Ask an Expert: Policies Requiring Board Approval

 Hi, Is there any way we can get a complete list of all policies that need to be board approved. We just want to make sure we are staying on top of things.

Thanks so much for submitting your question – we get asked this often!

Here are the policies within the Compliance manual.


  1. Sliding Fee Discount Program Policies
  2. Quality Assurance/Quality Improvement Program Policies ( if Risk Management falls with this category then it needs to be approved as well)
    1. Clinical guidelines, standards of care or standard of practice
    2. Patient safety and adverse events
    3. Patient satisfaction
    4. Patient grievances
    5. Periodic QI/QA assessments
    6. QI/QA report generation and oversight
    7. Confidentiality, privacy, security of patient records
  3. Financial Management and Internal control policies
    1. Drawdown, disbursement and expenditure of federal award funds
    2. Govern and track the use of non-grant funds
  4. Billing and Collections Policies
    1. Provision to waive or reduce fees owed by patients
    2. Third-party billing procedures or contracts
    3. AS APPLICABLE— refusal to pay policy (THIS IS AS APPLICABLE ONLY)
    4. Notifying patients of additional costs for supplies and equipment related to but not included in the service (THIS IS AS APPLICABLE ONLY)
  5. Personnel Policies


The footnote within the HRSA OSV Protocol, Board Authority, Footnote #6 states, “The governing board of a health center is generally responsible for establishing and/or approving policies that govern health center operations, while the health center’s staff is generally responsible for implementing and ensuring adherence to these policies (including through operating procedures).” If the policy governs the operation of a health center then it should be approved.

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