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Leadership Matters

Research has shown that higher-performing health care organizations are correlated with well-educated boards that discuss and monitor quality and safety in measurable, meaningful ways at every board meeting. However recent surveys of boards and their members show:

List quality and safety expertise as a top competency for new board members*


Receive continuous education on this topic*


Have some board members who are not confident in their skill to guide safety and quality oversight**


Board members do not feel their knowledge of safety and quality is adequate for their fiduciary duty**

*(AHA, 2019); **(Goeschel, et al, 2011)

Joint Commission Resources Can Help

JCR is uniquely positioned to assist with educating your board and its members on quality and safety topics. Our expansive interdisciplinary team of experts directly observe care delivery in hundreds of hospitals across the nation. They see first-hand where the challenges are and understand how to educate boards so they feel confident in their skill to guide safety and quality oversight. JCR offers a variety of resources to meet your needs.
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The governing body is ultimately accountable for the safety and quality of care, treatment, and services.

As the role of the board and its members in quality oversight continues to expand, it’s more important than ever to prioritize the focus on your board’s effectiveness. CMS is putting a focus on board involvement, including that hospitals must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program. The governance/board must:

  • Engage in oversight of QAPI for all services provided, including contracted services 
  • Document board member attendance at board quality committee and that QAPI is included in every agenda and in board meeting minutes
  • Approve a number of annual QAPI projects that represent the complexity of an organization
  • Ensure the focus is on high-risk; high-volume; problem-prone areas


The Joint Commission’s leadership requirements note that the governing body is ultimately accountable for the safety and quality of care, treatment, and services in the hospital and provides the resources needed to achieve this goal.

JCR advisory services experts can provide an assessment of your governing board’s current activities and guidance in areas such as*:

  • Development of board agendas, including key topic areas such as diversity, equity and inclusion and environmental sustainability 
  • Development and hosting of post survey board retreats with a focus on QAPI
  • Board Quality Committee assessments and education

*The use of Joint Commission Resources consultative technical or advisory services is not necessary to obtain a Joint Commission Accreditation award, nor does it influence the granting of such awards.

What your Board needs to know about quality and safety publication

Publication Specific to Educating Your Board

What Your Board Needs to Know About Quality and Patient Safety: A Joint Commission Guide educates boards about key topics related to quality & safety and offers recommendations for effective governance.

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The needs of your health care organization are unique.  Connect with an expert to explore the specific ways we can support your goals.