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Chapter 19, “Board Authority,” of the Health Resources and Services Administration (HRSA) Compliance Manual (HRSA Compliance Manual, Board Authority) and HRSA Site Visit Protocol (HRSA Site Visit Protocol) state, clinical policies that require board approval are those related to the Quality Improvement/Quality Assurance Program. These policies must be approved a minimum of every three years. Additionally, the board must evaluate the performance of the health center based on the receipt of the results of Quality Assurance/Quality Improvement assessments and ensure appropriate follow-up actions are implemented.
As a result, the health center must present the Quality Improvement/Quality Assurance Plan and Risk Management Plan, as well as clinical quality policies such as Clinical Guidelines, Peer Review, Patient Satisfaction, Patient Grievances and Patient Complaints to the Board of Directors for approval. Health centers that are lacking these policies may receive a finding of non-compliance under Chapter 10, “Quality Improvement/Assurance,” based on the requirements outlined in Element A and Element C of the Quality Improvement/Assurance section of the HRSA Site Visit Protocol (HRSA Site Visit Protocol, Quality Improvement/Assurance). Health centers that maintain these policies, although do not have these quality policies approved by the Board of Directors, may receive a finding of non-compliance under Chapter 19, “Board Authority,” based on the requirements outlined in Element D of the Board Authority section of the HRSA Site Visit Protocol (HRSA Site Visit Protocol, Board Authority).