COA - Council On Accreditation

	Governance

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

Administration and Management Narrative (CA-GOV):

The Administration and Management Narrative should provide an overview of key practices that contribute to the performance and productivity of your organisation. The Narrative supports, but should not duplicate, evidence provided elsewhere in your self-study.

The Governance Administration and Management Narrative should provide the Peer Review Team with a clear, concise description of how your governing body (Board of Trustees, Advisory Group, etc.) helps to shape, advance and sustain your organisation’s mission and strategic goals.

Purpose Standard: Governance (CA-GOV)

Sound governance increases the organisation’s viability and sustainability.

Provide responses to the following questions that address your organisation’s achievement of the Governance Purpose Standard. Highlight applicable obstacles and innovations, if any, in each of your responses.

1. Describe the activities of your governing body that contribute to effective governance. Include or discuss:

Changes in or unique characteristics in your corporate structures, including mergers and acquisitions; and
Any separate legal entities, such as foundations, not-for-profit corporations, for-profit subsidiaries, or holding companies that have been established on the organisation's behalf. If you are owned wholly or in part by another entity, please describe your governance relationship.

(e.g., Our organisation merged with another entity three years ago; the two boards were combined into one, and an equal number of representatives from each entity were included on the merged board with special attention to including representation from cultural groups…)

2. Cite 2-3 examples of activities or decisions that your governing body has undertaken which contributed to your organisation’s growth and development.

(e.g., The board approved plans to acquire additional space to expand its counseling services…)

3. Identify a part of your strategic plan that has been:

the most difficult to advance, and indicate the reasons why; and
the least difficult to advance, and indicate the reasons why.

(e.g., Due to recent funding cuts at the Provincial level in residential treatment services, we have been exploring new resources and diversification strategies in order to meet our strategic goal of expanding our services to one of the underserved populations in our community…)

4. Describe the data available to the governing body, and how it is used for setting strategic direction. Specify any significant political, regulatory, cultural or economic changes that have impacted the organisation’s direction and/or ability to fulfill its mission.

(e.g., We provide the board with a monthly report indicating changes in our staff so that the board can better review budget issues regarding in-service training and compensation…)

5. Describe how your governing body and CEO/Executive Director work together to strengthen your organisation’s capacity to meet its mission.

(e.g., Our CEO meets with the board chair regularly between board meetings to strategize about developing governance initiatives…)

6. Provide any additional information about your organisation’s governing body that would increase the Peer Team’s understanding of how the governance practice(s) increases the organisation’s viability and sustainability.

Attachments:

A list of Governing Body members, with brief bios, that includes qualifications per CA-GOV 2.02 and 2.03.
Community Demographic Profile.
All COA-approved NA Requests.
A list of all NAs applicable to your organisation provided within the standards.

Note:

Organisations being accredited for the first time: Please provide information for the last year.

Organisations being reaccredited: Please provide information for the period since the last accreditation review.


	Self-Study Documents	On-Site Documents	On-Site Activities
CA-GOV 1 Legal Authorisation to Operate		Bylaws/charter/articles of incorporation or other documents demonstrating legal authority to operate in force when Accreditation Agreement is signed	Interview: CEO/Governing Body Chair
CA-GOV 2 Governing Body and Community Representation*			Interview: Governing Body Personnel
CA-GOV 3 Mission		Organisation’s mission statement	Interview: Governing Body Personnel Persons served
CA-GOV 4 Community Involvement and Advocacy	Summary overview/listing of community education and outreach activities related to service needs and service provision for the previous two years		Interview: Governing Body CEO Programme and clinical managers Community stakeholders Persons served
CA-GOV 5 Organisation of the Governing Body	Bylaws/charter/article of incorporation	Governing Body Minutes Manual, as applicable	Interview: Governing Body Chair Governing Body Secretary Governing Body Programme managers
CA-GOV 6 Governance Responsibilities*	Long-term or strategic plan	Governing Body and/or committee meeting minutes including record of policy decisions Management letter from last two audits	Interview: Governing Body Chair CEO Governing Body CFO (CA-GOV 6.04 and 6.05) Governing Body Treasurer (CA-GOV 6.04 and 6.05) Management personnel (CA-GOV 6.06)
CA-GOV 7 Oversight of Investments*		Governing Body and/or committee meeting minutes including investment reviews	Interview: CEO/CFO Governing Body Personnel at all levels
CA-GOV 8 Executive Director		CEO job description CEO resume	Interview: CEO Governing Body Chair Personnel at all levels

Fundamental Practice Standards:


Essential Life and Safety	Health and Welfare	Client Rights

RELATED FILES


	ADMINISTRATION The personnel responsible for management functions of the organisation, including fiscal management, human resources, and service delivery. Such personnel determine organisational goals, acquire and allocate resources to carry out a programme, coordinate activities toward goal achievement, and monitor, evaluate, and make needed changes in processes and procedures to improve the likelihood of goal achievement. The term is synonymously used with MANAGEMENT.


	PRACTICE Established actions or ways of proceeding in the regular performance of organisational duties. Policies and procedures often guide practice.


	PERFORMANCE A measure of how well an organisational system provides services to consumers. Performance is often based on key indicators, such as rates of service, cost per consumer, degree of satisfaction with services, and extent of consumer access to services.


	PEER REVIEW An evaluation process in which professionals from similar backgrounds review the work of their associates.


	GOVERNING BODY A person or persons with the legal authority and responsibility to set policy and oversee the operations of an organisation. Generally, the governing body is a group, such as a board of directors or board of trustees. While the exact responsibilities of the governing body depend on the nature and character of the organisation, the governing body has minimum fiduciary responsibilities to the organisation set by Letters Patent, statute, regulation, and case law, and typically assume responsibilities for long term planning, risk management, and evaluation and effectiveness of management.


	ADVISORY GROUP A group of individuals selected by an organisation's governing body or management who possess unique skills and/or knowledge and whose role is to make recommendations, provide information, and/or share input from stakeholders. Advisory groups do not have formal governance authority or responsibilities. Advisory groups can be ongoing or ad hoc.


	SERVICE One or more organisation-operated programmes or activities that have a common general objective and deploy the organisation’s material and human resources in a planned and systematic manner. An organisation that publicly promotes or identifies itself in writing as offering a service, is licenced to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	COMMUNITY A specific group of people living in the same locality, and who may share a common culture, values, and norms. Communities can also be defined by race, religion, ethnicity, age, occupation, political status, interest in particular problems or outcomes, or other common bonds. The term "community" encompasses worksites, schools, residential neighbourhoods, business districts, recreational sites, and health and human service sites.


	IN-SERVICE TRAINING Educational programmes provided by an organisation to help personnel become more knowledgeable, skilled, and effective in accomplishing specific tasks or meeting the overall objectives of the organisation. Such training often occurs on the job and for short time periods.


	ACCREDITATION The formal evaluation of an organisation against accepted criteria or standards. A professional society, non-governmental organisation, or a governmental agency may conduct accreditation activities. A COA-accredited organisation has undergone a period of rigorous self-study and is capable of providing programmes and services that meet or exceed COA standards.


	MANAGEMENT See ADMINISTRATION


	EXECUTIVE DIRECTOR See CHIEF EXECUTIVE OFFICER


	PERSONNEL The body of employees and/or volunteers that carries out the organisation’s tasks under the organisation’s administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards.


	OUTREACH Contact initiated by a provider to identify persons in need of services, to provide information to them about services and benefits, and to encourage the use of appropriate services.


	BYLAWS The operating procedures developed by the governing body and adopted by the organisation for the regulation of its internal affairs, including the actions of the governing body and its relationship to the chief executive officer and any advisory board associated with the organisation.


	PROGRAMME A system of services offered by an organisation. For example, an organisation providing a mental health service may offer several mental health programmes to different populations, e.g., a mental health programme for adolescent teens. The word “programme” can be used interchangeably with the word “service” or to describe specific programmes.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	STAKEHOLDER Any person, group, or organisation that has a vested interest in the services provided by the organisation. Examples: clients, consumers, personnel, funding organisations, referral organisations, vendors, and governmental bodies.


	MANAGEMENT LETTER A letter addressed to an organisation containing an auditor’s conclusions regarding the organisation’s accounting policies and procedures, internal controls, and operating policies. The letter evaluates the organisation’s present system, identifies problems and recommends improvements. It is also referred to as a Letter of Recommendation.


	JOB DESCRIPTION Explicit obligations and specific tasks required of personnel as a condition of employment. Such descriptions are in writing and may include educational, experiential, and skill requirements associated with the job.