tracked action plan that is followed through is what makes the investigation worth doing.

Sample. Select every serious incident from the last 12 months.

1. A structured root cause analysis is used.

Method. Read the analysis for each serious incident and check that it follows the procedure.

Evidence to show. INC-SOP-001 Root Cause Analysis of Serious Incidents; INC-FRM-001 Root Cause Analysis Record.

Pass when. Each analysis follows the procedure and identifies root causes, not only the immediate event.

2. The analysis produces a tracked action plan.

Method. Check each action in the tracker for an owner, a date and a status.

Evidence to show. INC-REG-001 Incident Action Tracker.

Pass when. Every action has an owner and a date.

3. Actions are followed through to completion.

Method. Check the status of each action against its due date.

Evidence to show. INC-REG-001 Incident Action Tracker.

Pass when. Every action is closed or has a recorded reason for the delay.

Immediate fail (any one means the criterion is not met)

• A serious incident is closed with no root cause analysis, or its action plan is left open with no owner.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Hospital Safety Index: Guide for Evaluators, 2nd ed. Used for: Incident review and learning (2.6). https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/
2. World Health Organization (2020). Patient Engagement: Technical Series on Safer Primary Care. Used for: Learning from patient safety events (2.6). https://news.gmj.ge/guideline/patient-engagement-technical-series-on-safer-primary-care/
3. World Health Organization (2020). Patient Engagement: Technical Series on Safer Primary Care. Used for: Patient safety learning. https://news.gmj.ge/guideline/patient-engagement-technical-series-on-safer-primary-care/

Why it matters. Staff who are afraid to raise a concern will stay silent about the mistake that harms a patient. A validated survey, repeated and acted on, shows whether they feel able to speak up.

Sample. Review the survey records and action plans for the last 12 months.

1. A validated safety culture survey is used.

Method. Check the survey instrument and the procedure for its use.

Evidence to show. QUA-FRM-001 Safety Culture Survey (template); QUA-SOP-001 Safety Culture Survey Procedure.

Pass when. The instrument is a recognised, validated tool and the procedure is approved.

2. The survey runs on a defined schedule.

Method. Compare the survey dates with the schedule in the procedure.

Evidence to show. Survey records held under QUA-SOP-001 .

Pass when. Surveys run on the scheduled dates.

3. Results are reviewed and acted on.

Method. Check the action register for each result that needed follow-up.

Evidence to show. QUA-REG-001 Safety Culture Action Plan Register.

Pass when. Each result has a reviewed action, and follow-up is visible to staff.

Immediate fail (any one means the criterion is not met)

• No safety culture survey has been conducted in the last 12 months.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2021). Hospital Safety Index: Guide for Evaluators, 2nd ed. Used for: Safety culture (2.7). https://news.gmj.ge/guideline/hospital-safety-index-guide-for-evaluators-2nd-ed/

Why it matters. Patients who ask only after they leave may not say what went wrong during their stay. Feedback gathered during care, while there is still time to act, improves the care the patient is actually getting.

Sample. Review the feedback collected in the last quarter.

1. Feedback is collected during the stay.

Method. Check that the structured feedback form is used during the stay, not only after discharge.

Evidence to show. CON-FRM-004 Structured In-Stay Feedback Form; CON-SOP-002 In-Stay Patient Experience Feedback Procedure.

Pass when. Forms are completed during the stay.

2. Feedback is collected broadly.

Method. Compare the number of forms with the number of patients in the period, and check that patients who did not volunteer feedback were asked.

Evidence to show. CON-FRM-004 forms.

Pass when. Feedback is sought from patients who did not volunteer it.

3. Feedback is used to improve care.

Method. Read the quarterly summary and check for at least one improvement made from it.

Evidence to show. QUA-REG-002 Patient Feedback Summary (quarterly).

Pass when. The quarterly summary records a resulting improvement.

Immediate fail (any one means the criterion is not met)

• Patient experience is measured only after discharge, with no feedback during the stay.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2020). Patient Engagement: Technical Series on Safer Primary Care. Used for: Patient experience and feedback (2.8). https://news.gmj.ge/guideline/patient-engagement-technical-series-on-safer-primary-care/

Why it matters. Clinical staff sometimes face decisions about care that are hard to make alone, such as when treatment should stop. A usable ethics consultation route gives them somewhere to go before a poor decision is made.

Sample. Review the consultation log for the last 12 months.

1. An ethics consultation process is in place.

Method. Check the policy and the terms of reference for the committee, named resource or external arrangement.

Evidence to show. GOV-POL-004 Clinical Ethics Consultation Policy and Terms of Reference.

Pass when. The policy names a route that staff can use.

2. Staff know how to access it.

Method. Ask staff how they would request an ethics consultation.

Evidence to show. GOV-SOP-002 Ethics Consultation Procedure.

Pass when. Staff describe the route correctly.

3. The process has been used.

Method. Check the log for any consultation in the last 12 months.

Evidence to show. GOV-REG-003 Ethics Consultation Log.

Pass when. At least one consultation is recorded, or the reason none was needed is recorded.

Immediate fail (any one means the criterion is not met)

• No ethics consultation route exists, or it has never been used.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. Pan American Health Organization (2020). Ethics guidance for the use of scarce resources in the delivery of critical health care during the COVID-19 pandemic. Used for: Ethics support for difficult decisions (2.9). https://news.gmj.ge/guideline/ethics-guidance-for-the-use-of-scarce-resources-in-the-delivery-of-critical-health-care-during-the-covid-19-pandemic/
2. Pan American Health Organization (2020). Template and operational guidance for the ethics review and oversight of COVID-19-related research. Used for: Ethics review and oversight process (2.9). https://news.gmj.ge/guideline/template-and-operational-guidance-for-the-ethics-review-and-oversight-of-covid-19-related-research/
3. Pan American Health Organization (2020). Ethics guidance for the use of scarce resources in the delivery of critical health care during the COVID-19 pandemic. Used for: Ethics consultation. https://news.gmj.ge/guideline/ethics-guidance-for-the-use-of-scarce-resources-in-the-delivery-of-critical-health-care-during-the-covid-19-pandemic/
4. Pan American Health Organization (2020). Template and operational guidance for the ethics review and oversight of COVID-19-related research. Used for: Ethics review process. https://news.gmj.ge/guideline/template-and-operational-guidance-for-the-ethics-review-and-oversight-of-covid-19-related-research/

Why it matters. A service designed without the people who use it misses what matters to them. A patient or family representative in governance brings the view from outside the staff room.

Sample. Review the attendance register and minutes for the last 12 months.

1. A patient or family representative has a defined role.

Method. Check the role description in the policy.

Evidence to show. GOV-POL-005 Patient and Family Representative Role in Governance.

Pass when. The role is written, with duties in governance or quality review.

2. The representative takes part in discussion.

Method. Check the attendance register and the minutes for their contributions.

Evidence to show. GOV-REG-004 Attendance Register (governance meetings); minutes.

Pass when. The representative attends and contributes, not only observes.

3. Input has changed a decision.

Method. Ask for one recorded decision where patient or family input shaped the outcome.

Evidence to show. Minutes showing the decision.

Pass when. At least one decision is traceable to patient or family input.

Immediate fail (any one means the criterion is not met)

• No patient or family representative takes part in quality review or governance discussion.

Staff, training and documents

Each occupation carries its ISCO-08 code. Each row is one document: read across to see who does each step. Training evidence: a verified micro-credential in your GMJ Academy micro-credential portfolio, or your own training certificate kept in the staff file.

Staff responsible

E-learning: who must take each course.

Documents: who does each step

References

1. World Health Organization (2020). Patient Engagement: Technical Series on Safer Primary Care. Used for: Patient and family involvement (2.10). https://news.gmj.ge/guideline/patient-engagement-technical-series-on-safer-primary-care/