Integrated Hospital Governance for Quality, Safety and Value: A Narrative Review and Provisional Framework for Evaluation

CONTEXT: Hospitals are required to improve outcomes, strengthen patient safety, control costs, meet regulatory and audit requirements, sustain research activity and maintain operational continuity despite competing organisational pressures. Nevertheless, these responsibilities are often governed in isolation rather than through integrated organisational arrangements, thereby obscuring how quality, safety and value are collectively achieved. METHODS: A narrative review with thematic synthesis examined English-language conceptual papers, empirical studies, policy analyses and reviews addressing hospital-level quality, safety, accountability, value, learning or operational reliability. PubMed/MEDLINE, Web of Science, Scopus and Google Scholar were searched in October 2026 for literature published through 31 December 2025, supplemented by backward citation tracking. Foundational sources were retained; literature from 2023 to 2025 was prioritised. Thirty sources were purposively selected for conceptual relevance and cross-domain coverage and mapped onto five governance domains. Two subject-matter experts (Expert A and Expert B) independently and manually conducted eligibility screening, data extraction, domain coding and structured critical appraisal of all retained sources. Disagreements were resolved using documented criteria; methodological appraisal informed interpretation without numerical evidence weighting or overall evidence-certainty grading. FINDINGS: Five interdependent governance domains emerged from the purposively selected literature: cost stewardship linked to quality and safety; compliance, audit and internal control; medicines, consumables and supply resilience; research stewardship and organisational learning; and operational support systems, including infrastructure and maintenance. Across all five governance domains, fragmentation was identified as a persistent cross-domain governance risk: harm, delays, waste and diminished trust may emerge at organisational interfaces but be assessed through separate committees, datasets and accountability structures. The medicines, consumables and supply resilience domain emerged as a distinctive operational nexus because it links procurement integrity, bedside safety, continuity of care and financial stewardship, although its evidentiary basis remains relatively limited. The synthesis generated a provisional integrated governance framework, which extends clinical governance, board oversight and learning-health-system models by treating organisational interfaces as the unit of governance. This framework identifies shared dashboards, cross-domain review processes and pathway-level accountability as framework-derived options for hospital boards and executives and presents four testable propositions with candidate outcome measures. CONCLUSION: This provisional conceptual synthesis indicates that hospital quality, safety and value may be governed more coherently as an integrated organisational problem rather than through multiple separate managerial functions; this central proposition warrants rigorous empirical evaluation. For practice and policy, the framework proposes linked accountability structures, cross-functional oversight and measurement systems integrating outcomes, harms, costs, supply reliability and learning in contemporary hospitals.