Governance - Leadership

Rakesh Gupta MD is the medical director of the 
facility.  The governing body of the facility consists of the 
medical director.  The governing body will ensure the provision of quality 
health services and is responsible for the operation and 
performance of the organization. The governing body will 
provide full disclosure of ownership and will notify all 
accrediting organizations of changes in same.  All 
credentials of practicing physicians will be on file at the 
Responsibilities of this governing body/administration 
include, but are not limited to the following:
1.  Ensuring the facility and personnel are functioning at 
    highest standard possible
That there are sufficient numbers and mix of staff, 
        supplies, equipment, to provide safe patient care.
        All staff participate in safety and quality 
2. Oversight of the organization's infection control and   
   safety programs to ensure a safe environment of care 
    a) This includes various plans that respond to
            interruption to systems, unexpected emergencies
            or disasters etc.
3.  Establish organizational structure, functional 
    relationships among various components/personnel of the 
    organization as well as contracted relationships
         Leadership fosters a team approach
         Leaders create and maintain a culture of safety and

         quality throughout the organization; developing a
         code of conduct defining unacceptable behaviors and a process for 
         managing disruptive and inappropriate behaviors. 
All staff and physicians are encouraged to participate fully in 
safety and quality initiatives via committee forums, surveys, 
in-services, other education programs, advisories, clinical 
societies, website information, as well as one on one 
interaction. This organization and leadership supports an 
open door policy regarding concerns, discussions, and problem 
solving in the area of safety and quality.
This organization also encourages and supports patient 
population participation regarding safety and quality via the 
'participation in your own care' initiative, patient 
satisfaction and grievance program as well as one on one 
The culture of safety and quality is evaluated and changes 
are implemented as needed   
4.  Establish lines of authority, accountability, and 
    supervision of personnel.
5.  Assuring employment of qualified individuals
6.  Establish personnel policies regarding documentation of 
    credentials, responsibilities, authority; reviews 
    regarding performance, incentives, and knowledge of same 
    by employee.
7.  Establish rules for management of the organization. 
        Including long and short term goals
8.  Establish and enforce policy and procedures with regard 
    to the daily functioning of the facility, OSHA, and 
    in service.
    Education is provided that focuses on safety and 
        quality for staff and patients
9.  Establish a program of risk management.
a) this includes encouraging staff to speak up
        regarding any possible risk or incident without the
        fear of repercussions
10. Establish and maintain a quality assessment/performance 
    improvement program.
        Set priorities for PI/QI activities; re-prioritize as 
11. Establish a set of controls  regarding official documents
    of the organization's.
12. Establish controls regarding maintenance of 
    confidentiality issues, i.e. patient's charts, personnel 
    files, health records, etc.
13. Address all legal/ethical matters concerning the 
    organization and staff.
14. Maintain communication within the organization by 
    routinely meeting with members of the staff. Minutes will be recorded at all meetings.
    Support communication processes to foster an environment of safety and quality
15. Approve all outside services/care, i.e. labs, pathology, radiology, referral to outside physician.
16. Determine a policy for continuing education for personnel.
17. Establish a system of financial management.
18. Establish a system of record keeping regarding the 
    purchase and maintenance of equipment and materials.
19. Responsible for the development and maintenance of a
    disaster preparedness plan.
20. Responsible for the definitive policy and process 
    regarding Sentinel or Adverse Events which discusses
    what is considered a Sentinel or Adverse event, support
    for individuals involved in such an event, lessons
    learned from investigation or root cause analysis of the
    event, annual reporting of events and to that end 
    voluntary reporting of such events to appropriate  
    organizations such as the accrediting body, U.S. Food
    and Drug Administration, etc. Any mandatory reporting  
    requirements such as to the state or the department of 
    health is always completed. For further information
    please see the Policy Sentinel Event/Adverse Event in 
    Volume 3
Approved By Governing Board    
Control #330.7