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Increasing Governance Demands on Healthcare Organisations

Healthcare organisations have to meet a considerable number of governance obligations in addition to the clinical obligations that are placed on them.

These obligations arise as a result of, among other things, company law - if the organisation is a company, charity law - if the organisation is a charity, contractual arrangements with funders, and regulatory requirements.

Time and resource

For section 38 and section 39 organisations, governance obligations arise from a number of Health Service Executive (HSE) sources. These include:

  • The organisation’s service agreement (SA) with the HSE
  • The Annual Compliance Statement
  • The Code of Practice for the Governance of State Bodies, to the extent applicable, and
  • The HSE Code of Governance, to the extent applicable

When considered in conjunction with the governance obligations placed on section 38 and section 39 organisations by other legal requirements, the time and cost that it can take for a healthcare organisation to consider, analyse, demonstrate and record compliance with all of these governance obligations can be considerable.

Charities Governance Code

2021 was the first year that most charitable organisations were required to report on their compliance with the Charities Governance Code, as part of their annual report. Now that charities have completed two years of reporting on compliance, many will be familiar with the requirements of the Code, including the requirement to document “evidence” which demonstrates compliance with a particular standard of the Code.

Demonstrating compliance with the Code through other means

It is an opportune time for healthcare organisations to consider whether compliance with some aspects of the Code can be evidenced by compliance with other governance requirements. We have assisted a number of our healthcare clients with demonstrating that complying with certain extensive governance requirements required by one regulator is evidence of complying with (some or all of) the governance standards of another regulator. This reduces duplication of reporting, where an organisation is required to record compliance with governance requirements which are very similar to each other.

While the initial task of comparing certain governance standards against each other will inevitably take some time, this process can reap benefits over the years to come for those organisations who undertake this task, as they can potentially focus on reporting adherence to one set of governance standards instead of duplicating efforts.

If this is something that you consider might be useful to your organisation, feel free to get in touch with us and we would be happy to discuss it with you further.


In an era of increased regulation, it is important to seek efficiencies in relation to governance reporting obligations wherever they may arise and to reduce duplication as much as possible. While the importance of reporting on governance compliance is recognised, we are conscious that the time and resources of healthcare organisation needs to be focused on delivering the mission of the organisation.

We would be happy to assist with assessing whether efficiencies could be obtained regarding your organisation’s governance reporting. For more information and expert advice, contact a member of our Charity and Not-for-Profit team.

The content of this article is provided for information purposes only and does not constitute legal or other advice.

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