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Did You Know?

Understanding the Governing Body

Michelle Nolander, M.S.N., R.N., CNOR
ACHC Clinical Review Specialist

The smooth operation of an ambulatory surgery center requires staff, but the oversight of the organization becomes the responsibility of a specifically designated individual or group.

The Governing Body, which consists of one or more members of the organization, has ultimate responsibility for the overall operations of the organization and the quality of its services. The Governing Body member(s) must be appointed to take on the role(s) and responsibilities.

ACHC Standard: Condition for Coverage: Governing Body & Management (01.01.01, deemed 2021 version); and Governing Body (01.01.01, non-deemed 2022 version).

Many of the day-to-day operations may be delegated to individuals or groups. However, this delegation of authority must be documented in writing and included in the individual’s/individuals’ job description(s). The delegation of these responsibilities does not relieve the Governing Body of the responsibility for assuring that standards are met.

The Governing Body must have oversight and accountability for all policies, procedures, and programs. This oversight includes periodic review (according to the organization’s written policies or at regular intervals), and this review must be evidenced in the written minutes from the Governing Body meetings. If follow-up action is needed, ensure that it is addressed at the next or otherwise designated meeting.

As the Governing Body exercises its authority for actions such as letters of appointment; approval of policies, procedures, and programs; or any other documentation that requires Governing Body approval, all documents must be signed on behalf of the Governing Body. A deficiency frequently found in the review of documentation is that a document is signed by an individual with their title instead of being signed on behalf of the Governing Body.

ACHC Standard: Governing Body Bylaws Define Responsibilities (01.02.03, deemed 2021 version); Governing Body Responsibilities (01.01.02, non-deemed 2022 version).

In order to provide the Governing Body with structured guidelines, bylaws (or other similarly named documents that meet the requirements) must be written. This document should outline and define the responsibilities of the Governing Body. This includes but is not limited to:

1. How members are selected, reviewed, terms, duties, responsibilities, and procedures for removal.
2. Frequency of meetings and requirement of meeting minutes.
3. Governance of all policies and bylaws.
4. Fiscal responsibilities.
5. Provision of resources for safe and adequate care.
6. Patient rights and ethical oversight.
7. Ensuring compliance with all federal, state, and local programs that protect the health and safety of patients, staff, and visitors.

Tips for Compliance

• Familiarize yourself with Chapter 1: Governing Body by creating a checklist of all of the items the Governing Body is responsible for.
• Create a list of all policies and procedures within your organization with dates for review/approval. Review that list at every Governing Body meeting.
• Create a template for your Governing Body meeting minutes. Be sure to include standing agenda items, such as QAPI and Infection Prevention and Control committee reviews. Include an accreditation section for addressing any action items for plans of correction and monitoring plans that are required for discussion and review. Be sure to designate anything “outstanding” if it requires follow-up at the next meeting where minutes are reviewed.
• Ensure the Governing Body meets as outlined in the Governing Body Bylaws.
• Ensure any delegation of duties is documented in writing.
• Track your credentialing and privileging due dates, and be sure to include those in your Governing Body meeting template – before expiration has occurred.

Here to Help

To access the most recent Ambulatory Surgery Center Accreditation Standards Manuals from Accreditation Commission for Health Care (ACHC), please contact your Account Advisor or email us at customerservice@achc.org.

Some content presented in “Did You Know?” may consist of timely or topical articles deemed to be of interest to the provider community. These are presented for informational purposes as a service to our readers. The views, opinions, and positions expressed by the authors are theirs alone and do not necessarily reflect the views, opinions, or positions of ACHC, its related entities, or any employee thereof.