CA-GOV Standard. Generated 12/04/2022. ©2022 Council on Accreditation.
2022 Edition

Governance Introduction

Purpose

The organization's governing body guides and supports the planning, development, and achievement of the organization's mission and goals.

Introduction

COA’s Governance standards reflect how excellence develops over time in non-profit organizations. The standards address several key concepts found in the literature on effective, non-profit leadership including, but not limited to, evidence of an association between the leadership and culture of a human service organization and the achievement of positive outcomes for the people and communities it serves. The standards outline the responsibilities of agency leadership to foster a culture of transparency, accountability, and community responsiveness.
EAP

Interpretation

In the context of Employee Assistance Program (CA-EAP) services, the community, as used in these standards, is defined more specifically as the host or customer organization, subcontracting organizations, and the covered individuals eligible to receive services from the EAP.  It can also be defined by the customer organizations’ workplace demographics.
NA This agency is public.
Note: COA’s Governance standards do not apply to for-profit organizations. For-profit organizations should refer to COA’s Administration and Financial Management (CA-AFM) standards.

Note: Please see the CA-GOV Reference List for the research that informed the development of these standards.

Note: For information about changes made in the 2020 Edition, please see the GOV Crosswalk. See also the ETH Private Crosswalk for Ethical Practice standards that are now found in GOV.
 
2022 Edition

Governance (CA-GOV) 1: Mission

The organization’s mission:
  1. is responsive to the needs and aspirations of the community;
  2. guides the organization’s administrative operations and delivery of services; and
  3. serves as a benchmark of organizational effectiveness.
Related Standards:
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement, e.g.,
  • The mission statement is in effect and is being used to guide decision making across the organization, but it needs updating and is currently under review by the organization's governing body.
3
Practice requires significant improvement, e.g.,
  • The mission statement is poorly written and as a result, it has limited use in setting the organization’s strategic goals or guiding organizational decisions; or
  • Provision of human services are not identified as a major component or focus of the organization.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • There is no written mission statement or the organization's practices and services are at odds with its mission.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • See mission statement provided during application
No On-Site Evidence
  • Interviews may include:
    1. Governing body members
    2. Relevant personnel
 
2022 Edition

Governance (CA-GOV) 2: Strategic and Annual Planning

The organization engages in an inclusive long-term strategic planning process, and annually conducts short-term planning, in support of its mission.
Note: Please see the Governance Standards Tool Kit - Strategic Plan Template for additional guidance on this standard.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-GOV 2 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-GOV 2 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-GOV 2 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-GOV 2 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Strategic and annual planning procedures
  • Long-term strategic plan
  • Review of service population demographics
  • Assessment of strengths and weaknesses
  • Annual plans
  • Governing Body and/or committee meeting minutes where mission fulfillment and strategic planning were discussed
  • Interviews may include:
    1. CEO
    2. CFO
    3. Governing body
    4. Senior management
    5. Relevant personnel

 
Fundamental Practice

CA-GOV 2.01

Long-term strategic planning responsibilities of the governing body include:
  1. monitoring progress toward fulfilling the mission;
  2. envisioning and setting the organization’s strategic direction; and
  3. supporting inclusive, management-directed, organization-wide, long-term planning every four years.

Interpretation

Organizations may use a policy governance model to demonstrate that the governing body has developed the organization’s broad vision and provided oversight to the operational planning activities conducted by management. The governing body need not conduct these planning activities itself.

FEC

Interpretation

For credit counselling organizations long-term planning must occur every 2-3 years.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • Governing body involvement in the planning process is minimal; however, it does review and approve the long-term plan; or
  • Long-term planning has not been done in more than four years; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The governing body is not involved in the long-term planning process nor does it review or approve the plan; or
  • Long-term planning has not been done for more than five years.
  • The strategic plan is wholly inadequate or nonexistent

 
Fundamental Practice

CA-GOV 2.02

The governing body reviews and approves the long-term strategic plan to ensure that it encompasses:
  1. a review of the organization’s mission, values, mandates, and strategic direction;
  2. a review of the demographics of its defined service population;
  3. an assessment of strengths and weaknesses;
  4. measurable goals and objectives that support fulfillment of its mission and mandated responsibilities; and
  5. appropriate strategies for meeting identified goals, including the need to redirect, eliminate, or expand services to respond to changing community demographics and the needs of persons served.
Related Standards:
EAP

Interpretation

 In an EAP the demographic profile is representative of its customer base.
Examples: To enhance its assessment, organizations can draw upon the findings of other external needs assessments, such as those conducted by the United Way, municipal planning boards, universities, or other organizations with a community-wide focus.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The review of service population demographics did not include all populations served or geographic locations; or
  • The strategy (element (e)) for meeting one or two of the identified long-term goals needs greater specificity.
3
Practice requires significant improvement; e.g.,
  • One of the elements is not fully addressed; or
  • The mission has not been reviewed for more than four years; or
  • The organization did not review the demographics of its service population; or
  • Identified goals and objectives are vague; or
  • Most identified goals and objectives are not measurable; or
  • Strategies for meeting identified goals are cursory and do not provide a sufficient framework for success or implementation; or
  • Governing body involvement in the planning process is minimal, however it does review and approve the long-term plan; or
  • Long-term planning has not been done in more than four years.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Two of the elements are not fully addressed; or
  • The governing body is not involved in the long-term planning nor does it review or approve the plan; or
  • Long-term planning has not been done for more than five years; or
  • The strategic plan is wholly inadequate or nonexistent.

 
Fundamental Practice

CA-GOV 2.03

The organization develops and implements an annual plan that supports its mission and integrates the priorities and objectives of each of its departments and programs, and:
  1. operationalizes the goals and objectives of the long-term strategic plan;
  2. reflects changing conditions and needs such as, resource allocation, funding, and regulatory changes; and
  3. responds to information from PQI activities.
Examples: Annual plans can also incorporate other regular planning processes, including:
  1. HR planning;
  2. evaluation of training needs;
  3. budget planning;
  4. technology and information management planning; and
  5. PQI summary reports.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Departmental priorities and objectives could be better defined; or
  • While department and program plans are not integrated into an organization-wide annual plan, all but one or two departments or programs have developed a comprehensive annual plan.
3
Practice requires significant improvement, e.g.,
  • Management objectives are not included; or
  • Several departments or programs are not included in the most recent annual plan or have not done an annual plan; or
  • One of the elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Two of the elements are not addressed at all.
 
2022 Edition

Governance (CA-GOV) 3: Community Involvement and Advocacy

The organization:
  1. informs the public of its mission;
  2. remains knowledgeable about community needs and strengths;
  3. advocates for comprehensive and coordinated service delivery within the community; and
  4. encourages the elimination of social and economic injustice.

Interpretation

The standards in CA-GOV 3 describe a variety of activities related to the organization’s role within the community, including outreach and education, participation in community-wide advocacy efforts, and advocacy on behalf of service recipients who need help navigating the system. Given the broad range of activities outlined in CA-GOV 3, activities conducted by “the organization” are the responsibility of the governing body, CEO, stakeholder advisory group, management, direct service personnel, and/or other personnel, as appropriate to the activity and their role.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-GOV 3 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-GOV 3 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-GOV 3 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-GOV 3 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • A list of Governing Body members, with brief bios
  • Community Demographic Profile
  • See website URL and links to social media sites provided during application
  • Copies of PSAs, newspaper articles, other print media, or communication methods used within the past 12 months
  • Documentation of participation in community advocacy efforts
  • Interviews may include:
    1. Governing body
    2. Relevant personnel
    3. Community stakeholders
    4. Persons served

 

CA-GOV 3.01

The organization provides the public with clear, timely, and accurate information about the organization’s mission, programs, activities, service recipients, and finances.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • While social media or the website provides accurate information, some written materials that continue to be distributed are outdated; or
  • Some segments of the general public do not have access to accurate and timely information.
3
Practice requires significant improvement; e.g.,
  • Generally, public information is not current; or
  • Some important information is not available to the public.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-GOV 3.02

The organization conducts ongoing community outreach and education to:
  1. communicate its mission, role, functions, capacities, and scope of services;
  2. provide information about the strengths, needs, and challenges of the individuals, families, and groups it serves;
  3. build and maintain effective community support/partnerships and presence and maintain effective partnerships; and
  4. elicit feedback as to unmet needs in the community that can be addressed by the organization as its top advocacy priorities.
Examples: Examples of public outreach and education activities may include:
  1. regular communication with the media and the general public;
  2. informing the public of the positive impact the organization's programs are having on the community and its residents; and
  3. fostering positive relationships with the local media.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the elements is not fully addressed; or
  • The organization has an ongoing program of community education, but it does not cover some of its programs or services.
3
Community outreach and education efforts need significant improvement; e.g.,
  • Efforts are informal and infrequent; or
  • Efforts only address some of the organization’s programs or services, or populations served; or
  • Element (a) or (b) is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-GOV 3.03

The organization collaborates with community members and persons served to advocate for issues of mutual concern consistent with the organization’s mission, such as:

  1. improvements to existing services;
  2. filling gaps in service to offer a full array of community supports;
  3. the full and appropriate implementation of applicable laws and regulations regarding issues concerning the service population;
  4. improved supports and accommodations for individuals with special needs, marginalized communities, or different ethnic origins;
  5. solutions to community-specific needs including racial equity and cultural and linguistic diversity; 
  6. service coordination; and
  7. a coordinated community response to public health emergencies.
Examples: The organization can work at several levels to advocate with, and on behalf of, persons, groups, and families served. For example, direct service personnel can be given the time to carry out advocacy activities so they can support persons and families served to solve problems related to their individual cases. Advisory board members, management, and other personnel, along with persons served, can engage in legislative and other system-wide advocacy activities. They may also work collaboratively with other community organizations to monitor federal, state, and/or local activity that impacts the service population.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • One of the elements is not addressed at all.
3
Practice requires significant improvement; e.g.,
  • Two of the elements are not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Little or no effort is made to collaborate with community members or persons served as described in the standard.

 

CA-GOV 3.04

The governing body:
  1. reflects the demographics of the community it serves;
  2. represents the interests of the community it serves;
  3. serves as a link between the organization and the public or community; and
  4. is sufficiently diverse in strengths and capabilities to plan and deliver appropriate services to its defined community.

Interpretation

COA recognizes that Board recruitment is a significant challenge for many organizations and that meeting the standard may be a long-term process. In the interim, an organization can establish a stakeholder advisory group that is representative of the community and include strategies for plan for strengthening its Board in its long-term or strategic plan.
Examples: The governing body should reflect a wide range of skills, abilities, community knowledge, and professions. Examples of board member strengths and capabilities may include:
  1. governance expertise, including leadership ability and policy development skills;
  2. relevant business experience;
  3. financial expertise;
  4. knowledge of consumer issues and trends;
  5. familiarity with and access to community leaders, political representatives, and other relevant local organizations;
  6. public recognition and respect; and
  7. commitment and ability to fundraise or to connect the organization with potential resources, as applicable.
Note: Please see the Governance Standards Tool Kit - Board Skills Worksheet for additional guidance on this standard.
1
The organization's practices reflect full implementation of the standard.

The organization's governing body reflects its community and possesses the skills and expertise necessary to effectively govern.
2
Practices are basically sound but there is room for improvement; e.g.
  • One of the standard's elements is not fully addressed; or
  • The governing body does not reflect its community, but a representative stakeholder advisory group is in place and there is a plan for diversifying the board.
3
Practice requires significant improvement; e.g.,
  • Two of the elements are not fully addressed; or
  • One element is not addressed at all; or
  • A stakeholder advisory group is in place to address lack of representativeness, but it is not very active, or there is no plan for long-term remediation.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
2022 Edition

Governance (CA-GOV) 4: Organization of the Governing Body

The governing body exercises leadership through a functional, effective structure.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-GOV 4 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-GOV 4 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-GOV 4 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-GOV 4 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Bylaws
  • Board Manual
  • Governing Body Minutes for the previous 12 months
  • Interviews may include:
    1. Governing body chair
    2. Governing body members

 

CA-GOV 4.01

The governing body establishes in the organization’s charter, bylaws, or similar document:
  1. the organization’s structure and scope;
  2. its roles and responsibilities, including number of meetings held per year and their quorum;
  3. the body to which it will delegate interim authority; and
  4. a process for assessing and implementing responsibilities, such as establishing task forces/committees.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation related to one of the elements is outdated or does not reflect current practice.
3
Practice requires significant improvement; e.g.,
  • Documentation related to two or more elements are outdated and do not reflect current practice; or
  • One of the elements is not addressed at all, e.g., no written delegation of authority.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-GOV 4.02

The governing body establishes in writing:
  1. eligibility requirements for membership, including the prohibition of having staff and/or relatives of staff on board;
  2. mechanisms for recruitment, selection, rotation, and duration of membership; and
  3. mechanisms for election of officers and duration of terms.

Interpretation

If the chief executive retains board privileges as a voting member, the organization’s by-laws and/or conflict-of-interest policy must clearly define limits for the use of those privileges. The chief executive should be excused from deliberations on matters related to executive compensation, evaluation, and other areas that present apparent conflicts of interest.
Note: See CA-GOV 7 for more information on establishing a Conflict of Interest policy.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Documentation related to one of the standard's elements is outdated and does not reflect current practice.
3
Practice requires significant improvement; e.g.,
  • Written by-laws related to two or more elements are outdated and do not reflect current practice; or
  • One of the elements is not addressed at all; or
  • The executive director is a full voting member with no limits; or
  • Another staff member, or a relative of a staff member is a voting member of the board; or
  • The by-laws have not established terms of service on the board.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-GOV 4.03

Governing body members receive an orientation that addresses membership responsibilities and an overview of the organization and its mission.
Examples: The board orientation may include: information on the organization's history, goals and objectives, governing body structure and procedures, ethics, programs and activities, introductions to staff, and facility and program tours.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-GOV 4.04

The organization maintains a board file that includes governing body-approved policies and up-to-date minutes and records of all meetings.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Although up-to-date policies, minutes, etc. have been distributed to governing body members, they have not been incorporated into the manual.
3
Practice requires significant improvement; e.g.,
  • Governing body minutes and/or minutes of committee meetings are incomplete, or are too cursory to accurately reflect decisions or action taken, or are outdated; or
  • The manual is missing key policies; or
  • Policies have not been approved.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The governing body does not maintain a manual that meets the requirements of the standard or the manual is wholly inadequate.
 
2022 Edition

Governance (CA-GOV) 5: Governing Body Responsibilities

The governing body actively fulfills its legal responsibilities, sets a tone of responsible stewardship, and ensures policies and performance uphold the public trust and support achievement of the organization’s mission.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-GOV 5 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-GOV 5 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-GOV 5 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The governing body is ineffective, inactive, poorly organized, or does not otherwise fulfill its fiduciary responsibilities; or
  • The executive director dominates the governing body to the extent that it does little more than ratify decisions already made by the executive director.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Succession planning procedures
  • Succession plan
  • Governing Body and/or committee meeting minutes from the previous 12 months addressing each of the CA-GOV 5 practice standards
  • Interviews may include:
    1. Governing body chair
    2. Governing body treasurer
    3. Governing body members
    4. CEO
    5. CFO

 
Fundamental Practice

CA-GOV 5.01

Policy development responsibilities of the governing body include:
  1. adopting policies;
  2. reviewing policies at least every four years and when legislation, regulations, contracts, and programs change;
  3. adopting any changes to policies resulting from recommendations; and
  4. evaluating management’s implementation of policies.
Related Standards:

Interpretation

An organization that follows a policy governance model may not typically develop, ratify, and maintain statements known as “policies.” However, distillations of the organization’s principles, philosophies, practice, or “ends” may be considered policies for the purposes of this standard.

For organizations with Boards that delegate the responsibilities for adopting, reviewing, changing, and/or evaluating implementation of policy to the Executive Director, evidence of presenting and discussing with the Board, any changes, additions, etc. related to policies should be reflected in the Board minutes to demonstrate Board involvement.
1
The governing body actively exercises its policy-setting prerogatives as per the requirements of the standard, and policy decisions are reflected in comprehensive and up-to-date minutes of the governing body meetings. 
Policy setting is viewed as the board's major means of providing a framework and guidance for the organization's overall direction.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Governing body practice related to one or two of the elements could be strengthened in some minor way.
3
Practice requires significant improvement, e.g.,
  • A systematic review of policies has not been conducted for more than four years; or
  • In some instances, organizational policies have been implemented prior to, or without, governing body review or approval; or
  • The governing body review of management implementation of policies is sporadic.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The organization's executive director approves policies without involvement of the governing body; or
  • One of the elements is not addressed at all.

 
Fundamental Practice

CA-GOV 5.02

The governing body:
  1. works with management to evaluate the organization's financial capacities and the resources needed to provide services;
  2. works with the CEO to secure adequate resources to implement the organization's strategic planning and budgeting decisions; and
  3. oversees fundraising activities including establishing fundraising targets and goals that flow from the strategic plan.
Related Standards:
Examples: Actively supporting work to secure funding that is aligned with the organization’s planning and budgeting decisions is one way the governing body can support the achievement of mission and improved outcomes for persons served.
 
Examples: While not all organizations fundraise, it is a vital means to achieving a flexible revenue base and is a traditional role assumed by nonprofit governing bodies. Strategies for resource development can include, for example, fundraising, grants, contracts for service, and new business development opportunities.
1
The organization's governing body actively fulfills its resource development responsibilities as per the requirements of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The link between resource development and strategic goals and objectives needs clarification.
3
Practice requires significant improvement; e.g.,
  • Management is largely responsible for resource development with the governing body taking a secondary role while providing limited oversight of management's activities.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The governing body is not involved in resource development.

 

CA-GOV 5.03

The governing body's responsibilities regarding the executive director include:
  1. appointment of the executive director;
  2. collaboration with the executive director;
  3. delegation of the authority and responsibility for organization management and policy implementation to the executive director;
  4. oversight and annual evaluation of the executive director's compensation and performance against the organization’s strategic goals and additional responsibilities outlined in the CEO’s job description;
  5. approval of the executive director's employment activities outside of the organization to ensure they do not interfere with her/his administrative responsibilities; and
  6. evaluation of the effectiveness of its partnership with the executive director, at least every two years.
Examples: Organizations may use a performance review tool to help examine the many facets of the CEO’s performance including, for example: leadership, management of the organization, working relationship with the board and staff, and management of the organization’s finances.
 
In addition, criteria for evaluating compensation may include, for example: compensation paid to other CEOs in similar positions, compliance with regulations and guidelines regarding reasonable compensation, cost of living considerations, and the total professional experience of the CEO including advanced degrees and other experiences and skills that uniquely contribute to the success of the organization.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • There is minor confusion or overlap as to the relative roles of the governing body and the executive director (e.g., resource development); or
  • The governing body annually reviews the executive director's compensation but could improve the quality of its analysis with industry practice and/or federal requirements.
3
Practice requires significant improvement, e.g.,
  • The governing body evaluates the executive director's performance less than annually; or
  • The evaluation of the executive director is informal (not written, dated, or signed); or
  • The evaluation of the executive director is not comprehensive or does not use specific performance criteria; or
  • The executive director is not involved in the evaluation process; or
  • The executive director has not received governing body approval for unrelated external business activities; or
  • The governing body does not evaluate its partnership with the executive director.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • At least two of the elements are not addressed at all.

 

CA-GOV 5.04

To ensure continuity during transitions in leadership, the organization maintains succession planning procedures and a succession plan.
Related Standards:
Examples: Information included in a succession plan may include, for example:
  1. critical positions within the organization and their key leadership and management functions;
  2. under what conditions interim authority can be delegated for those positions, including unexpected leadership disruptions and planned departures, and the limitations of that authority;
  3. to whom various leadership and management functions will be delegated;
  4. governing body and staff responsibilities as they relate to transition planning;
  5. how succession planning and leadership transitions will be communicated to the governing body, staff, and other relevant stakeholders; and
  6. mechanisms for assessing readiness to assume leadership positions and for providing training, mentorship, and other leadership development opportunities to support readiness.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 
Fundamental Practice

CA-GOV 5.05

The governing body annually assesses overall risk to the organization, including the organization's continuing ability to pursue strategic goals and meet the needs of persons served.

Interpretation

 Organization staff may be responsible for assessing different areas of risk throughout the year and sending the results of the assessments to the governing body to inform its annual review of overall risks.

Examples: Areas of potential risk can include, for example:

  1. compliance with legal requirements;
  2. disruption of operations due to a public health emergency;
  3. technology and information management;
  4. insurance and liability;
  5. health and safety of administrative and service environments;
  6. human resources practices, including use of independent contractors and volunteers;
  7. contracting practices and compliance;
  8. client rights and confidentiality issues;
  9. financial risks;
  10. public relations, branding, and reputation; and
  11. conflicts of interest.
Financial risk assessment involves the identification of factors or conditions related to funding and financial health that may pose a threat to the achievement of an organization’s objectives and mission including, for example, the effectiveness and efficiency of financial operations and the reliability of financial reporting. Areas of known financial risk include:
  1. fraud and misuse of funds;
  2. investments;
  3. tax liabilities;
  4. physical assets and financial information;
  5. fundraising practices;
  6. funding of benefits, including health retirement benefits, pensions, etc.; and
  7. deferred revenue.
1
The organization's practices reflect full implementation of the standard.
2

Practices are basically sound but there is room for improvement; e.g., 

  • While the governing body assesses risk annually, risk related to different aspects of the organization are reviewed by the board at different times of the year, inhibiting its ability to comprehensively assess overall risk.
3
Practice requires significant improvement, e.g.
  • The governing body has not conducted a risk assessment within the last two years; or
  • Documentation of the annual risk assessment in minutes is weak or missing.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • A comprehensive risk assessment has not been conducted for more than two years or did not involve the governing body.
 
2022 Edition

Governance (CA-GOV) 6: Organization Leadership

The executive director effectively collaborates with the governing body to enunciate and achieve the organization’s mission and vision, promote a healthy organizational culture, and oversee and manage the organization’s operations.

Interpretation

There are varying titles for the head of an organization, such as President/CEO and Executive Director. Depending upon the type of organization or service, the individual fulfilling this role may have other designations, such as Operating Manager, Program Director, or Program Officer. The standard requires that there is a clearly identified person to whom the governing body delegates the day-to-day management of the organization and whom it holds accountable for the organization's performance.
 

Interpretation

 If the organization's Executive Director/CEO is an independent contractor the organization's governing body is responsible for meeting the standards in CA-GOV 6, by:
  1. including each of the responsibilities listed in the CA-GOV 6 standards in the Executive Director/CEO's contract;
  2. directly assuming those responsibilities as individual governing body members or as a governing body; or
  3. a combination of the above.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-GOV 6 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-GOV 6 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-GOV 6 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-GOV 6 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • CEO job description
  • CEO resume
No On-Site Evidence
  • Interviews may include:
    1. CEO
    2. Governing body chair
    3. Governing body members

 

CA-GOV 6.01

The executive director’s primary responsibilities are:
  1. management of the organization;
  2. implementation of organization-wide, long-term strategic planning and periodic reviews;
  3. development of policies governing the organization’s program of services with the governing body;
  4. attendance at all meetings of the governing body; and
  5. provision of regular reports to the governing body on the organization’s operations, finances, and implementation of the long-term plan.
Related Standards:
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The executive director does not attend, or have a representative at every board meeting; or
  • Minor communication problems exist; or
  • The executive director and governing body are actively working to improve their effectiveness as a team in response to a few identified issues; or
  • One of the elements is not fully addressed, e.g., executive director reports to the governing body sometimes lack depth.
3
Practice needs significant improvement; e.g.,
  • The executive director tightly controls information the board receives, so that the board frequently lacks the information needed to make informed decisions and effectively govern; or
  • The executive director does not attend or provide staff support for two or more governing body and/or committee meetings per year; or
  • The executive director often provides only verbal reports, or provides written reports that are cursory or otherwise do not provide timely or useful information; or
  • Two of the elements are not fully addressed; or
  • One element is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • The partnership between the executive director and governing body is completely ineffective or nonexistent; e.g.
  • The governing body is asked only to ratify decisions or is told of decisions after the fact; or
  • The executive is excluded by the governing body action from most committee activity; or
  • More than three of the elements of the standard are not fully addressed; or
  • Two or more elements are not addressed at all.

 

CA-GOV 6.02

The executive director is qualified by:
  1. an advanced degree from an accredited college or university in a field related to the organization’s mission and services;
  2. at least five years of related leadership experience;
  3. experience administering services to families, adults, youth and/or children;
  4. the skills to oversee human resources and financial management matters; and
  5. the ability to work effectively and proactively with other providers, and local, provincial/territorial, and federal entities.
FEC

Interpretation

In credit counselling organizations the executive director is qualified by a bachelor's degree and does not require competence in administering services to families, adults, youth and/or children (element c).

EAP

Interpretation

 In an EAP the executive director is qualified by experience in workplace programs, an understanding of the dual client relationship, and does not necessarily require competence in administering services to families, adults, youth and/or children (element c).
1
The organization's executive director is qualified as per the requirements of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The executive director does not meet element (a), however he/she is qualified as per elements (b) – (e); or
  • The executive director meets the advanced degree requirement but has less than five years of related leadership experience; or
  • The executive director has limited skills to oversee human resource and/or financial management matters but is receiving training to develop/enhance these skills or has consultants that provide support and advice.
3
Practice requires significant improvement; e.g.,
  • The executive director does not meet two of the standard's elements.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.
 
2022 Edition

Governance (CA-GOV) 7: Conflict of Interest

The organization prevents the enrichment of insiders and other abuses through the adoption and enforcement of a conflict of interest policy.
Note: Please see the Conflict of Interest Policy and Procedures Template for additional guidance on this standard.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the CA-GOV 7 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the CA-GOV 7 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the CA-GOV 7 Practice standards; e.g.,
  • Conflict of interest policy provides minimal guidance to stakeholders due to lack of specificity, significant missing elements, or significant stakeholders not covered; or
  • Minor conflict of interest concerns are noted.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the CA-GOV 7 Practice standards; e.g.,
  • Significant conflict of interest concerns have been reported.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Conflict of interest policy
  • Ethical referral policy
  • Policy prohibiting preferential treatment
  • Governing body and/or committee meeting minutes documenting discussions of potential and apparent conflicts of interest from the previous 12 months
  • Interviews may include:
    1. CEO
    2. Governing body
    3. Advisory group
    4. CFO
    5. Relevant personnel
    6. Persons served/community members

 
Fundamental Practice

CA-GOV 7.01

A conflict of interest policy is tailored to the organization’s specific needs and characteristics, and:
  1. defines conflict of interest;
  2. identifies groups of individuals within the organization covered by the policy;
  3. addresses policy enforcement;
  4. provides a framework for evaluating situations that may constitute a conflict; and
  5. invests management with developing procedures that facilitate disclosure of information to prevent and manage potential and apparent conflicts of interest.
1
The organization has implemented a conflict of interest policy as per the requirements of the standard.
2
Practices are basically sound, but there is room for improvement; e.g.,
  • One of standard's elements is not fully addressed.
3
Practice requires significant improvement; e.g.,
  • The policy provides minimal guidance to stakeholders due to lack of specificity; or
  • Stakeholders are unaware of the policy; or
  • Two of the elements are not fully addressed; or
  • One of the elements is not addressed at all.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • No policy exists; or
  • The policy is not enforced or is ignored in practice.

 
Fundamental Practice

CA-GOV 7.02

The conflict of interest policy requires governing body members, advisory group members, personnel, and consultants who have a financial interest in the organization’s assets, business transactions, leases, or professional services to:
  1. disclose this information; and
  2. not participate in any discussion or vote taken with respect to such interests.

Interpretation

Governing body members who receive compensation for professional services they provide as consultants cannot be part of the organization’s audit review process.
1
The organization’s conflict of interest policy fully addresses the requirement for disclosure of conflicts of interest and for recusal from decisions related to such interests.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The policy related to one of the standard's elements needs clarifying.
3
Practice requires significant improvements; e.g.,
  • Applicable stakeholders are not clearly identified; or
  • The types of transactions that must be disclosed are not delineated; or
  • Safeguards regarding disclosure or recusal are insufficient; or
  • Governing body members or other important stakeholders are not aware of the policy.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Conflict of interest violations have occurred.

 

CA-GOV 7.03

The conflict of interest policy addresses nepotism with regard to hiring, supervision, and promotion.

Interpretation

This standard permits the hiring of relatives, provided that relatives are qualified and do not work within the same hierarchy of supervision.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Some aspect of the policy requires clarification.
3
Practice requires significant improvement, e.g.,
  • Staff report that there have been instances of nepotism or preferential treatment; or
  • The organization chart indicates that at least one person is directly supervised by a relative.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

CA-GOV 7.04

The organization prohibits:
  1. making or accepting payment or other consideration in exchange for referrals;
  2. preferential treatment of organization members, community partners, members of the organization's governing body, advisory groups, personnel, or consultants applying for and receiving the organization’s services; and
  3. steering or directing referrals to private practices in which personnel, consultants, or the immediate families of personnel and consultants are engaged.

Interpretation

It is permissible to include on referral lists personnel and consultants with private practices, or family members of personnel and consultants, but the organization may not actively direct service recipients to the practices of these individuals and must clarify in writing the relationship between the private practitioners and the organization.
 

Interpretation

When private practice is permitted on the organization’s premises persons served should receive information clarifying the relationship between the private practitioner and the organization.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • Some aspects of the policy are vaguely written, but there have been no ethical violations of the principles outlined in the standard.
3
Practice requires significant improvement, e.g.,
  • Significant aspects of the policy are vaguely written or confusing; or
  • The policy does not address at least one of the standards elements; or
  • The policy exists but enforcement is lax and there have been a few instances where it has been violated; or
  • The policy is generally understood but it is an unwritten expectation.
4
Implementation of the standard is minimal or there is no evidence of implementation at all: e.g.,
  • No policy exists; or
  • The policy is not enforced or is ignored in practice.
 
2022 Edition

Governance (CA-GOV) 8: Protection of Reporters of Suspected Misconduct

The organization prohibits employment-related retaliation against employees, and others affiliated with the organization, who come forward with information about suspected misconduct or questionable practices, and provides an appropriate, confidential channel for reporting such information.
Note: Please see the Whistleblower Policy Template for additional guidance on this standard. 
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement; e.g.,
  • The definition of what constitutes a reportable violation lacks specificity.
3
Practice requires significant improvement; e.g.,
  • There is a perception among staff that procedures do not adequately protect anonymity; or
  • Procedures are not readily available, or staff and board members are not aware they exist; or
  • Procedures do not adequately protect against retaliation.
4
Implementation of the standard is minimal or there is no evidence of implementation at all; e.g.,
  • Staff report feeling afraid or intimidated.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • Policy protecting reporters of suspected misconduct
  • Procedures for reporting suspected misconduct
  • Documentation of any grievances/incidents related to retaliation
  • Interviews may include:
    1. CEO
    2. HR director
    3. Relevant personnel
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