Quarterly Compliance Article: Creating a Forward Thinking Board

Creating a Forward Thinking Board

Although HRSA requires Board of Directors to have certain composition requirements, it is important to remember that these requirements are the floor and not the ceiling. Board of Directors are required to provide oversight of the health center program and are given specific duties, but governance of a non-profit goes beyond these requirements. As the healthcare landscape becomes more progressive and forward thinking, it’s important that the Board of Directors follow suit; in other words, non-profits should be aiming to create a forward thinking Board.  Forward thinking Board of Directors view their role as more than just supporting the CEO and making motions to approve the basic HRSA requirements. They are able to engage in conversation related to challenges, participate in strategic planning, have the confidence to make decisions for the health center, and work collaboratively to develop achievable short and long term goals. What are some ways to engage the Board to achieve this?

  1. Focus on Governing: This means understanding the difference between governing and management. Governing means exercising accountability by setting goals, making policy and strategic decisions, and overseeing their implementation. (What the Board of Directors are supposed to do).  Management delivers the results by implementing policy and strategies, managing operations and reporting on performance. (What the CEO and their team completes).

  2. Develop a strong Board-CEO relationship: Having a strong relationship means ensuring the CEO has an up to date job description, is evaluated on their position based on the job description, and has achievable goals. A best practice could be to evaluate the CEO on a set of achievable goals that are related to the strategic plan. It is important to outline the role the CEO plays versus the role of the board. Provide education and training on roles and responsibilities. (Remember, you can’t hold individuals accountable for actions if they don’t understand their roles). Finally, provide education to the board on how to work with health center staff.

  3. Effective and Efficient Board Meetings: Ensuring board meetings are productive means providing the board with the board packet at least one week (this is a best practice) ahead of time and allowing them to review the material prior to the board meeting. Health Center staff reporting to the board should summarize the information and allow the board to ask questions to facilitate a discussion. Remember to capture the discussion in meeting minutes. Information provided to the board should be in a manner that is easy to understand. For example, if providing clinical or financial metrics, presenting data in a graph method may be easier to understand and visualize. Ask the board if the data and information they are getting allows them to be able to make decisions.

  4. Healthy Board Culture: A board’s culture can be defined as a “set of unwritten rules that guide and influence the relationships between board members and as a result influence board decisions”. There are various factors that can affect a board’s culture. First, ensuring that Robert’s Rules of Order are followed for the structure of the meetings. This method of facilitation provides the gold standard on how board meetings should be conducted. Ensure that monthly meetings follow appropriate motions and approvals. More information can be found at https://www.boardeffect.com/blog/roberts-rules-of-order-cheat-sheet/. Second, it’s important to have open and honest conversations. Board members should hold each other accountable for attendance and behaviors. Decisions for the health center should be made as a collective group and using the information brought by the CEO and their team. Remember that no one board member has the power to make decisions. 

  5. Work towards a Generative Governing Board of Directors: Less than 15% of health center boards are considered Generative Board of Directors. Generative boards are high functioning visionary boards. While monthly meetings have regular business and the completion of board’s responsibilities required by HRSA, generative boards use most of their meeting time pursuing more information, questioning assumptions, and seeking the meaning behind the solution. The “why” doesn’t matter. A “big picture” discussion with questions takes place versus current operations and strategic priorities. Generative boards ask questions such as, “What is the meaning behind the increase of diabetes in our community?”, “What will be the differences with our health center between now and five years in the future?”,  or “What do we want our health center’s legacy to look like?”. Generative boards work within their various committees to get the work done and come together to identify and discern important challenges, problems, opportunities, and questions.

Creating a forward thinking Board of Directors is not easy, especially when there needs to be a shift in culture. Have open and honest discussions about necessary changes if a health center wants to respond to the ever changing needs of the healthcare landscape. The pandemic has taught health centers that in a matter of moments we need to be able to pivot, and the Board of Directors must be able to support these changes. Review your mission and vision to ensure that it is aligned with the direction the health center is moving. Finally, remember that patients depend on your health center. Dysfunction can disrupt improvement of key quality metrics and hinder high quality care.   
 For HRSA Requirements on Board and Composition requirements, please visit:

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