Approval, Authorization and Responsibility Matrix APPROVED 12/14/2005 REVISED 11/29/2017

Transcription

1 Senior & Executive I. Governance - Appointments and Removals A. Board s election and removal B. Establishment of Board Committees C. Executive Selection and Termination 1. 2 Other Executives Required in District Bylaws: Any Chief 3.Other Executives D. Performance iew for Executives Other Executives II. Governance - Reserved Powers & Approvals A. Approve System Mission, Vision and Values B. Adhere to Bylaws C. Responsibility Matrix D. Strategic Plan E. Approve the creation or dissolution of MIHS subsidiaries, partnerships or joint ventures III. Financial Planning, Budgeting and Oversight A.Financial planning and budgeting calendar CFO B. Oversee financial planning activities CFO C. Approve Board financial policy statements D. Approve strategic financial plan ( 5 year) E. Approve annual budgets F. Approve external auditor selection G. Approve internal audit plans Page 1 of 7

2 Senior & Executive IV. Contracting and Procurement A. Approve and/or execute construction (as defined in the Procurement Code), revenue and/or expenditure contracts, in accordance with approved plans and budgets, for construction projects, the purchase of goods, purchased services with estimated purchases of : 1. $0 - $50,000 with aggregate annual amount 2. $0 - $100,000 with annual aggregate amount 3. $0 - $250,000 with aggregate annual amount 4. $250,001 and above with aggregate annual amount 5. Emergency Procurements greater than $25, Emergency Procurements not exceeding $25, Intergovernmental Agreements and any Amendment to an IGA B. 1. Approve all non-capital GPO (Group Purchasing Organization) supplier sub-contracts that also involve reduction in price or expansion of scope of work with aggregate annual amount up to $250, Approve all non-capital GPO (Group Purchasing Organization) supplier sub-contracts that also involve reduction in price or expansion of scope of work with aggregate annual amount in excess of $250,001. C. Grant Applications Approval Authority - Determined by Grantor/Funder Requirements D. Approve acceptance of donations; donate surplus/obsolete equipment and materials to charitable organizations E. All involving the sale, lease, and purchase of Real Property F. Approve all lawsuit settlements less than $100,000 (Not covered by Self Ins. Plan) G. Approve all lawsuit settlements more than $100,000 (Not covered by Self Ins. Plan) H. Approve and/or execute purchase requests for capital expenditures 1. Budgeted 2. Substitution within Budget I. Approve sale, trade-in, disposal of excess/surplus materials a. <$100,000 b. >$100,000 J. Purchase Authorization Where There is No Underlying Contract: 1. $0 - $ $0 - $1, $0 - $5, $0 - $25, $0 - $99, $100,000 - $250, Greater than $250,001 K. Procurement Card (P-Card): Approve purchase of goods and services in accordance with current Procurement Card Policy & Procedure and authority limits L. Notwithstanding any other section in this Matrix, any contract procured via MIHS formal procurement process, with expenditure greater than $50,000 per year and that has a term of beyond 5 years or that is to be extended beyond a term of 5 years. Refer to current Procurement Card Policy & Procedure for Authority Limits Page 2 of 7

3 Senior & Executive V. Information Technology (CIO & IT dept approvals) A. Approve software/hardware acquisitions (Functional Compatibility) CIO B. Develop policy and procedures for network usage, , intellectual property, telecommunications, radio, cell phones, pagers. CIO C. Maintain Business Continuity and Recovery Plans VI. Patient enue Activities (Dept & Mgr approvals) A. Financial Assistance, Payer Discounts, Refunds, Check Requests, and Administrative Adjustments, Lien Settlements, & approval of write-offs B. Any individual negotiated adjustment 1. <$50, >$50,000 - $100, >$100,000 - $250,000 CFO 4. >$250,001 - $500, >$500,000 C. Payment Plans 1. exceeding more than 12 months 2. Less than $100/month VII. Physicians and Medical Staff (CMO approvals) A. Provide physician leadership education and training B. Medical Staff/HP Credentialing & Privilege Delineation C. Monitor procedural due process for members of the Medical Staff D. Maintain timely communications by and between the Medical Staff E. Approve changes to Medical Staff bylaws, regulations and policies F. Approve Medical Staff Department Chairs consistent with Medical Staff Bylaws Page 3 of 7

4 Senior & Executive VIII. Developing and Executing Quality Initiatives A. Key Quality Focus Area Responsibilities 1. Development 2. Monitoring 3. Implementation and reporting B. Approve quality targets and plans to achieve quality targets C. See that corrective actions are taken when needed D. Monitor malpractice data I. Accreditation, Regulatory, Compliance, Risk A. Approve MIHS Compliance Program, Design, Structure and Policies B. Compliance with appropriate regulatory requirements including but not limited to TJC, DNV, CMS, TDIL, AHCCCS, CAP, NCQA, IRS, CARE, IDI, etc. C. Approve PI Process, Safety, Disaster Planning,. Human Resources A. Overall Compensation Policy B. Overall Benefit Plan C. Overall Performance iew Plan D. Operating Policies: E. New Hires, Transfers, Terminations 1. Within Approved Budget 2.Not Budgeted F. Annual Performance iews G. Promotions and Salary Adjustments 1. < 10% 2. > 10% H. Bonus, ie, Sign-on, Referral, Retention, etc I. Relocation Policy J. Personnel Action Forms (PAF) 1. Within Approved Budget 2.Not Budgeted K. Personnel Requisitions 1. Within Approved Budget 2.Not Budgeted Page 4 of 7

5 Senior & Executive I. Risk Issue/Transaction I. Risk A. Approve MIHS insurance coverage, and insurance and self-insurance policies B. Approve claim settlement less than $99,999 (covered by Risk Insurance & Self-Insurance Plan) C. Approve claim settlement $100,000 - $250,000 (covered by Risk Insurance & Self-Insurance Plan) D. Approve settlement claim $250,001 (covered by Risk Insurance & Self-Insurance Plan) E. Approve revisions to MIHS Risk Insurance & Self-Insurance Plan F. Approve valid claim related expenses (covered by Risk Insurance & Self-Insurance Plan) G. Patient Account Adjustments less than $15,001 Senior & Executive Compliance Director Risk Claims Committee Page 5 of 7

6 II. PROPOSITION 480 PROJECTS MANAGEMENT Issue/Transaction CEO with Concurrent CFO with Concurrent with Written Approval by CEO and Telephonic and E- mail within 24 Hours of Taking Action with Telephonic and within 24 Hours of Taking Action A. Program Planning and Development 1. Business Plans for All Projects 2. Tactical Plan 3. Program, Procurement and Contracting Process 1. Financial Planning and Budgeting Calendar 2. Oversight Financial Planning Activities 3. Strategic Financial Plan 4. Annual Budget 5. External Auditor 6. Internal Audit Plans C., Procurement, and Group Purchasing Organization (GPO) 1., GPO and Guaranteed Maximum Price (GMP) Amendments to Previously Approved When the Total Contract Price Remains Under $500, Guaranteed Maximum Price (GMP) Amendments to Previously Approved When the Total Contract Price Is Over $500, Over $500, Procurement Card: Purchases of Goods and Services with a MIHS Procurement Card and in Preapproved Amounts as Determined by the P-Card Holder's Manager and the C.F.O. in Accordance with the Procurement Card Policy Refer to current Procurement Card Policy & Procedure for Authority Limits Plus Quarterly Reports to the Board Page 6 of 7

7 II. PROPOSITION 480 PROJECTS Approval, Authorization and Responsibility Matrix MANAGEMENT Issue/Transaction CEO with Concurrent CFO with Concurrent with Written Approval by CEO and Telephonic and E- mail within 24 Hours of Taking Action with Telephonic and within 24 Hours of Taking Action D. Emergency Change Orders and Authorizations 1. Emergency Change Orders and Authorizations Under $500, Emergency Change Orders and Authorizations Over $500,000 But Under $1,000, Emergency Change Orders and Authorizations Over $1,000,000 "Emergency" is as any occurrence which halts or severely adversely impacts ongoing construction of a Project and therefore requires an immediate decision E. Non-Emergency Change Orders and JOC Work Orders 1. Subject to E. 4 Below, Non-Emergency Change Orders and JOC Work Orders Under $250, Subject to E.4 below, Non-Emergency Change Orders and JOC Work Orders Over $250,000, But Under $500, Non-Emergency Change Orders and JOC Work Orders Over $500, Cumulative Change Orders and JOC Work Orders on any Project: (i) Exceeding 5% of the Project Cost or $5,000,000, whichever is Less; or (ii) That Create a Significant Change In Project Scope Beyond Prior Approval by the Board F. Risk 1. Settlements of Proposition 480 Related Lawsuits Not Covered by the District s Self Insurance Plan Under $100, Settlements of Proposition 480 Related Lawsuits Not Covered by the District s Self Insurance Plan Over $100, Approval of MIHS Insurance Coverages, Self-Insurance Policy Retention Amounts, and Related Premiums G. Excess/Surplus Materials 1. Sale, Trade-in, and/or Disposal of Excess/Surplus Materials Under $500, Sale, Trade-in, and/or Disposal of Excess/Surplus Materials Over $500,000 Page 7 of 7