STANDARD 2: Leadership

2.1 Legal Authority and Governing Body 

1. The healthcare organization shall have a Governing Body appointed according to this standard which shall define and control the relevance, purpose, structure, and the strategic direction of the healthcare organization. 

2. The Governing Body shall be aware of influences, information, and other factors relative to the defined strategic direction and scope of service defined above. This shall include consideration of relevant customer needs and interested party satisfaction (internal and external). 

3. The Governing Body shall appoint a Managing Director to establish, implement, maintain, and improve all processes of the healthcare organization in accordance with this standard. 

4. The Governing Body shall have formal, documented meetings to review the performance and outcomes of the Managing Director’s leadership within the healthcare organization as defined above. These meeting shall occur at least quarterly within a calendar year. 

 2.2 Managing Director 

1. The Managing Director shall ensure that the authority and areas of responsibility are established, understood, and communicated within the healthcare organization in accordance with this AACI Standard. 

2. The Managing Director shall establish Top management roles for supervision and control of strategic processes within the healthcare organization. 

3. The Managing Director shall establish strategic plans for the healthcare organization and implement an aligned quality management system. 

4. The Managing Director shall ensure that the healthcare organization has defined, communicated, understood, and documented mission, vision, and values in keeping with requirement 4.3. of this standard. 

5. The Managing Director shall establish leadership roles commensurate with the requirements of the delivery of medical care, financial solvency, establishment of the quality management system all in alignment with the strategic plans of the healthcare organization. 

6. The Managing Director shall plan, ensure, and provide all resources needed for quality care within the healthcare organization. These shall include: 

a) care shall be provided according to recognized standards and internationally or nationally accepted evidence-based protocols and guidelines to assure that the associated processes delivered their intended outputs; 

b) human resources; 

c) infrastructure and environmental resources; 

d) equipment related to patient care including calibration traceability and service records; 

e) accumulated organizational knowledge; 

f) awareness of the value of the healthcare organization; 

g) coordination between departments and functions and with relevant external services; 

h) communication infrastructure within the healthcare organization; 

i) documented information. 

7. The Managing Director shall control the discretionary provision of information relative to the healthcare organization’s quality management system where required or otherwise indicated by qualified interested parties (governmental, community, or public relations). Published data shall be valid and current. 

8. Documents related to the above requirements shall be retained and maintained as documented information. 

 2.3 Medical Director 

1. The medical staff shall appoint a Medical Director who has responsibility for medical staff and all clinical operations. This appointee shall be approved by the Managing Director. 

2. The Medical Director shall have the necessary medical, clinical, and administrative experience as determined by the scope of services provided, and the resources of the healthcare organization. 

3. This Medical Director shall be responsible along with the Managing Director for liaison between medical and administrative departments as required throughout this standard to implement and achieve the strategic direction of healthcare management system. 

 2.4 Healthcare Providers 

1. The healthcare organization shall be responsible for appointing all practitioners providing patient care. The categories of these practitioners shall include physician and non-physician individuals depending on the scope of practice of the healthcare organization and its resources. 

2. The healthcare organization shall determine whether to grant, deny, continue, revise, discontinue, limit, or revoke specified privileges, including medical staff membership, or a specific practitioner after considering the recommendation of the medical staff. 

 2.5 Organizational Plan and Budget 

1. The healthcare organization shall have an overall organizational plan that meets the following conditions: 

a) the plan shall include an annual operating budget that is prepared by the appointed Financial Director according to generally accepted accounting principles; 

b) the budget shall include all anticipated income and expenses; 

c) the plan shall provide for capital expenditures for at least a 3-year period, including and identifying the anticipated sources of financing for capital expenditure that relates to the following: 

i. acquisition of land; 

ii. improvement of land, buildings, and equipment; 

iii. replacement, modernization, and expansion of buildings and equipment. 

2. The plan shall be prepared under the direction of the Governing Body and by a Committee consisting of representatives of the Governing Body, Top management, the administrative staff, and the medical staff of the healthcare organization. 

3. The above-mentioned authority shall be responsible for periodic review to assure that the intent of the budget, as approved in section 2. above, is met and in keeping with the quality management system and aligned with strategic planning. 

 2.6 Outsourced Services 

1. The healthcare organization shall ensure that externally provided processes, products and services conform to requirements. 

 2. The healthcare organization shall define a criteria-based procedure for selecting clinical and non-clinical services or products. 

3. The healthcare organization shall ensure that all services are performed and provided in a safe and effective manner. 

4. The healthcare organization shall ensure that externally provided processes, products and services do not adversely affect the healthcare organization’s ability to consistently deliver conforming services to its patients. 

5. Contracts shall include specifications for quality management, specifically, monitoring, review, and corrective action as determined. 

6. The healthcare organization shall conduct a minimum yearly review of all outsourced services. 

7. The outcome of the above processes shall be considered for contract renewal and/or ongoing selection for the outsourced service in question. 

8. Documented information shall be maintained and retained.