Board Policy Manual

Part 1: The Hospital

The Organization

  • 1-A-02 Corporate Mission, Vision and Values
  • 1-A-03 Board Accountability Statement
  • 1-A-04 Code of Conduct (including board)
  • 1-A-06 Ethics Framework
  • 1-A-08 Strategic Plan
  • 1-A-10 Operating Plan
  • 1-A-11 Annual Quality Improvement Plan
  • 1-A-12 Capital Plan
  • 1-A-13 IT Strategic Plan
  • 1-A-15 CMH Programs
  • 1-A-20 Organizational Chart

Relationships and Partnerships

  • 1-B-02 The Health Care Environment (reference to OHA GtoGG)
  • 1-B-04 Ministry of Health and Long-Term Care (organizational chart)
  • 1-B-05 Making Healthy Change happen
  • 1-B-06 Waterloo-Wellington LHIN
  • 1-B-10 Volunteer Association
  • 1-B-12 Foundation
  • 1-B-15 Corporate communication policy

Legal Structure

  • 1-C-02 Legislative and Regulatory Requirements (info)
  • 1-C-05 Letters Patent and Supplementary Letters Patent
  • 1-C-10 By-laws
  • 1-C-12 Credentialing and granting privileges to professional staff Medical Advisory Committee
  • 1-C-20 Reporting on Compliance

Part 2: The Board

Structure, Roles and Responsibilities

  • 2-A-02 Principles of Governance
  • 2-A-04 Roster of Directors
  • 2-A-06 Committee Membership
  • 2-A-08 Board Charter
  • 2-A-10 Audit Committee Charter
  • 2-A-11 Tri-Hospital Research Ethics Board (THERB) Terms of Reference 
  • 2-A-12 Executive Committee Charter
  • 2-A-14 Resources Committee Charter
  • 2-A-15 Capital Projects Sub-Committee Charter
  • 2-A-16 Governance Committee Charter
  • 2-A-18 Quality Committee Charter              
  • 2-A-19 Medical Advisory Committee
  • 2-A-20 Role Description for Chair of the Board
  • 2-A-22 Role Description for Vice-Chair
  • 2-A-24 Role Description for Secretary
  • 2-A-26 Role Description for the Board Secretary
  • 2-A-28 Role Description for Committee Chair
  • 2-A-30 Responsibilities of Director
  • 2-A-31 Ex-Officio Directors
  • 2-A-32 Responsibilities of a Non-Director Committee Member
  • 2-A-34 Confidentiality Policy
  • 2-A-36 Conflict of Interest Policy
  • 2-A-38 Attendance Policy

Oversight of Management and Professional Staff

  •  2-B-05 Role Description of the CEO
  • 2-B-06 Role Description of the Chief of Staff
  • 2-B-10 Succession planning for the CEO and Executive Staff
  • 2-B-12 Succession planning for the COS
  • 2-B-15 Recruitment and selection of the CEO
  • 2-B-16 Recruitment and selection of the COS
  • 2-B-20 CMH Executive Compensation Policy
  • 2-B-25 CEO performance review policy
  • 2-B-26 COS performance review policy
  • 2-B-32 CNE role description

Corporate Performance and Oversight

  • 2-C-10 Quality and Patient Safety
  • 2-C-20 Enterprise Risk Management
  • 2-C-30 Financial objectives
  • 2-C-31 Financial planning and performance
  • 2-C-32 Asset protection
  • 2-C-34 Approval and signing authority
  • 2-C-36 Borrowing
  • 2-C-38 Investment
  • 2-C-40 Capital Projects - Change Order Approval Policy
  • 2-C-50 Performance Monitoring (information about scorecards)

Board Processes

  • 2-D-02 Board Policy Development, Review and Approval
  • 2-D-04 Annual board work plan (including committee work plans)
  • 2-D-06 Board meeting agenda (including Consent Agenda)
  • 2-D-07 Quorum and voting at meetings
  • 2-D-08 Board and Committee Meetings policy
  • 2-D-09 Procedure for members of the public addressing the board
  • 2-D-10 Decision making process, conflict resolution, meeting procedures
  • 2-D-16 Meeting of independent directors
  • 2-D-18 Board succession planning
  • 2-D-20 Recruitment, selection, and nomination of directors
  • 2-D-21 Staff member recruitment to Quality Committee 
  • 2-D-22 Board Declaration
  • 2-D-24 Directors and officers liability insurance
  • 2-D-30 Orientation for new directors and committee members
  • 2-D-32 Board Education policy
  • 2-D-34 Board director travel and expense policy
  • 2-D-40 Evaluation of board, committee, and individual performance
  • 2-D-45 Removal of a director, committee member
  • 2-D-48 Whistleblower Policy
  • 2-D-50 Prequisites Policy
  • 2-D-60 Board member recognition

Glossary of Terms