2. (1) Every hospital shall be governed and managed by a board.  R.R.O. 1990, Reg. 965, s. 2 (1). (1.1) In addition to the members of the board appointed or elected in accordance with the authority whereby the hospital is established, the following persons shall be members of the board: (a) the administrator of the hospital; (b) the president of the hospital’s medical staff; (c) the chief of staff of the hospital or, where there is no chief of staff, the chair of the hospital’s medical advisory committee; and (d) the chief nursing executive of the hospital.  O. Reg. 448/10, s. 1 (1). (2) Where the following persons are members of the board, they may not be voting members: 1. Any member of the medical staff, dental staff, extended class nursing staff or midwifery staff of the hospital. 2. Any employee of the hospital.  O. Reg. 156/10, s. 1 (1); O. Reg. 159/17, s. 2. (3) The board shall, (a) monitor activities in the hospital for compliance with the Act, the regulations and the by-laws of the hospital; (b) take such measures as the board considers necessary to ensure that the provisions of the Act, the regulations and the by-laws of the hospital are being complied with; (c) in the case of a hospital whose by-laws provide for the position of chief of staff, appoint the chief of staff as chair of the medical advisory committee; (d) in the case of a hospital whose by-laws do not provide for the position of chief of staff, appoint a member of the medical advisory committee to be chair of the medical advisory committee; (d.1) in the case of a hospital whose by-laws provide for a nursing advisory committee, appoint the chief nursing executive as chair of the nursing advisory committee; and (e) ensure that the administrator, medical staff, chief nursing executive, staff nurses and nurses who are managers develop plans to deal with, (i) emergency situations that could place a greater than normal demand on the services provided by the hospital or disrupt the normal hospital routine, and (ii) the failure to provide services by persons who ordinarily provide services in the hospital.  R.R.O. 1990, Reg. 965, s. 2 (3); O. Reg. 64/03, s. 2. (3.1) The board shall ensure that the administrator establishes a system for ensuring that a committee appointed by the hospital reviews every critical incident, as soon as is practicable after the critical incident occurs. O. Reg. 484/16, s. 1 (1). (3.2) A system established under subsection (3.1) must require that a person designated by the hospital who has responsibility in the area of patient relations or in providing patient perspectives to the hospital participate in each review of a critical incident. O. Reg. 484/16, s. 1 (1). (3.3) Where, pursuant to a system established under subsection (3.1), a review is conducted of a critical incident, a person acting on behalf of the hospital shall offer to interview the affected patient, or, (a) if the affected patient is incapable, a person lawfully authorized to make treatment decisions on behalf of the patient; or (b) if the affected patient has died, (i) the patient’s estate trustee, or the person who has assumed responsibility for the administration of the patient’s estate, if the estate does not have an estate trustee, or (ii) a person who was lawfully authorized to make treatment decisions on behalf of the patient immediately before the patient’s death, or who would have been so authorized if the patient had been incapable. O. Reg. 484/16, s. 1 (1). (4) The board shall ensure that the administrator establishes a system for ensuring the disclosure of every critical incident, as soon as is practicable after the critical incident occurs, to the medical advisory committee and the administrator and, (a) to the affected patient; (b) if the affected patient is incapable, to a person lawfully authorized to make treatment decisions on behalf of the patient; or (c) if the affected patient has died, (i) to the patient’s estate trustee, or to the person who has assumed responsibility for the administration of the patient’s estate, if the estate does not have an estate trustee, or (ii) to a person who was lawfully authorized to make treatment decisions on behalf of the patient immediately prior to the patient’s death, or who would have been so authorized if the patient had been incapable.  O. Reg. 423/07, s. 2; O. Reg. 156/10, s. 1 (2). (5) The disclosure referred to in subsection (4) shall include, (a) the material facts of what occurred with respect to the critical incident; (a.1) a description of the cause or causes of the critical incident, if known; (b) the consequences for the patient of the critical incident, as they become known; and (c) the actions taken and recommended to be taken to address the consequences to the patient of the critical incident, including any health care or treatment that is advisable.  O. Reg. 423/07, s. 2; O. Reg. 484/16, s. 1 (2). (5.1) The board shall ensure that the administrator establishes a system for ensuring, following a disclosure of a critical incident under subsection (4), that the incident is analyzed and a plan developed with systemic steps to avoid or reduce the risk of further similar critical incidents.  O. Reg. 156/10, s. 1 (3). (5.2) The board shall ensure that the administrator provides aggregated critical incident data related to critical incidents occurring at the hospital to the hospital’s quality committee established under subsection 3 (1) of the Excellent Care for All Act, 2010 at least two times per year.  O. Reg. 448/10, s. 1 (2). (5.3) The aggregated data shall include data about all critical incidents occurring at the hospital since the previous aggregated data was provided to the quality committee.  O. Reg. 448/10, s. 1 (2). (6) The board shall ensure that the administrator establishes a system for ensuring that at an appropriate time following a disclosure of a critical incident under subsection (4), there be a disclosure to the person referred to in clauses (a) to (c) of subsection (4) of the systemic steps, if any, that the hospital is taking or has taken in order to avoid or reduce the risk of further similar critical incidents, and that the content and date of this further disclosure be recorded.  O. Reg. 423/07, s. 2; O. Reg. 484/16, s. 1 (3). Responsibility of Administrator