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Ask an Expert: Approval of Clinical Policies

We currently send all of our clinical policies to the Board of Directors for approval.  Is this required?  We are not sure which clinical policies must be board approved and which ones do not.

 

Prior to the release of the Health Resources and Services Administration (HRSA) Compliance Manual (HRSA Compliance Manual), a number of clinical policies required approval by the Board of Directors.

Upon the release of the HRSA Compliance Manual, those requirements changed.  For example, the health center’s Credentialing and Privileging Policy no longer requires approval by the Board of Directors.

The HRSA Compliance Manual and HRSA Site Visit Protocol (HRSA Site Visit Protocol) state the only clinical policies that require board approval are those related to the Quality Improvement/Quality Assurance Program, which must be approved at a minimum of every three years. The health center must send the Quality Improvement/Quality Assurance Plan and Risk Management Plan, as well as clinical quality policies, such as Peer Review, Patient Satisfaction and Patient Complaints to the Board of Directors for approval.

Health centers that do not have these clinical policies approved by the Board of Directors will 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).  Keep in mind, there are policies in the areas of Admin/Governance and Fiscal that require approval by the Board of Directors.  

The guidance provided in the HRSA resources above provide the minimum standards for compliance, as it relates to clinical policy approval.  Although not required, industry standard best practice demonstrates high performing health centers continue to have clinical policies approved by the Board of Directors.  

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