Skip to main content

Hospital governance accountability structure: a scoping review



Hospitals, as complex organizations with clinical, financial, and social functions, face different barriers to providing high-quality and safe services at reasonable costs. Various initiatives have been carried out in hospital governance to improve quality, safety, and accountability. This research aims to identify the structures and dimensions that make hospital governance accountable.


The research used Arksey and O'Malley's scoping review framework to examine the research literature on hospital governance structure and accountability. The literature review included PubMed, Web of Science, Embase, Scopus ProQuest, Google search engine, and Google Scholar databases from 2010 to 2023. Data were analyzed using the content analysis method.


Excluding unrelated and duplicate sources, 40 articles and reports were included in the study. The studies were reviewed and analyzed based on organizational type, type of source, year of publication, objectives, and key findings. Accountable governance features were extracted from the selected articles and reports. The four main themes include inclusive governance, commitment to accountability, planning for accountability, and autonomous governance. Thirteen subthemes were extracted from the study literature.


Various initiatives have been implemented regarding the reform of the governance structure of public hospitals in different countries. Many of these reforms aim to improve financial and clinical accountability. The study results could be used to identify the structures and dimensions that make hospital governance accountable.

Peer Review reports


One of the fundamental factors of an organization's success is accountability [1]. Accountability in organizations that provide health services is defined as the responsibility of an individual or an organization regarding its actions and performance [2]. Accountability in hospitals refers to responsibility for the overall quality and safety of care [3]. Hospital governance can be defined as the set of structures and processes that define the strategic direction for the hospital and the means by which resources are assembled and allocated to achieve them [4]. Hospital governing bodies have a fundamental role in overseeing quality and safety by defining priorities and objectives, crafting strategy, shaping culture, and designing organizational control systems [3]. An accountability regime will always be based on three elements: a clear definition of desirable goals or objectives (the object of accountability), the ability to measure and monitor goal achievement, and a set of consequences for providers or organizations if achievements regarding goals or objectives are not satisfactory [5] In recent years, improving the accountability of healthcare organizations has been one of the main motivations for reforms in health systems [2]. Studies have introduced accountability as a tool for increasing transparency and improving healthcare quality [6, 7].

However, in developing countries, health sector reforms have concentrated primarily on increasing financial accountability and have paid less attention to other forms of organizational accountability [8]. The Health Services Delivery Program of the World Health Organization introduces five components of accountability: a) legal accountability, which includes planning, contracting, and budgeting; b) financial accountability, which includes tracking and reporting on fund allocations, funds disbursement, and ethical use of resources; c) professional accountability, which promotes service delivery according to legal, ethical, and professional standards; d) political accountability, which ensures that governments fulfill public trust, represent the public's interest, and respond to societal needs and concerns; and e) public accountability, which includes public engagement at all levels and appropriate structures to support information flow between decision-makers and different public involvement fora [9].

The concept of accountability has traditionally been drawn somewhat narrowly by public lawyers to encompass the formal duties of public bodies to account for their actions to ministers, parliament, and courts [10], so a common understanding of hospital governance accountability is where an upstream entity such as a government, regional health agency, board of trustees, or professional association can hold providers or organizations accountable for achieving specific goals or objectives [5]. Hospital governance might promote or undermine health performance [11, 12]. The governance structure defines the strategic direction, objectives, policies, legislation, regulations, and programs and monitors and assesses their achievement [13]. In this study, we consider both internal and external accountability.

Hospital governance leadership differs from other institutions or industries [14,15,16,17]. The external environment of the hospital is constantly under the pressure of public opinion and governments to spend resources more efficiently [14]. The internal environment of the hospital has various independent specialists, such as physicians, nurses, paramedics, financial affairs, and management professionals, who communicate and make them accountable for achieving hospital goals, which is a complex matter [18].

Hospital leaders should question whether the current organizational governance structure is optimal for converting inputs into clinical and financial outputs [19,20,21]. The perceived problems in ensuring the accountability of hospitals and the efficiency of their performance led governments to various governance structure initiatives. Autonomous hospitals, corporate hospitals, hospitals with boards of trustees, hospitals with public‒private partnerships, and budgetary hospitals are examples of these structural initiatives [22, 23]. These structural reform initiatives had different positive and negative outcomes [23].

Clinical professionals try to achieve health goals, and the management team tries to achieve financial and management goals in their way. This shows the necessity for aligning these teams to a specific and robust hospital administration and management structure. The point where many of them are the most critical problem in hospitals is existing clinical and nonclinical parts and making both parts accountable [18, 24, 25]. Hospital governance refers to the balancing mechanisms and controls that shape the decision-making process in hospitals. Clinical participation and management professionalism are essential aspects of the governance structure in a hospital [20]. Clinical and nonclinical actors have different patterns of thinking and doing at different organizational levels in hospital districts and different perspectives on accountability. In this setting, the gap between managerial identity accountability (i.e., to comply with governance policies issued by the political institution) and the accountability of medical professionals in their domain leads to accountability tensions [26].

Hospital decision-making is a complex and often diffuse process involving key people, including physicians, administrators, and boards. Physicians are essential in clinical decisions and should be accountable for high-quality, safe care. Administrators influence hospital policy and planning activities [27]. Medical staff usually involved in the hospital governance structure as board members or organized in a separate structure have been called under various names, including medical staff council or medical advisory committee, to create accountable clinical departments [28, 29].

The most important task of the hospital is to provide safe and quality clinical services [30]. If it is not considered in the hospital's governing structure, the capacity for this function cannot be sure of its accountability [31]. Hospital governance can only be fully understood by taking the role of the medical staff into account. Therefore, hospitals should use medical staff as financial and planning committees in their governance structure [32]. As a result, while the administrative structures of the hospital are legally responsible for monitoring quality and safety, they delegate authority for monitoring quality and safety in the scope of the medical staff council [21].

A typical model of hospital governance to overcome accountability problems is adding upstream structures, such as the Board of Trustees, to the hospital governance structure [33, 34]. Having a professional, vigilant, independent board greatly impacts the performance of any organization, including hospitals [35]. Empowered by a strong and effective board, a well-performing hospital will be able to ensure that social obligations can be fulfilled and that patients will receive proper treatment and care while maintaining economic and financial sustainability [36]. Some studies show that a common factor in the inefficiency of various governance structures is weakness in monitoring and responding to quality issues in public hospitals [37]. The importance of governance for the accountability of health systems is broadly recognized. Despite this recognition, accountable governance definitions continue to be disputed, and arguments and confusion persist about how governance structure interventions influence hospitals' accountability and health outcomes. Governance-related linkages or interventions often need to be better understood and documented. This lack of evidence can result in reticence and hesitation to invest in hospital governance structure improvements or overreliance on a limited set of successful governance interventions [36, 38].  An accountable governance structure is necessary because public hospitals play an essential role in health systems. However, identifying the characteristics and activities of this structure to achieve accountability has received less attention. The present study aimed to identify accountable governance structures in public hospitals through a scoping review of the global research literature.


Eligibility criteria

The present study uses the Arksey and O'Malley framework to examine the extent, range, and nature of research activity on the accountable governance structure in public hospitals. Arksey and O’Malley’s framework includes six stages, the sixth being optional: a) identifying the research question that it is necessary to include three parts of the research question: a) Population b) Concept c) Context (PCC question); b) identifying relevant studies, a process that is as comprehensive as possible; c) study selection, with the establishment of inclusion/exclusion criteria, based on familiarity with the literature; d) charting the data, a stage that includes sifting, charting, and sorting information according to key issues and themes; e) collating, summarizing, and reporting the results, which provides both a descriptive and numerical summary of the data and a thematic analysis; and f) a consultation exercise, an additional, parallel step involving key stakeholders to inform and validate study findings [39]. Peer-reviewed papers and the gray literature (government reports, policy documents, reports of consultants, unpublished reports) were written in English between 2010 and January 2023. Databases of ongoing research and unpublished literature were searched. According to the research question, studies about P= public hospitals, C=accountable governance, and C= all over the world were included in the study. Other inclusion criteria were published after 2010 and written in English. For gray literature, the inclusion criteria were free online full-text versions, English language, documents related to public hospitals, and the study's time frame. The exclusion criteria were missing full text, articles focused on nonhospital entities, and papers focused on accountable care organizations.

Information sources

The PubMed, Web Of Science, Embase, Scopus ProQuest databases, and Google Scholar search engine were searched. The Google search engine obtains gray literature, including reports, regulations, guidelines, and policies. Google search without a time limit based on the first 200 results added to the search regardless of date. To determine the keywords of the research, after searching the sources and consulting with the experts, the three main concepts of accountability, governance, hospital, and their synonyms were searched in different databases. The search strategies in different databases are reviewed based on the characteristics of the database and presented in Table 1.

Table 1 Search strategy summary for the scoping review

Selection of sources of evidence

First, we entered the literature search from different databases into Mendeley software. The remaining sources are examined after removing the duplicates. Titles and abstracts were screened. In this stage, articles were excluded if they were not relevant. In the next stage, the full text of the remaining sources is screened. Moreover, they were excluded from the study if there were no relevance or exclusion criteria. Finally, the remaining articles were reviewed (Fig 1).

Fig. 1
figure 1

PRISMA flow diagram for included studies

The included sources were reviewed. A summary was prepared. Key points of each reference were identified, and a summary, including the first author's name, the date of publication, the country, the purpose, and the main findings, was prepared (Table 2).

Table 2 Characteristics of the included studies in the scoping review in the order of publication date

Critical appraisal of individual sources of evidence

A scoping study will need some analytic framework or thematic construction to present a narrative account of the literature. There is no attempt to present a view regarding the 'weight' of evidence about particular interventions or policies [39]. Per guidance on conducting scoping reviews and consistent with scoping reviews on health-related topics, the methodological quality of the included reports was not appraised [39, 40].

Synthesis of results

The studies were categorized based on the characteristics of the hospital governance structure, methodology, settings, and key findings. Then, topic construction was performed using the attributes of various hospital governance structures (Table 2). The strategy of data analysis in the present study is qualitative content analysis. Using qualitative content analysis is one of the usual methods for synthesizing results in scoping review studies. This method helps to obtain a summary of the data by coding [41]. The research identifies the components of governance structure and accountability of hospitals worldwide.


Of the 40 sources included in the study, 85% were published in peer-reviewed journals. Moreover, 15% had organizational reports at the national or international level. Sixty-two percent of the sources were published between 2015 and 2022. Seventy-five percent were about the governance and accountability structure in hospitals, and 25% were about hospitals and other health system components. A total of 27.5% of the studies were conducted in the United States, and 37.5% were conducted in European countries and the United Kingdom. A total of 22.5% of the studies were completed with quantitative research methods and the same amount with qualitative research methods. Table 3 describes the sources used (Table 3).

Table 3 Description of included studies

After categorizing and analyzing the data, four main themes and thirteen subthemes were extracted (Table 4).

Table 4 The main themes and subthemes of the study

Inclusive governance

Hospitals are complex entities. Public hospitals face pressure from public opinion and politicians to be accountable for public resource usage. Additionally, the internal environment of the hospital faces various specialties. Management, economics experts, and medical and nursing staff try to achieve their goals. Aligning financial and clinical goals is challenging for hospital governance [26]. In addition, the clinical and administrative departments probably cannot be accountable to each other, so an intermediate structure is necessary to make the two departments accountable simultaneously [18, 24, 26]. For this purpose, the public hospital should use the presence of a board in its structure [19, 43, 53]. This Board can be called the Board of Trustees, the Governing Board, or the Board of Directors [42,43,44,45,46,47,48]. This structure can have medical staff members or a counterpart structure called the council of medical staff [26, 44, 45, 48, 50, 51, 55,56,57]. f [49, 50, 55, 59, 60]. Additionally, the presence of nurses' representatives in the governance structure helps to make nursing and paramedical departments accountable [50, 51, 54, 58]. Forming various hospital committees also helps minimize the gap between clinical and nonclinical groups. These committees lead to a common understanding of barriers and resources [26, 46, 52,53,54].

Commitment to accountability

Accountability has different dimensions and forms. However, developing countries are primarily satisfied with defining it as a financial issue [70]. Public hospitals consume public funds, so the public population is defined as its stakeholders [8, 44,45,46, 48, 52, 60, 61, 63]. This definition ignores their role in providing health care as the essential function of hospitals. Therefore, it needs to be considered a comprehensive definition. An essential part of hospitals' accountability is their clinical accountability. The hospital's governance structure should be committed to providing safe and high-quality care and evaluating its achievement [52, 61, 71]. Another type of accountability is the political and social accountability of the hospital. As a healthcare organization, the hospital has the role of political and social accountability and cannot ignore it. Social and political accountability includes the hospital's responsibility regarding social and political issues, emphasizing their most critical role, namely, the clinical role [45, 46, 52, 61, 64]. Social and political accountability refers to the degree to which governments and institutions deliver on promises, act in the best interest of citizens, and respond effectively to societal needs [61].


In traditional accountability models, hospitals should be accountable to an upstream entity such as the Ministry of Health, local health department, or university. However, implementing external accountability is complex and may not be accurate [72]. In contrast, the hospital may have a structure that goes beyond the administrative bureaucracies of government organizations to monitor its performance and take necessary measures [52, 57, 68, 69]. The hospital should be able to be accountable to its governance structure (board, council of medical staff) for all performances, including financial, clinical, sociopolitical, strategies, and operations [26, 36, 46, 52]. Having a completely independent or hybrid governance structure is a way that hospitals follow to improve their accountability. The meaning of hybrid governance is that, in addition to having an internal structure for accountability, the hospital can also be accountable to the government parts, such as the Ministry of Health, for providing safe, quality services at a reasonable cost [47, 52, 54, 55, 69].

Planning for accountability

The existence of a specific program for accountability helps all stakeholders in hospitals, including clinical and nonclinical staff, patients, and the community, to know their responsibilities and authorities. This document contains an articulated set of responsibilities and associated financial, clinical, social, and political accountabilities. Hospital staff, patients, and society know which kind of accountability structure is run in the hospital and how they can use it if needed [43, 48, 58, 65, 66]. The existence of a clear reporting line that allows each employee to know what structure and people they are responsible for helps to reduce confusion and allows employees to make correct decisions in sensitive situations and benefit from the advice of others. The reporting line will reach the hospital's governance structure, i.e., the board or council of medical staff. Employees must account for these structures regarding their performance [44, 47, 50, 52, 55, 66, 67].


Accountability is an essential part of social relations in societies. Individuals and organizations must be held accountable for what they do or do not do. Organizations that use public funds require high levels of accountability and transparency. Accountability ensures that public funds are properly allocated and closer to their predetermined results. The concept of accountability is considered a key concept in the health system. Since hospitals use the majority of health resources in all health systems, it is necessary to be accountable. The relationship between governance structure in the hospital and accountability is clear. The governance structure in public hospitals is required to provide a basis for achieving accountability in various areas.

The hospital's governance structure must be a combination of its key stakeholders. The presence of management and economic experts, doctors and nurses, and representatives from the community in the hospital's governance structure can effectively increase its accountability. These individuals can be present on the Board, its committees, or similar structures. Atuesta et al. have shown that hospitals whose governance structure also has medical groups can provide better quality and safer services [73]. Nurses are one of the most critical groups in hospitals. The present study emphasizes their role in the hospital governance structure. This finding is in accordance with the study of Esfandnia in Iran. This study also shows that the presence of nurses in the hospital governance structure can improve patient safety [74]. The presence of community representatives on the hospital board was considered in the present study. Wright also criticizes the structure of the hospital's Board of Trustees in Britain and calls for the role of community representatives to play earnest roles [75]. The presence of these categories can provide the report line to the specialized forces in each field. The hospital is a specialized structure, and the existence of different groups in it will probably require a governance structure that can professionally manage each department and person to become accountable for their performance regardless of the type of expertise.

Although there is no unique definition of accountability, different types have been identified in different studies. The commitment of the health system and hospital managers to financial, clinical, and social-political accountability is one of the important findings of this study. Commitment to accountability is an important issue for the hospital's primary goal: clinical accountability. These findings have been confirmed in Cornock's study. In that study, the vital role of the clinical accountability of health professionals was mentioned [76]. However, some studies, such as Cornelese's study, argue that if this account is in the form of accountability to other physicians and specialists because of the psychological influence of peers, it will have adverse effects when an error occurs [77]. In the present study, social-political accountability is a form of accountability considered necessary for hospitals. These findings in Gorji's study are also confirmed, emphasizing that even the hospital's clinical performance faces challenges without fulfilling its social and political responsibility [78]. However, studies such as Byrkjeflot recommend that this type of accountability should not limit the accountability of hospitals regarding their clinical performance [79]. Financial accountability improves the hospital's financial status and reduces its costs, and clinical accountability provides high-quality and safe services for consumers. Social and political accountability, in addition to facilitating the hospital's achievement of its goals, can play an essential role in providing political support. and social responsibility of the hospital. When the managers' commitment to accountability is considered as a whole, it can be hoped that the hospital can achieve organizational success and provide sufficient benefits to all stakeholders.

Hospitals are an important part of the health system. If it is a public hospital, it operates as a department under the supervision of the Ministry of Health or regional health organizations. This creates an opportunity for external accountability in the hospital. External accountability can be applied in all financial, clinical, and sociopolitical contexts. However, it probably will not be enough on its own. Public hospitals have a complex internal environment; this environment may cause external organizations to not be able to respond accurately. Therefore, attention should also be paid to internal accountability. Internal accountability requires some authority in the governance structure and makes the hospital's independence necessary in many financial and administrative matters. Many initiatives worldwide have been carried out to reduce hospitals' dependence on the government. Preker divides hospitals into five categories: budgetary, independent, corporate, nonprofit, and private [22]. Similar to the present study, Badr's research also emphasizes that it is necessary to have independence in the hospital's governance structure [80]. The hospital's independence can increase its internal accountability and the governance's ability to exercise authority. By exercising the power of governance, the hospital can take necessary actions in case of deviation from proper performance in the financial, clinical, and social-political fields according to specific regulations.

The accountability plan for the hospital, in which the responsibilities and duties of each person and department are clearly mentioned, prevents confusion in accountability and possible neglect of part of it. Clinicians, doctors and nurses, and society and political officials should clearly understand how the hospital responds and effectively benefits from the hospital's response. Austin argues that having an accountability program and transparent reporting structure will help make hospitals more accountable [43]. Different hospitals need different programs to respond in all dimensions, and these programs cannot be communicated in a single form by a high-ranking institution such as the Ministry of Health. In addition to holding different departments accountable, this program can also help the hospital in terms of execution because the limits of each person's duties and powers are clear in it, and the hospital's governance structure can ask the person or department about the performed functions and ask for a specific answer.


Vast social and economic changes have made health systems inevitably face accountability challenges worldwide. Hospitals are one of the most important entities in the health system and can only continue their practical life with accountability. The accountability of the hospital is primarily related to its governance structure. The current research findings emphasize the four dimensions of responsive governance in the health system. First, the governance structure should be comprehensive and include management, medical, nursing, and community representatives. Second, the governance structure should be open to all types of accountability, including financial, clinical, and social-political accountability. Third, the hospital governance structure should be independent to exercise its sovereignty and power if needed while monitoring accountability. The fourth important issue will be the definition of an accountability plan for the hospital, in which the duties and authority of each department and each person are clear. It is suggested to research the quantitative determination of the impact of each of the themes of the present study on accountability and, ultimately, the quality of health services. Be made. Using the findings of the current research can help hospitals provide their services more responsively and achieve better health outcomes.

Availability of data and materials

The Excel dataset is available in the supplementary materials; for further details, contact the corresponding author (A.R.).


  1. Ahlin J. Governance Structure of Hospitals. ontairo medical students assosiation 2012.

  2. Suter E, Mallinson S. for coordinated/integrated health services delivery.

  3. Millar R, Mannion R, Freeman T, Davies HT. Hospital board oversight of quality and patient safety: a narrative review and synthesis of recent empirical research. Milbank Q. 2013;91(4):738–70.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Eeckloo K, Delesie L, Vleugels A. Where is the pilot? The changing shapes of governance in the European hospital sector. J R Soc Promot Health. 2007;127(2):78–86.

    Article  PubMed  Google Scholar 

  5. Denis JL. Accountability in healthcare organizations and system. Healthcare Policy. 2014;10(SP):8.

    PubMed  PubMed Central  Google Scholar 

  6. Sudirman I. Measuring Hospital Accountability. Journal of Economics and Business. 2020;3(3).

  7. Henry M, Hudson Scholle S, Briefer French J. Accountability for the quality of care provided to people with serious illness. J Palliat Med. 2018;21(S2):S68–73.

    Article  PubMed  Google Scholar 

  8. Van Belle S, Mayhew SH. What can we learn on public accountability from non-health disciplines: a meta-narrative review. BMJ open. 2016;6(7):e010425.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Suter E, Mallinson S. Accountability for coordinated/integrated health services delivery. Accountability for coordinated/integrated health services delivery: working paper2015.

  10. Scott C. Accountability in the regulatory state. Administrative Law: Routledge; 2018. p. 397–419.

    Google Scholar 

  11. Jha A, Epstein A. Hospital governance and the quality of care. Health Affairs. 2010;29(1):182–7.

    Article  PubMed  Google Scholar 

  12. Bismark MM, Studdert DM. Governance of quality of care: a qualitative study of health service boards in Victoria Australia. BMJ Qual Saf. 2014;23(6):474–82.

    Article  PubMed  Google Scholar 

  13. Anwari Z, Shukla M, Maseed BA, Wardak GFM, Sardar S, Matin J, et al. Implementing people-centred health systems governance in 3 provinces and 11 districts of Afghanistan: a case study. Confl Health. 2015;9(1):1–16.

    Article  Google Scholar 

  14. Wallenburg I, Quartz J, Bal R. Making hospitals governable: performativity and institutional work in ranking practices. Adm Soc. 2019;51(4):637–63.

    Article  Google Scholar 

  15. Genovese U, Del Sordo S, Pravettoni G, Akulin IM, Zoja R, Casali M. A new paradigm on health care accountability to improve the quality of the system: four parameters to achieve individual and collective accountability. Journal of Global Health. 2017;7(1).

  16. Barasa EW, Molyneux S, English M, Cleary S. Hospitals as complex adaptive systems: a case study of factors influencing priority setting practices at the hospital level in Kenya. Soc Sci Med. 2017;174:104–12.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Oliveira AR, Meyer V Jr, Pascuci LM. Micro strategies and hospital management: an analysis through the lens of complexity. Revista de Negócios. 2018;22(2):34–47.

    Article  Google Scholar 

  18. Scholten G, Muijsers-Creemers L, Moen J, Bal R. Structuring ambiguity in hospital governance. Int J Health Plann Manage. 2019;34(1):443–57.

    Article  PubMed  Google Scholar 

  19. Botje D, Klazinga NS, Wagner C. To what degree is the governance of Dutch hospitals orientated towards quality in care? Does this really affect performance? Health Policy. 2013;113(1–2):134–41.

    Article  PubMed  Google Scholar 

  20. De Regge M, Eeckloo K. Balancing hospital governance: A systematic review of 15 years of empirical research. Soc Sci Med. 2020;262:113252.

    Article  PubMed  Google Scholar 

  21. Kuntz L, Pulm J, Wittland M. Hospital ownership, decisions on supervisory board characteristics, and financial performance. Health Care Manage Rev. 2016;41(2):165–76.

    Article  PubMed  Google Scholar 

  22. Preker AS, Harding A. Innovations in health service delivery: the corporatization of public hospitals: World Bank Publications; 2003.

  23. Geng J, Yu H, Chen Y. Preparing for the introduction of hospital autonomy in Laos: an assessment of current situation and suggestions for policy-making. Int J Health Plann Manage. 2016;31(2):148–66.

    Article  PubMed  Google Scholar 

  24. Burns LR, Alexander JA, Andersen RM. How different governance models may impact physician–hospital alignment. Health Care Manage Rev. 2020;45(2):173–84.

    Article  PubMed  Google Scholar 

  25. DePalma SM. The value of PAs in hospital medical staff governance. JAAPA. 2019;32(1):41–3.

    Article  PubMed  Google Scholar 

  26. Mutiganda JC. Budgetary governance and accountability in public sector organisations: An institutional and critical realism approach. Crit Perspect Account. 2013;24(7–8):518–31.

    Article  Google Scholar 

  27. Gray BH. Physician involvement in hospital decision making. The New Health Care for Profit: Doctors and Hospitals in a Competitive Environment: National Academies Press (US); 1983.

  28. Eeckloo K, Van Herck G, Van Hulle C, Vleugels A. From Corporate Governance To Hospital Governance.: Authority, transparency and accountability of Belgian non-profit hospitals’ board and management. Health Policy. 2004;68(1):1–15.

    Article  PubMed  Google Scholar 

  29. Rotar A, Botje D, Klazinga N, Lombarts K, Groene O, Sunol R, et al. The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries. BMC Health Serv Res. 2016;16(2):99–109.

    Google Scholar 

  30. Sheffield JV, Young A, Goldstein EA, LoGerfo JP. The public hospital mission at Seattle’s Harborview Medical Center: high-quality care for the underserved and excellence in medical education. Acad Med. 2006;81(10):886–90.

    Article  PubMed  Google Scholar 

  31. Executives TACoH. The Organized Medical Staff—Moving from Autonomy to Accountability. Chicago, USA; 2010.

  32. Saltman RB, Durán A, Dubois HF, Organization WH. Governing Public Hospitals: Reform strategies and the movement towards institutional autonomy: World Health Organization. Regional Office for Europe; 2011.

  33. Bank W. Fixing the public hospital system in China: World Bank; 2010.

  34. Thiel A, Winter V, Büchner VA. Board characteristics, governance objectives, and hospital performance: An empirical analysis of German hospitals. Health Care Manage Rev. 2018;43(4):282–92.

    Article  PubMed  Google Scholar 

  35. Chen K. The impact of board characteristics on financial performance: evidence from Dutch hospitals: University of Twente; 2022.

  36. Governance H, Association T. Principles & Guidelines for Governance in Hospitals, Egypt. 2014.

  37. Brown A. Understanding corporate governance of healthcare quality: a comparative case study of eight Australian public hospitals. BMC Health Serv Res. 2019;19(1):1–14.

    Article  Google Scholar 

  38. Brinkerhoff DW, Jacobstein D, Kanthor J, Rajan D, Shepard K. Accountability, health governance, and health systems: uncovering the linkages. Washington, DC: USAID; 2017.

    Google Scholar 

  39. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.

    Article  Google Scholar 

  40. Munn Z, Peters MD, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):1–7.

    Article  Google Scholar 

  41. Peters MD, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Chapter 11: scoping reviews. JBI manual for evidence synthesis. 2020;169(7):467-73.

  42. Pronovost PJ, Armstrong CM, Demski R, Peterson RR, Rothman PB. Next level of board accountability in health care quality. J Health Organ Manag. 2018;32(1):2–8.

    Article  PubMed  Google Scholar 

  43. Austin JM, Demski R, Callender T, Lee KHK, Hoffman A, Allen L, et al. From Board to Bedside: How the Application of Financial Structures to Safety and Quality Can Drive Accountability in a Large Health Care System. Jt Comm J Qual Patient Saf. 2017;43(4):166–75.

    PubMed  Google Scholar 

  44. Uddin S, Mori Y. Shahadat K. A story of west meets east. Social Science and Medicine: Private management and governance styles in a Japanese public hospital; 2020. p. 245.

    Google Scholar 

  45. Nyland K, Pettersen IJ. Hybrid controls and accountabilities in public sector management Three case studies in a reforming hospital sector. Int J Public Sect Manage. 2015;28(2):90–104.

    Article  Google Scholar 

  46. Mattei P, Mitra M, Vrangbæk K, Neby S, Byrkjeflot H. Reshaping public accountability: Hospital reforms in Germany, Norway and Denmark. Int Rev Adm Sci. 2013;79(2):249–70.

    Article  Google Scholar 

  47. Glenngård AH. Pursuing the objectives of support to providers and external accountability through enabling controls - A study of governance models in Swedish primary care. BMC Health Services Research. 2019;19(1).

  48. Goeschel CA, Wachter RM, Pronovost PJ. Responsibility for quality improvement and patient safety: Hospital board and medical staff leadership challenges. Chest. 2010;138(1):171–8.

    Article  PubMed  Google Scholar 

  49. MacDonald D, Barnes M, Crawford M, Omeni E, Wilson A, Rose D. Service user governors in mental health foundation trusts: accountability or business as usual? Health Expect. 2015;18(6):2892–902.

    Article  PubMed  Google Scholar 

  50. Zenty TF, Bieber EJ, Hammack ER. University Hospitals: creating the infrastructure for quality and value through accountable care. Front Health Serv Manage. 2014;30(4):21–33.

    Article  PubMed  Google Scholar 

  51. Vaughn T, Koepke M, Levey S, Kroch E, Hatcher C, Tompkins C, et al. Governing Board, C-suite, and Clinical Management Perceptions of Quality and Safety Structures, Processes, and Priorities in US Hospitals. J Healthc Manage. 2014;59(2):111–28.

    Google Scholar 

  52. Dixon A, Storey J, Rosete AA. Accountability of foundation trusts in the English NHS: Views of directors and governors. J Health Serv Res Policy. 2010;15(2):82–9.

    Article  PubMed  Google Scholar 

  53. Jiang HJ, Lockee C, Fraser I. Enhancing board oversight on quality of hospital care: An agency theory perspective. Health Care Manage Rev. 2012;37(2):144–53.

    Article  PubMed  Google Scholar 

  54. Jha AK, Epstein AM. A Survey Of Board Chairs Of English Hospitals Shows Greater Attention To Quality Of Care Than Among Their US Counterparts. HEALTH AFFAIRS. 2013;32(4):677–85.

    Article  PubMed  Google Scholar 

  55. Kuhlmann E, Shishkin S, Richardson E, Ivanov I, Shvabskii O, Minulin I, et al. Understanding the role of physicians within the managerial structure of Russian hospitals. Health Policy. 2019;123(8):773–81.

    Article  PubMed  Google Scholar 

  56. Jones L, Pomeroy L, Robert G, Burnett S, Anderson JE, Fulop NJ. How do hospital boards govern for quality improvement? A mixed methods study of 15 organisations in England. BMJ Qual Saf. 2017;26(12):978–86.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Fayed AAMS, Elshoura SMY, Mosallam RA. Governance structures and practices in for-profit and not-for profit hospitals in Egypt. Int J Health Plan Manage. 2021;36(4):1069–80.

    Article  Google Scholar 

  58. Szekendi M, Prybil L, Cohen DL, Godsey B, Fardo DW, Cerese J. Governance Practices and Performance in US Academic Medical Centers. Am J Med Qual. 2015;30(6):520–5.

    Article  PubMed  Google Scholar 

  59. Kaini BK. Healthcare governance for accountability and transparency. J Nepal Health Res Counc. 2013;11(23):109–11.

    CAS  PubMed  Google Scholar 

  60. Kickbusch I, Gleicher DE. Governance for health in the 21st century. WHO Regional Office for Europe; 2012.

  61. Vian T. Anti-corruption, transparency and accountability in health: concepts, frameworks, and approaches. Global Health Action. 2020;13(sup1).

  62. Reich MR. The Core Roles of Transparency and Accountability in the Governance of Global Health Public-Private Partnerships. Health Syst Reform. 2018;4(3):239–48.

    Article  PubMed  Google Scholar 

  63. Kesale AM, Mahonge C, Muhanga M. The quest for accountability of Health Facility Governing Committees implementing Direct Health Facility Financing in Tanzania: A supply-side experience. PLoS One. 2022;17(4):e0267708.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. George AS, Erchick DJ, Zubairu MM, Barau IY, Wonodi C. Sparking, supporting and steering change: grounding an accountability framework with viewpoints from Nigerian routine immunization and primary health care government officials. Health Policy Plan. 2016;31(9):1326–32.

    Article  PubMed  Google Scholar 

  65. Network LHI. FCHS Multi Service Accountability Agreement. Ontario canada: Middlesex Hospital Alliance; 2020 2020.

  66. Executive HS. Accountability framework: performance accountability framework for the health services. Dublin; 2016.

  67. Territories GotN. Performance Measurement and Accountability Framework Report. canada; 2014.

  68. De Geyndt W. Does autonomy for public hospitals in developing countries increase performance? Evidence-based case studies. Soc Sci Med. 2017;179:74–80.

    Article  PubMed  Google Scholar 

  69. Askim J, Christensen T, Laegreid P. Accountability and Performance Management: The Norwegian Hospital, Welfare, and Immigration Administration. Int J Public Adm. 2015;38(13–14):971–82.

    Article  Google Scholar 

  70. Ravaghi H, Foroughi Z, Nemati A, Bélorgeot VD. A holistic view on implementing hospital autonomy reforms in developing countries: a systematic review. Health Policy Plan. 2018;33(10):1118–27.

    Article  PubMed  Google Scholar 

  71. Reich MR. The core roles of transparency and accountability in the governance of global health public–private partnerships. Health Syst Reform. 2018;4(3):239–48.

    Article  PubMed  Google Scholar 

  72. Kromm SK, Baker GR, Wodchis WP, Deber RB. Acute care hospitals’ accountability to provincial funders. Healthcare Policy. 2014;10(SP):25.

    PubMed  PubMed Central  Google Scholar 

  73. Atuesta Camacho LM, Bustos Cifuentes NV, Caballero Carranza M, Duque Torres J, Muñoz Lemus CA, Novoa Gamba CJ, et al. Gobierno corporativo hospitalario y sus efectos en la gestión organizacional. 2022.

  74. Esfandnia F, Mohammadi E, Mohammadi M, Cheraghi R, Esfandnia N, Esfandnia A. A. Relationship between patient safety and accountability of nurses in Al-Zahra Gilangharb Hospital in 2015. J Med Life. 2015;8(Spec Iss 3):141.

    CAS  PubMed  PubMed Central  Google Scholar 

  75. Wright JS, Dempster PG, Keen J, Allen P, Hutchings A. The new governance arrangements for NHS foundation trust hospitals: reframing governors as meta-regulators. Public Adm. 2012;90(2):351–69.

    Article  Google Scholar 

  76. Cornock M. Legal principles of responsibility and accountability in professional healthcare. Orthopaedic Trauma Times. 2014;23:16–8.

    Google Scholar 

  77. Cornelese M. Accountability in healthcare Searching for a balance between feeling responsible and being held accountable. 2020.

  78. Gorji HA, Niknam N, Ghaedchukamei Z, Gharavinia A, Safari M, Elahi M, et al. Evaluation of social accountability in hospital managers. Journal of Education and Health Promotion. 2021;10.

  79. Bytautas J, Dobrow M, Sullivan T, Brown A. Accountability in the Ontario cancer services system: A qualitative study of system leaders’ perspectives. Healthcare Policy. 2014;10:45–55.

    PubMed  PubMed Central  Google Scholar 

  80. AlMubarak SaH, Alfayez AS, Alanazi AT, Alwuhaimed LA, Bo Hamed SS. Autonomy, accountability, and competition: The privatisation of the Saudi health care system. J Taibah Univ Med Sci. 2021;16(2):144–51.

    PubMed  Google Scholar 

  81. O’Connor N, Kotze B, Wright M. Blame and accountability 2: on being accountable. Australas Psychiatry. 2011;19(2):119–24.

    Article  PubMed  Google Scholar 

  82. Pascal C, Claveranne J-P, Farnsworth Mick SS. Hospital Accountability in France: Small Steps Toward Reform. Management & Avenir Santé. 2015;N° 2(1):5-18.

  83. Rosen M, Mueller BU, Milstone AM, Remus DR, Demski R, Pronovost PJ, et al. Creating a Pediatric Joint Council to Promote Patient Safety and Quality, Governance, and Accountability Across Johns Hopkins Medicine. Jt Comm J Qual Patient Saf. 2017;43(5):224–31.

    PubMed  Google Scholar 

  84. Mannion R, Davies HTO, Jacobs R, Kasteridis P, Millar R, Freeman T. Do Hospital Boards matter for better, safer, patient care? Soc Sci Med. 2017;177:278–87.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  85. Bonde M, Bossen C, Danholt P. Translating value-based health care: an experiment into healthcare governance and dialogical accountability. Sociol Health Illn. 2018;40(7):1113–26.

    Article  PubMed  Google Scholar 

  86. Alhothaly W, Alhanawi M. Accountability in Healthcare Organizations; A Survey-Based Study among Patients in Government Hospital, Makkah. Am J Public Health Res. 2021;10(1):3–10.

    Article  Google Scholar 

Download references


The authors wish to thank the Vice-Chancellor of Research Affairs at Isfahan University of Medical Sciences.


This study was part of a Ph.D. thesis supported by the School of Management and Medical Information Sciences, Isfahan University of Medical Sciences (Grant No. 34001011). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author information

Authors and Affiliations



M.J., A.R., and N.S. conceived the study and participated in its design. The search strategies were drafted by NS and further refined through team discussion. Each included study was abstracted by one team member (M.J.) and verified by a second reviewer (N.S.). As an additional data cleaning step, a third reviewer team (A.R.) verified all the changes made by the second reviewer to ensure data accuracy. All authors reviewed and edited the manuscript and approved the final draft of the manuscript.

Corresponding author

Correspondence to Ahmad Reza Raeisi.

Ethics declarations

Ethics approval and consent to participate

This study was part of a Ph.D. thesis supported by the School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, and the Ethics Committee of Isfahan University of Medical Sciences approved this study (Ethics Code: IR.MUI.NUREMA.REC. 1400.223). Consent to participate is not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jalilvand, M.A., Raeisi, A.R. & Shaarbafchizadeh, N. Hospital governance accountability structure: a scoping review. BMC Health Serv Res 24, 47 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: