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
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
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
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
Approved By Governing Board