Reviewing your organisational structure’s effectiveness

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When Governance arrangements are appropriately structured and provide clear lines of accountability and responsibility at all levels, they offer assurances to the quality and safety of the healthcare service. A well-developed governance structure ensures that staff know their own responsibilities, the responsibilities of other staff and who they report to. It helps to manage expectations and enables better communication and decision making.

In HCI’s Research Paper The Healthcare System: Will We Ever Learn? Review of the common themes arising from UK and Ireland healthcare inquiries, HCI found that throughout the inquires reviewed, Governance, or lack thereof, was identified as being central to systematic failures that facilitated catastrophic patient outcomes. An inadequate governance structure was one of the key governance failings. In the Savita Halappanavar investigation, the HIQA report communicated the Authority’s concern at the complexity of the governance structure and the large numbers of committees in place within the Hospital, with a number of these involving the same members, many of whom also had full-time clinical responsibilities (HIQA, 2013). Similarly, the Portlaoise Investigation found that the committees responsible for providing safe effective services through leading and directing the performance of the Hospital did not address quality and safety issues, with overly complicated structures that were ultimately not effective (HIQA, 2015).

It is important to evaluate the organisational structures to determine if the correct people are in the roles and that they are doing what they are supposed to be doing. In this blog we offer some considerations and evidence to look for when reviewing the effectiveness of the organisational structure.

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Organisational Structure Effectiveness

Board of Directors

Ultimate responsibility for all aspects of service delivery lies with the Board of Directors. Therefor it is crucial that the organisation has a clearly identified Board of Directors. There must be a mix of experts who are highly experienced, have an appropriate balance of skills and knowledge of the organisation to enable them to perform their duties effectively.

It is important to regularly evaluate the effectiveness of the Board of Directors. Some areas to consider when determining the effectiveness of the Board.

  • Do they have a Board Code of Conduct? (like a Terms of Reference)
  • Who are the Board members? Do they have a complement of relevant experience?
  • Do they have regular meetings? (minimum annual, recommended monthly)
  • Is there a clear and relevant agenda?
  • Minutes should follow the agenda. Are they clear and do follow up on actions from previous minutes?
  • Do they review relevant quality and safety data, KPIs, inspection reports etc?
  • Are they taking actions when necessary?
  • Has training been provided to Board members on the roles and responsibilities of being a Board member?

Management and Staff

When reviewing the governance and organisational structure you must consider evidence from Management to front line staff to determine the effectiveness of each role. Look at job descriptions, roles and responsibilities and reporting structures. Areas to consider for each role include:

  • Is it clearly defined who this person is?
  • Is there a clear role / job description for the position?
  • How does everyone report to them, on the chart and in reality?
  • What happens when they are not on duty / on leave?
  • Is the position vacant? If so, who is fulfilling the role in practice?
  • How are they aware of what is happening in the organisation? 

Teams and Committees

The teams and committee structure should be reflective of the organisational structure. Teams and committees should be minimised and focus on specific areas relevant to the service. When collecting evidence as to the effectiveness of the various teams and committees, consider the below questions:

  • What is their function?
  • Who is on the team?
  • Who actually attends the meetings?
  • How often are the meetings held and how often should they be held?
  • How long are the meetings?
  • What is discussed at the meetings?
  • Are actions from previous meetings dealt with?
  • Are the minutes clear and comprehensive?
  • Is the team and committee in practice reflective of the Terms of Reference?
  • Has the team and committee been reviewed/evaluated, and any changes made based on this review?
  • When was information from the team and committee last communicated to another team?

Tips for Developing an Organisational Chart

Organisational charts will vary from each organisation, depending on size and the type of service. However, there are a number of points that should be considered when developing the organisational chart:

  • Registered Provider / Board of Directors / Most senior entity should be included
  • Aim for max 6 – 8 reportees to each Line Manager
  • Everybody needs a manager to support them
  • ‘Dual’ reporting should be minimised, and clearly defined
  • Staff cannot report to a committee
  • HCAs cannot report to ‘the nurses’
  • Clear delineation between clinical and support services
  • Org chart forms the basis for the team and committee structure


Appropriate governance and organisational structures are vital to the overall quality and safety of delivery of services. It is important for services to regularly review these structures to ensure that they are operating as they should be.

HCI is a provider of professional services in relation to patient safety, quality improvement, and regulatory compliance. We have over 16 years’ experience in supporting health and social care organisations in building robust governance arrangements, helping them to ensure effective oversight and improve the quality and safety of services.

HCI Research Paper: The Healthcare System: Will We Ever Learn? Review of the common themes arising from UK and Ireland healthcare inquiries

Click here to download a copy of HCI’s Research Paper The Healthcare System: Will We Ever Learn? Review of the common themes arising from UK and Ireland healthcare inquiries.


Contact HCI

For more information contact or Phone +353 (0)1 6292559.