Sumter Family Health Center

XXXXX

BOARD OF DIRECTORS’

GOVERNANCE POLICY MANUAL

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Approved by the Board of Directors:

Original Creation Date:

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TABLE OF CONTENTS

Introduction ...........................................................................................................4

Mission Statement/Commitments .........................................................................5

Culturally Competent Organization ......................................................................6

Role of the Board of Directors ..............................................................................7

Job Description and Responsibilities ....................................................................8

Size and Composition ...........................................................................................9

Commitments ..................................................................................................... 11

Training and Development ................................................................................ 15

Committees ........................................................................................................ 17

Standing Committees ......................................................................................... 19

Officer Roles ...................................................................................................... 22

Meeting Structure and Logistics ........................................................................ 24

Board Member Liability..................................................................................... 25

Appendix I: Board Member Position Description ............................................. 28

Appendix 2: Who Does What in Healthcare Operations ................................... 30

Appendix 3: What Does the Board of Directors’ Do? ....................................... 31

Appendix 3: What Does the Chief Executive Officer Do? ................................ 34

Appendix 3: Division of Responsibilities .......................................................... 36

Appendix 4: Annual Work Plan ......................................................................... 38

Appendix 5: Policy & Procedure Review Schedule .......................................... 41

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INTRODUCTION

The XXXX (“Center”) Board Governance Policy Manual defines the role of the Board and

delineates how the Board will carry out its responsibilities. The Board Governance Policy

Manual and the Bylaws are the primary governing documents for the Center.

The purpose of these policies is to:

 make clear Board intent, goals, and aspirations

 promote consistency of Board action

 clarify Board member’s roles, responsibilities, and commitments

The Board Governance Policy Manual is available at each Board meeting and provides guidance

for decision making. A copy of the Board Governance Policy Manual will be given to each

Board member and revisions will be distributed, as appropriate.

Board policies are adopted through a majority vote of the Board and only at Board meetings.

Before adopting any policy, all Board members will receive a copy of the proposed policy in

advance of the meeting at which the vote is to be taken. All policies will be reviewed on a

regular basis by the Board for accuracy and appropriateness, and recommendations will be made

for amendment, addition, or elimination.

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XXXX

MISSION STATEMENT

XXXX’s mission is to provide quality health care services to the medically underserved

populations of our communities.

VISION STATEMENT

XXXX, working with private and public health partners, and by leveraging and efficiently using

its limited resources, will help to create a seamless system of access to compassionate, high

quality cost-effective primary and preventive health care for all residents of the communities it

serves. XXXX strives to improve the health status within the communities it serves, particularly

for those residents who are economically or otherwise disadvantaged.

OUR VALUES

CARING AND COMPASSION:

We treat those we serve and one another with concern, kindness and respect.

HONESTY AND INTEGRITY:

We act openly and truthfully in everything we do.

TEAMWORK:

We work together cooperatively, recognizing the power of our combined efforts exceeds what

we can accomplish individually.

COMMUNITY:

We acknowledge our vital role in local communities, and we seek to understand and serve their

needs.

EXCELLENCE AND QUALITY:

We are committed to quality and to adding value in every aspect of our work, and we strive to

exceed the expectations of our customers.

EDUCATION, TEACHING AND TRAINING:

We strive to create an educational environment for our patients, our employees, our Board

members and for the training of medical professionals dedicated to serving the disadvantaged.

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CULTURALLY COMPETENT ORGANIZATION

The Center strives to be a culturally competent organization that accepts and respects individual

differences. Diversity within the organization provides the Center with a full range of

perspectives and contributes to the ability to better meet the needs of the diverse community we

serve.

The Center’s commitment will be reflected through an environment that not only promotes the

awareness of ethnic, cultural, racial, economic, sexual orientation and gender issues, but also

values diversity. The Center will provide quality primary health care services without regard to a

person’s culture, ethnicity, economic status, sexual orientation, gender or ability to pay. To

realize this goal, the Center will train staff to be culturally sensitive, and to the extent reasonable

and possible, actively recruit and hire culturally diverse staff. In addition, at times of Board

member transitions, the Board will identify any gaps in representation of the patient populations

served by the Center and will actively recruit Board members who represent the diverse

community.

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ROLE OF THE BOARD OF DIRECTORS

In carrying out its responsibilities, the Board of Directors for XXXX has the following role:

 Assuring MISSION

 Embracing a future VISION

 Making VALUES explicit

 Setting STANDARDS

 MONITORING performance

 MISSION – assuring:

 clarity around what, for whom, and at what cost

 responsiveness to the community served

 services/programs appropriately address patient needs

 decisions are made in light of Mission

 VISION – embracing a future:

 by thinking beyond today

 toward leading and away from reacting

 VALUES – making explicit:

 what we believe

 what we stand for

 what is important

 STANDARDS – setting:

 financial, personnel, and healthcare policies

 current programs

 MONITORING – performance:

 patient access/provider productivity

 recruitment and retention needs

 based on measurable indicators of success

 maintaining fiscal health and availability of resources

 evaluating CEO’s effectiveness

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JOB DESCRIPTION AND RESPONSIBILITIES

The Board serves as Directors of the Center. The Board guides to act in the public interest and

meet the needs of the community. The Board is responsible for:

 Establishing goals and monitoring outcomes of the organization

 Monitoring the organizational performance in fulfilling the mission of the center

 Assuring the center has the necessary resources and is fiscally healthy

 Reviewing and approving grant submissions

The Department of Health and Human Services (DHHS), Health Resources and Services

Administration (HRSA), Bureau of Primary Health Care (BPHC) provides oversight of the

Center’s Federal 330 grant. As defined by the BPHC, the Board of Directors has the

responsibility for establishing policies, including but not limited to:

 Approval for the selection and dismissal of the CEO

 Review the performance of the CEO

 Establishing operating policies including human resources and financial management

policies

 Establishing health care policies including scope and availability of services, location

and hours of services

 Assuring the Corporation is operating in compliance with federal, state, and local

laws and regulations

 Evaluating healthcare activities of the Corporation, including but not limited to

patient access indicators including clinician productivity, recruitment and retention

 Assess and Monitor Needs of Target Population, overseeing progress in meeting

XXXX’s mission and goals

The Board of Directors will perform a self-evaluation of Board operations on an annual basis.

The Board will use the results to identify problems and set goals for improvement.

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SIZE AND COMPOSITION

According to Section 5.2 of the Center’s bylaws, The Corporation shall have no fewer than nine

(9) and no more than fifteen (15) Directors. The Board will be diverse in its representation by

gender, race, ethnicity, and profession and a majority of Board members must be active

consumers of services of the Health Center.

Consumer Board Members:

 At least 51% of the Board members will be recipients of services at the Center.

Consumer members are members of the Board, who are current registered patients of

the Health Center, or parent/legal guardians of a dependent who is a registered

patient, and must have accessed the health center in the past 24 months to receive at

least one or more in-scope services(s) that generated a health center visit.

 Consumer members will be reflective of the population served by the Center in terms

of race, ethnicity, and sex. The Board will include a review of its latest filed annual

Uniform Data System (UDS) report as a guideline in determining the mix of

members.

Non-Consumer Board Members:

 The remaining members of the Board of Directors will be representative of the

community primarily served by the practice location of the Center.

 Non-consumer Board members will be selected for their expertise in community

affairs, local government, media, education, medicine, finance and banking, legal

affairs, business, and social services.

 No more than one-half of the non-consumer Board members and up to no greater than

twenty five percent (25%) of the total membership of the Board, will be individuals

who are employed in healthcare and therefore derive more than 10% of their annual

income from the health care industry.

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Elections:

 Board composition will be assessed annually, prior to Board elections, to determine

whether the composition meets the aforementioned guidelines. Any deficiencies in

the area of consumer members will be addressed when filling any Board vacancy.

The Board Nominations Committee we undertake a process to reach those Board

Composition goals.

Board Nominations Recruitment Process:

 Develop an initial list of prospective Board members that would best fit the criteria

and reflect the recruiting priorities, meeting composition needs.

 Contact potential candidates to determine interest and answer questions.

 Schedule and conduct an in-person orientation for those candidates who expressed

interest.

 Meetings are then arranged with the Board Nominations Committee to interview all

candidates that best fit the recruiting priorities.

 Board Nominations Committee will meet to evaluate the potential candidates,

reviewing recruiting priorities and Board composition.

 Board Nominations Committee will recommend appointments to the full Board and

action taken and documented in Board meeting minutes.

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COMMITMENTS

Board members are elected and agree to serve for a three-year term. There are no limits to the

number of consecutive board terms that a Board member is eligible for. Elections for Board

members will be held at the September Board meeting. Renewing Board members will be asked

by the CEO well in advance of the September Board meeting as to their intention to serve an

additional three year term. The CEO will then alert the Board Chairman and the Chair of the

Board Nominating Committee as to whether an existing Board member is willing to serve

another term or if they will be vacating their position resulting in the need to fill that Board

position. If a seat becomes vacant the Board Nominating Committee will then move forward

with its process of recruitment, evaluation with recommendations going to the full board at its

next regular meeting.

Board Officers, i.e. Chair, Vice Chair, Treasurer and Board Secretary, are also elected annually

through a process completed at the September Board meeting. The CEO will reach out to both

the existing Board officers and to all Board members well in advance of the September Board

meeting to seek their consideration for filling one of the Board officer positions. If more than one

Board member wishes to fill one of the Board Officer positions, a written ballot election will

take place at the September Board meeting with a simple majority vote determining who fills

that specific Board Officer position.

During the three-year term, Board members make the following commitments:

Accountability:

 Board members should understand the Center, its mission, goals, objectives, and

programs.

 Board members should make decisions on issues, policies, goals and objectives based on

careful consideration of the facts and all relevant data.

 Board members should participate fully and openly in meetings; share insights, ideas, and

suggestions.

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Attendance – Board Meetings:

 As pledged in the Center’s Board Member Expectations, Board members are to commit

to a high priority of attendance at all Board and Committee meetings (goal of 75%).

 An expectation of accepting responsibility of being an XXXX Board member is a

commitment to attend a large majority of Board meetings as well as Committee meetings

that you are specifically assigned to. The Board has established a goal of attending at

least 75% of meetings throughout the fiscal/calendar year. At the end of each

fiscal/calendar year, those board members who have not achieved 75% attendance will be

notified of their attendance by either or both a letter and/or phone call or other

communique by the Board Chair with the expressed intention of determining what steps

that board member intends to take to ensure compliance with this goal. Exceptions to this

policy goal can be determined by either the Board Chair or other delegated Board

Officer, for situations like serious health issues that may require time away from Board

service in any given year.

Attendance – Committee Meetings:

 As pledged in the Center’s Board Member Expectations, all Board Members agree to

serve on at least one Committee or task force, and participate in the accomplishment of

its objectives. If the Board member chairs the committee or task force they are to:

1. Call meetings as necessary until objectives are met

2. Ensure that the agenda and support materials are mailed/emailed to all members

in advance of the meetings

3. Conduct the meetings in an orderly, fair, open and efficient manner

4. Make committee progress reports/minutes to the Board at its scheduled meetings,

using the adopted format

To participate in:

1. The strategic planning retreat

2. Board self-evaluation programs

3. Board development workshops, seminars, and other educational events

that enhance my skills as a Board member

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Time Commitment:

 Board members are expected to review all pre-meeting reading materials in advance

of the Board or Committee meeting.

 When absent from any meeting, Board members are expected to review minutes and

materials from the missed meeting.

 During the Director’s three-year term, each member is expected to:

1. Attend a new member orientation meeting (first year).

2. Participate on at least one standing committee.

3. Participate in the strategic planning retreat held at least once every three

years.

4. Attend/participate in regular Board training/development opportunities

typically offered as part of regular Board meeting agendas and/or attend

regional state or Federal Community Health Center meetings (e.g.

NACHC, CPCA, HANC, etc).

Accepting Leadership Roles:

 During the Director’s three-year term, each member will be offered the opportunity to

serve in at least one leadership role. Leadership roles might include:

1. Officer position

2. Committee Chair

3. Ad-Hoc/Task Force Committee Chair

Conflict of Interest:

 Board members shall support the mission and goals of the Center and the community

it serves. Board members must avoid any/all conflicts of interest.

 Board members shall, upon installation, sign an Annual Disclosure of Potential

Conflicts of Interest Statement, and will update the form on an annual basis. If a

Board member has any perceived conflicts of interest, these must be disclosed to the

Board.

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 When the Board is to decide upon an issue about which a member has an unavoidable

conflict of interest, the member must remove themselves from comment during the

deliberation and the vote.

Speaking as One Voice:

 Board members may not attempt to exercise individual authority except as explicitly

set forth in Board Bylaws and/or policies.

 Board members may not speak individually for the Center unless authorized by the

full Board or if in an urgent matter, with the support of the Board Executive

Committee.

 Once a decision has been reached on any Center issue, the Board will speak with one

voice.

Confidentiality:

 Board members should not disclose information about the Center’s activities unless

those activities are already known by the public or have become a part of public

record.

Interaction with Staff:

 Board members must not use their positions to obtain employment in the Center, or

for preferential medical treatment for themselves, family members or close associates.

 Board members should not attempt to resolve staff complaints. When confronted

with a staff complaint, Board members will:

a) express concern and desire that the complaint be handled appropriately as

outlined in the Personnel Policy

b) explain that an individual Board member has no authority to deal with staff

complaints; therefore, the Board member will not attempt to mediate or resolve

their complaint

c) explain that the Board has delegated staff, including complaints, to administration

and the staff person should address their concern with the Chief Executive Officer

or his/her delegate.

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TRAINING AND DEVELOPMENT

Board members agree to participate in ongoing training and development.

New Board Member Orientation:

New Board members will attend an initial orientation and training session delivered by the CEO

prior to their first regularly scheduled Board meeting. Throughout the orientation and training,

new Board members will receive the following documents for review and consideration:

 Mission Statement and Core Values

 Board of Director’s Governance Policy Manual

 Org Chart

 Access to Board Approved Operating Policies including Personnel and Finance

 Board Bylaws and Articles of Incorporation

 Access to minutes of meetings for the last year

 Federal grant application, including budget

 Most recent audit and financial statements

 Current list of all Board Members

 History/Brochures/Program Descriptions

 BPHC Governing Board Handbook

 List of Commonly Used Acronyms

Center staff will assist in the orientation, which will include a tour of the center; instruction on

how to read budget and financial reports; and an overview of Board meetings.

In-services for Board Members:

In-services for Board members are essential to Board development. The Center will also pay

reasonable travel and meeting expenses for a limited number of Board members each year to

attend state or national meetings of Community Health Centers. Special consideration will be

given to Board members who have not participated in previous state and national meetings.

Travel expenses will be reimbursed according to The Center’s Personnel Policy.

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Board members who attend conferences will make a presentation at the next Board meeting of

the new ideas and insights gained at the conference.

Ongoing Board Development:

The primary Board development strategy is through materials and presentations made at a

regular or special Board meeting. Such items may be included in the agenda of Board meetings.

A speaker may be invited to the meeting or a Board or staff member may update the Board on a

relevant topic. In addition, Board members who attend regional, state or federal training/policy-

oriented programs that are sponsored by XXXX will be asked to report to the full Board a

summary or highlights of what they learned at those meetings. Information obtained through the

Board self-evaluation will be used to help craft the content of future Board development agenda

items.

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COMMITTEES

The Board appoints both standing committees and ad-hoc committees. This policy applies to

both, whether or not they include non-Board members.

 Board standing and ad-hoc committees are created to advise the Board. When the Board

takes action to establish a committee, they will also assign a specific charge and suggested

membership.

 Membership on committees may include: currently elected Board members, former Center

Board members including ex-officio Board members, Center staff and other individuals from

the community with specific skills sets and experience useful to the Committee.

 Committee meetings are open to all Board members. Only the appointed members of the

committee are allowed to vote.

 The Chairperson of the Board will be an ex-officio member of all committees, but will only

vote on the committee to which they are assigned.

 The Chief Executive Officer, or delegated representative, will be a nonvoting member of all

committees as a staff resource to the committee.

 Only the full Board or Executive Committee can exercise authority over the Chief Executive

Officer.

 Only the full Board or Executive Committee may speak or act for the Board.

 Board committees do pre-Board work by clarifying issues, identifying alternatives, and

determining implications of proposed actions.

 Recommendations resulting from committee action will be presented by the Chairperson, or

a member of the committee, in the form of a motion at a full Board meeting.

 Minutes and attendance will be taken at all committee meetings.

 There are five standing committees of the Board:

a) Executive Committee

b) Finance Committee

c) Audit Committee

d) Board Nomination and Development Committee

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e) Compliance Committee

The Chairperson of the Board of Directors will appoint the Chairpersons and members of each

standing committee at the beginning of each Board election year, typically at the September

Board meeting or at such other times as the Chairperson shall determine.

Ad-hoc committees are established whenever a special need arises, and then disband once their

charge is complete.

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STANDING COMMITTEES

Executive Committee:

 The purpose of the Executive Committee is to take actions on behalf of the Board between its

meetings, as necessary, to conduct the business of the Center.

 Membership will include Board officers.

 The Executive Committee oversees the evaluation of the Chief Executive Officer including

developing the criteria used for evaluation, interviewing staff participating in evaluation, and

preparing summary information for consideration by the full Board.

 All business transacted by the Executive Committee will be reported at the next Board

meeting.

 Executive Committee meetings will be called as necessary.

 The Chairperson of the Board will serve as the Executive Committee’s Chair.

Finance Committee:

 The purpose of Finance Committee is to:

a) Oversee the financial operations of the Center, including revenues and expenses and

other operational indicators that impact fiscal performance such as clinical productivity.

b) Oversee the preparation of the annual budget and monitor budget variances with actual

revenue and expenditures

c) Review year-end financial statements

d) Review financial statements on a monthly basis

 The Finance Committee will meet monthly

 There will be a minimum of three Directors on the Finance Committee

 The Treasurer of the Board will serve as the Committee’s Chair

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Audit Committee:

 Selects a qualified auditing firm with the expertise and understanding of current financial

auditing laws, regulations and best practices including a demonstrated understanding of audit

issues, as required by HRSA, of Federally Qualified Health Centers.

 Ensures that an annual financial audit is conducted by a professional auditing firm in

accordance with federal guidelines.

 Receipt of the final audit by the Audit Committee with an in-person presentation by the

Auditing firm disclosing the outcome of the audit, including any findings and any

management reporting requirements with a full report to the Board.

 Upon receipt of the final annual fiscal audit, make a recommendation to the full Board as to

the acceptance of the audit.

(Please Note: California law requires that less than 50% of the Audit Committee members may also be members of

the Center’s Finance Committee).

Board Nomination and Development Committee:

 The purpose of Nominating Committee is to:

a) Recruit new Board members with deference to the preferred mix of members needed to

carry out the regulatory requirements under FQHC guidance and in keeping with best

practices in non-profit Board Governance.

b) Develop and provide new Board member orientation, assist in identifying Board

development and training goals and Board training schedule.

 There will be a minimum of three Directors, including any ex-officio members, on the

Nominating Committee

 The chairperson of the Nominating Committee shall be a Director

Compliance Committee:

 The purpose of Compliance Committee is to:

a) To oversee and evaluate the Center’s Compliance Program.

b) To make recommendations to assist the Board in approval and oversight of the

development, maintenance, and implementation of the Center’s Compliance Program

policies and activities.

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c) Meetings of the Compliance Committee will occur as deemed necessary in any given

year but no less than twice a year. The Center’s Compliance Officer will be the primary

staff person to this Committee.

 There will be a minimum of three Directors on the Compliance Committee

 The chairperson of the Compliance Committee shall be a Director

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OFFICER ROLES

There are four officers of the Board:

 Chairman

 Vice-Chairman

 Secretary

 Treasurer

As determined in the Center’s Bylaws Article VI, the officers shall be appointed annually at the

September Board meeting. In addition to the duties outlined in the Bylaws, the officers have the

following roles:

Chairman’s Role:

Responsible for:

 Planning and leading Board meetings

 Integrity of the Board process

 Managing the participation of Board members

 Appointing committee chairpersons and membership

 Chairing the Executive Committee

 Assuring the Board’s work is completed

Vice-Chairman’s Role:

Responsible for:

 Performing duties of the Chairman in their absence

 Manage special assignments as requested by the Board Chairman

Secretary Role:

Responsible for:

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 Ensure the accuracy and integrity of the Center’s official Board records including all

official minutes of proceedings including all actions taken by the Board and other Board

Committee records or minutes.

 Ensure that at the principal office in California of the Center that a copy of the Articles of

Incorporation and By-laws, as amended to date, are kept.

Treasurer Role:

Responsible for:

 Integrity of the Center’s financial affairs

 Assuring the Board remains knowledgeable of the financial status of the center

 Chairing the Finance Committee

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MEETING STRUCTURE AND LOGISTICS

 Board meetings are held monthly, 12 times per year.

 Board meetings will be held on the fourth Thursday of each month at a designated

location, or as so determined by the Directors in office from time to time. The November

and December Board meeting dates will be revised from year to year, so as to not conflict

with statutory holidays and to ensure a quorum of Board members. Notice will be

provided in advance.

 The Board will receive a packet for the upcoming meeting either couriered or mailed and

electronically transmitted at least four days prior to the meeting. Board pre-meeting

reading materials include a tentative meeting agenda, the previous month’s minutes

including the Chief Executive Officer’s report and the Chief Medical Officer’s report

including key quality and financial reports, and any information requiring review prior to

the meeting. Other members of the Center’s Senior Management Team, including the

Chief Operations Officer/Compliance Officer, Chief Information Officer and Chief of

Planning and Development will also provide a report each month highlighting issues of

importance to Board members.

 At the beginning of each calendar year, the Board Chairperson, with the assistance of the

CEO, will prepare a work plan and objectives for the upcoming year, as well as measures

of success.

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YOUR LEGAL RESPONSIBILITIES

AS A

BOARD MEMBER

BOARD MEMBER LIABILITY

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A. The governing Board of Directors is the legally responsible entity and can be sued.

Minimizing liability can be done by:

1. Keeping well informed – attend meetings, review reports, ask questions, know what’s

going on

2. Perform your duty wisely, honestly and to the best of your ability

3. Keep in mind the following principles:

a. Conflict of Interest – declare any conflict of interest and refrain from attempts to

influence when there is a conflict of interest

b. Corporate Liability - follow the law and assure that the legal obligations of the

corporation are being met

c. Duty of Care – perform your duties in good faith with the best interests of the

center in mind

d. Duty of Loyalty – the Center should come before your own interests

B. Practice “Risk Management”:

1. Maintain adequate insurance coverage.

2. Maintain written policies, adequate controls, and reporting systems to govern

operations.

3. Keep “Paper trails” – written documentation of all important activities – meetings,

hiring and firing processes, medical records, etc.

4. Keep the corporate compliance plan current and verify that management is

following the compliance plan and reporting back findings to the Board Compliance

Committee and then to the full Board.

5. Files – especially personnel and financial – should be kept up to date and retained

even after an organization closes its doors (at least three years).

6. Attend Board and Committee meetings regularly.

7. Be familiar with the minutes of Board meetings and the minutes of your committee

assignments.

8. Be familiar with the Center’s publications.

9. Treat the affairs of your Center as you would your own.

10. Be certain the Center’s records are audited by a reputable CPA firm.

11. Be familiar with the Center’s goals, objectives and programs.

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12. Insist that all committee meetings are reported at Board meetings in either oral or

written form.

13. Know the Center’s budget, budget process, and financial situation.

14. Know who is authorized to sign checks and in what amount.

15. Avoid self-serving policies.

16. Inquire if there is something you do not understand or if something comes to your

attention which causes you to question a policy or a practice.

17. Insist that there is a well-established personnel program with a competent staff and

Chief Executive Officer

18. Avoid the substance or appearance of conflicts of interest.

19. Be certain your Center is fulfilling all aspects of its not-for-profit and tax exempt

status.

20. Monitor the community and professional image of your Center.

21. Be certain that policies are clearly identified, and the Board acts on them as a whole

rather than action by a small group of individuals.

22. Know the Center’s Board of Directors, financial condition, programs and staff.

23. Require that your Center has proper legal counsel.

24. Monitor the activity of your CEO to ensure it does not overstep its authority.

25. Insist on the Board having a policy relative to Board volunteer liability.

26. Lastly, keep in mind this not-for-profit law: Directors and Officers shall discharge

their duties in good faith and with the degree of diligence, care and skill which

ordinarily prudent men would exercise under similar circumstances in like

positions.”

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APPENDIX I

EXAMPLE

BOARD MEMBER POSITION DESCRIPTION

DUTIES AND RESPONSIBILITIES OF INDIVIDUAL BOARD MEMBERS

1. To put the interests of the health center above any personal or other business interest

2. To maintain the confidentiality of Board information

3. To serve on at least one Board committee

4. To attend Board and committee meetings regularly

5. To review information provided to the Board

6. To exercise reasonable business judgment in the conduct of Board business

7. To participate actively in Board issues by critiquing reports and providing innovative

resolutions to problems

REQUIRED KNOWLEDGE AND SKILLS OF INDIVIDUAL BOARD

MEMBERS

1. Ability to read and understand standard financial statements.

2. Understanding of the concept and operation of a HRSA/BPHC funded health center.

3. Training and/or experience in one or more of the following areas (does not necessarily

apply to consumer members):

a. management

b. health care delivery

c. law

d. financial management

e. marketing/public relations

f. employee relations

g. personnel management

h. community affairs

i. social services delivery

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j. Ability to work with others on the Board and in the committee setting.

OTHER

1. Board meetings are held monthly and last approximately one to two hours.

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Appendix 2

WHO DOES WHAT IN HEALTH CENTER OPERATIONS?

Board Role

CEO’s Role

Develop Mission Statement

Communicate Mission Statement

Guide Strategic/Long-Range Planning

Implement Strategic/Long-Range Planning

Establish/Approve Policy

Implement Policy

Select and Evaluate Qualified Chief

Executive Officer

Ensure Timely and Accurate Reporting to

Board on Achievement of Organizational

Goals and Objectives

Evaluate Center Operations

Manage Center Operations

Review Quality of Care

Monitor Quality of Care

Represent Community Interest

Represent Health Center Needs

XXXXX – Board Governance Manual ------------------------ 31--

XXXX

BOARD – STAFF

RELATIONSHIPS

WHAT DOES THE BOARD OF DIRECTORS DO?

The Board of Directors provides the continuity on which your Center is based. Individual

members of the staff and the Board come and go, but the entity of the Board exists as long as

your organization does. Individual members of the Board, together form a corporate body that

has the overall responsibility for the organization.

What are the specific functions of the Board of Directors? Board members generally assume

responsibilities in the following areas:

A. Budget and Finance:

Board members approve the budget, which is generally prepared by the Chief Financial

Officer (CFO), and reviewed by the CEO and Senior Management. They monitor

program expenditures and determine sound fiscal policy and internal control practices.

They assume responsibility for the fiscal accountability of the Center.

B. Fund Raising:

Board members ensure that adequate funds are available for financing the Center’s

operations. They approve the general fund-raising methods used by the center, and they

participate in fund-raising activities. Individual Board members may serve as a contact

for the Center for specific funding sources.

XXXXX – Board Governance Manual ------------------------ 32--

C. Program Evaluation:

Board members monitor program effectiveness. They review program-evaluation reports

on a regular basis, and they advise staff on the Center’s self-evaluation activities.

D. Planning:

Members of the Board of Directors participate in and approve the long-range Strategic

Plans of the center, including the program’s goals and objectives. They assist the staff in

the development of these plans and set organizational priorities for action.

E. Personnel:

The Board of Directors hires the Chief Executive Officer, monitors the effectiveness of

the Director’s performance, and removes the Director when his or her performance is

unsatisfactory. It determines the salary scales and benefits for the staff, and it develops

personnel policies. However, staff members are hired, evaluated, and, if necessary,

removed by the Chief Executive Officer, not the Board.

F. Board Development:

The Board of Directors determines the structure of the Board and committee

membership. It nominates and selects new Board members and sets the standards for its

own periodic self-evaluation. Self-evaluation by Board members is an important process

as it provides feedback to the Board Chair and with the help of the CEO, as to potential

training opportunities as well as other opportunities for improvement at the Board level.

XXXXX – Board Governance Manual ------------------------ 33--

G. Public Relations:

When appropriate, the Board of Directors communicates with funders, community

leaders, and other interested parties about the Center’s programs. On occasion, Directors

represent the Center in the community. More typically, Board members advise the staff in

the development of public relations responses to community and/or Health Center issues

as appropriate.

H. Policy:

Members of the Board determine the Center’s policies. Policies can be defined as the

broad guidelines that provide a framework for future decision making. Policies are

reflected in procedures, which are the more specific, narrow parameters that are used in

organizational decision making.

Procedures clarify what steps must be taken, what rules must be followed, and who must

be included in the process. Procedures are generally formulated by the staff rather than

by the Board. Organizational Policies and Procedures are routinely brought to the Board

for review and approval on a regular basis.

XXXXX – Board Governance Manual ------------------------ 34--

WHAT DOES THE CHIEF EXECUTIVE OFFICER DO?

The Chief Executive Officer is appointed by and responsible to the Board of Directors and is

charged with providing leadership and over-all direction and administration of the operations of

the Center. He or she interprets and applies the policies of the Board of Directors; establishes

basic policies within which the various activities are carried out; guides and develops short and

long-range planning; and evaluates activities in terms of objectives.

A. Planning:

Develops and gains Board approval on the goals, objectives and priorities for the Center.

B. Budget and Finance:

Reviews and approves the Center’s budget for Board approval (following review and

recommendation by the Board Finance Committee) as prepared by the CFO.

C. Staff:

Supervises staff in carrying out the plans and programs of the Center. Determines

responsibilities and authority among staff and assures that high standards of performance

are being met.

D. Resources:

Works with Board to secure adequate resources to carry out the center’s programs and

monitors the allocation of these resources to insure they are used effectively and

efficiently.

E. Administration:

Is responsible for the day-to-day administration of the activities of the Center.

F. Review and Evaluation:

Monitors, and revises when necessary, the activities of the Center in order to gain greater

program effectiveness. Assists Board in evaluating progress and outcomes of programs,

and recommends revisions of goals or objectives when needed in order to improve

organizational performance.

XXXXX – Board Governance Manual ------------------------ 35--

G. Public Relations

Works with the Board to ensure community awareness of the Center’s goals, mission,

objectives and programs, and obtaining community support for the Center. The CEO, or

his/her delegate, is the chief spokesperson for the Center, unless otherwise directed by the

Board Chair.

XXXXX – Board Governance Manual ------------------------ 36--

DIVISION OF RESPONSIBILITIES

FUNCTION

BOARD

CEO

Budget & Finance

Planning

Review and Evaluation

Securing Resources

(fund raising included here)

Public Relations

Hire/Fire Chief Executive Officer

Hire/Fire Other Staff

Day-to-Day Administration

Setting Policy

Board Development

XXXXX – Board Governance Manual ------------------------ 37--

Appendix 4

Annual Work Plan

January – June Meeting Activities

January

February

March

April

May

June

New Board

member

orientation (as

appropriate)

Review key

statistics from

UDS Report

(moved to

April)

Review and

Update

Board

Governance

Manual

(Reviewed in

January)

Presentation of

the annual

audit by an

independent

CPA firm

Sign annual

Conflict of Interest

forms

Review the

performance

of the Chief

Executive

Officer

Review

Compliance

Work Plan

Board Training

and

Development

Program –

Roles and

Responsibilities

Review

Strategic

Plan

Objectives

Featured

Policy Update

Sign

Confidentiality

forms

Review

BPHC

program

expectations

Review and

approval of

Scope of

Services,

locations and

hours of

operation

Fee schedule

update

Featured

Policy

Update

Review of

Mission

Statement/

Bylaws

Update

Biographical

Information

Assessment

of the

Board’s

composition

Review Quality

Policies

Review and

approval of

HRSA 330

business plan,

health plan and

grant budget

Review key

statistics from

UDS Report

Review and

approval of

Executive

Compensation Plan

Featured

Policy

Update

Approve

Annual CEO

Professional

Objectives

Featured Policy

Update

Review annual

community

needs

assessment

Review Chief

Executive Director

Salary Survey

Continued on

next page=>

January

February

March

April

May

June

Update Annual

Board Work

Plan/Governanc

e Manual

Review facility

needs

Featured Policy

Update

XXXXX – Board Governance Manual ------------------------ 38--

Featured Policy

Update**

* The timing of this item is driven by HRSA from year-to-year

** Please see Appendix 5 for the Policy Review Schedule

XXXXX – Board Governance Manual ------------------------ 39--

July – December Meeting Activities

July

August

September

October

November

December

Featured

Policy Update

Notify those

Board

Members

whose term is

ending and

whether they

wish to

continue for

another three-

year term

with Board

resolution

occurring at

the September

Board

meeting.

Election of

members due

to vacancies

Board

Member Boot

Camp

Review

results from

Annual Board

Self Appraisal

Review and

approve

operating

budget for the

upcoming

fiscal year

Remind

Board

Members the

availability of

Board Officer

positions (i.e.

Chair, Vice-

Chair,

Treasurer and

Board

Secretary)

with Board

resolution to

occur at the

September

Board

meeting.

Re-

appointment

of Board

Members to

succeeding

three year

term

Distribution

of Annual

Board Self

Appraisal

Review and

approve

holiday

bonuses

Featured

Policy Update

Featured

Policy Update

Election of

Officers

Featured

Policy Update

Featured

Policy Update

Distribution

of the annual

calendar of

meetings for

the upcoming

year

Continued on

next page=>

Continued on

next page=>

XXXXX – Board Governance Manual ------------------------ 40--

July

August

September

October

November

December

Committee

appointments

CEO to

submit

proposed new

Fiscal Year

management

objectives

Recognition

for departing

Board

members and

year’s officers

Capital

Budget

Approval

Compliance

Committee to

Review

Corporate

Compliance

Plan and

compliance

with state,

local, and

federal

regulations

403(b)

Matching

Approval

Fee schedule

update

(possible)

Featured

Policy Update

XXXXX – Board Governance Manual ------------------------ 41--

Appendix 5

XXXX

2015 Policy & Procedure Review Schedule

Proposed

Month

Policy

Responsible Person

January

Telemedicine

Quality Improvement Management Plan

February

HIPAA Security Compliance Plan

Billing Policy and Procedure

Finance Policy and Procedure

March

Center Operations

340B Policy and Procedures

Infection Exposure Control Plan

April

HIS Policy & Procedure

Credentialing & Privileging Policy

Dental Policy and Procedure

Safety and Emergency Operations Plan

May

Risk Management Policy

June

None

July

Medical Staff Manual

Information Technology Services Policy Manual

August

HIPAA Privacy Manual

September

CME Program Policy & Procedures

Employee Handbook

October

Compliance Plan

Central Supply and Quality Control Testing Policy

and Procedure

November

None

December

Nursing Policy Manual

Medication Management Policy