Use Your Board Meeting Minutes to Reflect Compliance with Health Center Program Requirements for Board Authority

Health Center Program Requirements

Health Centers are required to have a board with at least nine and no more than 25 members with a patient majority of at least 51 percent. The patient members must be a reasonable representation of the people who seek and receive health services at the clinic in terms of the demographic attributes identified in the health center’s Uniform Data System (UDS) reporting. Non-patient board members must be representative of the community in which the health center is located; this can be met with individuals who live, work or have some other type of identifiable connection to the community.

Health Center board members provide leadership and oversight to ensure that underserved community members have access to health care services. The health center governing board must have authority for establishing or adopting policies for the conduct of the health center program project and for updating these policies when needed. Part of the way that they accomplish these goals is by creating and implementing board-approved policies needed to demonstrate health center program compliance.

The health center governing board must be able to demonstrate specific aspects of board authority:

  • Establish a governing board that has specific responsibility for oversight of the health center program.
  • Develop bylaws which specify the responsibilities of the board.
  • Assure that the center is operated in compliance with applicable federal, state, and local laws and regulations.
  • Hold monthly meetings and record minutes.
  • Establish or adopt policies for the conduct of the health center; update as needed.
  • Review and approve the annual health center program project
  • Strategic planning and follow-up/evaluation:
    • Identifying health center priorities.
    • Adopt a three-year plan for financial management and capital
  • Evaluate health center achievement:
    • Service utilization patterns.
    • Productivity (efficiency and effectiveness) of the center.
    • Patient
  • Ensure that a process is developed for hearing and resolving patient

Best way to demonstrate board compliance with Health Center Program requirements

The easiest way to demonstrate board compliance is to document the required actions and policy decisions in the health center’s monthly meeting minutes.

  • Evaluating and revising the Sliding Fee Discount Program policy (SFDP); clearly document input from patient board members. Approving nominal fee (if there is one).
  • Establishing a QI/QA Program and discussing QI/QA reports including achievement of project objectives, service utilization patterns, quality of care, efficiency and effectiveness of the center and patient satisfaction/patient grievances.
  • If a new CEO/Executive Director (ED) has been hired since the beginning of the project period, document prior approval from HRSA.
  • Discussing Conflict of Interest and annual disclosure; sign conflict of interest agreements if applicable.
  • Monitoring financial status - financial reports to the board (budget to actual comparison); Accepting annual audit report and any required follow-up.
  • Revising service utilization/dashboard reports.
  • Reviewing and updating Bylaw (as applicable).
  • Revising/approving major policy revisions/approvals.
  • Updating co-applicant agreement (as applicable).
  • Documenting CEO/ED annual performance evaluation (may note it was discussed / completed in an executive session).
  • Documenting monthly meetings – including attendance.
  • Evaluating the performance of the health center (QA/QI, financial performance, progress toward goals/strategic plan).
  • Updating the strategic plan.
  • Approving the health center’s site locations.
  • Approving the health center’s services and provision of said services.
  • Approving hours of operation.
  • Approving sub-awards or contracts for a substantial portion of the health center program.
  • Conducting long-range planning (at least every three years).
  • Selecting board members (nominations and elections).
  • Selecting officers.
  • Removing board members or officers (as applicable).
  • Verifying (periodically – annually or during selection process) that board members are not current employees of the health center, or immediate family members of current employees (spouses, children, parents, or siblings through blood, adoption, or marriage).
  • Reporting risk management including completed risk management activities; status of the health center’s performance relative to established risk management goals; and proposed risk management activities that relate and/or respond to identified areas of high organizational risk. Include any follow-up reports on risk management actions.
  • Privileging and re-privileging providers.

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