MMHA 6452 Week 4 Board Policy Draft Example

Westfall Community Health Center Board Policy: Volunteer Engagement

Student Name

Walden University

MMHA 6452: Board Governance and Volunteer Management

Instructor Name

Month Day, Year

Westfall Community Health Center Board Policy: Volunteer Engagement

Policy Number and Status

Policy GOV-14. Status: draft for Governance Committee review. Owner: Board of Directors. Administered by: Chief Executive Officer. The board asked for this draft so that the rules would exist before the first volunteer is recruited. It reflects the board's role under the Health Center Program, which places policy adoption with the board and day-to-day operation with the CEO (Health Resources and Services Administration, 2018).

1. Purpose

This policy establishes the conditions under which Westfall Community Health Center engages volunteers. It protects patients, volunteers and the center by defining what volunteers may do, how they are selected and supervised, and what the board retains authority over.

2. Scope

This policy applies to every individual who performs unpaid work for the center on a regular or occasional basis, including individual volunteers, volunteers placed by partner organizations such as congregations or schools, student volunteers who are not enrolled in a clinical training agreement, and members of board committees who are not directors. It does not apply to students in clinical rotations under a written training agreement, contractors or employees performing work outside their paid hours, who are covered by other policies.

3. Standard

3.1 Every volunteer role has a written description approved by the CEO that lists its tasks, the tasks it excludes and its supervisor.

3.2 No volunteer performs any clinical task, gives medical advice, handles medications or interprets clinical conversations between patients and clinicians.

3.3 Every volunteer completes the screening required for the access level of the role before beginning work, and screening is documented in the volunteer's file.

3.4 Every volunteer whose role involves any access to patient information completes privacy training before beginning work, consistent with the center's obligations for its workforce (45 C.F.R. § 164.530), and signs a confidentiality agreement.

3.5 Every volunteer has a named staff supervisor who is on site whenever the volunteer is working.

3.6 Volunteers are not used to fill vacant paid positions or to reduce paid staff hours.

3.7 The center maintains insurance coverage for volunteers' activities.

3.8 Volunteers may raise concerns through the same channels available to staff and are protected from retaliation for doing so in good faith.

3.9 Volunteers are informed in writing, before they begin, of the tasks their role excludes and of the staff member to call when a patient asks for help outside the role.

3.10 Volunteers who are also patients of the center may serve, but they do not volunteer at the site where they receive care unless they request it in writing, and their volunteer files are kept separate from their medical records.

4. Procedure

4.1 The CEO designates a volunteer program coordinator, who maintains role descriptions, screening records, training records and schedules.

4.2 The coordinator screens candidates according to a protocol approved by the CEO that sets screening tiers by the access each role involves.

4.3 Site managers approve volunteer schedules for their sites and confirm that a supervisor is present.

4.4 The compliance officer reviews screening and training records annually and reports any gaps to the CEO.

4.5 The coordinator ends a volunteer's engagement when the volunteer breaches this policy, with notice to the site manager and a record of the reason.

5. Delegation and Board Retained Authority

5.1 The board delegates to the CEO the design, operation and day-to-day management of the volunteer program within the limits of this policy, including approval of role descriptions, the screening protocol and the orientation program.

5.2 The board retains authority to approve the establishment of the program, to end it, to amend this policy, to approve any volunteer role involving unaccompanied contact with patients in clinical areas, and to approve any agreement under which an outside organization places volunteers at the center.

5.3 The CEO reports to the board twice a year on the number of active volunteers, roles filled, screening and training compliance, incidents and patient or staff concerns. Boards function best when they set limits and expect reports on whether those limits are honored, rather than approving each operational decision (Carver, 2006).

6. Definitions

Volunteer: an individual who performs services for the center without compensation and without expectation of compensation. Clinical task: any activity that involves assessing, treating or advising a patient about health, including taking vital signs. Patient information: any information that identifies a patient or relates to a patient's health or payment for care. Partner organization: a congregation, school, employer or other group that recruits volunteers and places them at the center under a written agreement. Supervisor: the staff member named in a role description who directs the volunteer's work during a shift and is reachable throughout it. Access level: the degree of contact a role has with patients, patient information and restricted areas, as defined in the screening protocol.

7. Review

The Governance Committee reviews this policy one year after adoption and every two years thereafter, and earlier if the program adds a role involving unaccompanied patient contact or if a serious incident occurs. Studies of volunteer management suggest that rules borrowed from paid employment do not always fit volunteers' circumstances (Studer, 2016), so the first review should include feedback from volunteers themselves. The review should also compare the program's actual roles with the limits in section 3, ask site managers whether any volunteer has been asked to do excluded work, and confirm that the reports required under section 5.3 have reached the board on schedule. A review that finds the policy has drifted from practice should correct whichever one is wrong, rather than assuming the written text is right.

8. Approval

Related policies: Confidentiality of Patient Information (PRV-02), Conflict of Interest (GOV-03), Background Screening (HR-11), Incident Reporting (QI-05) and Grievances (PT-07). Where this policy and a related policy conflict, the stricter requirement applies. Recommended by the Governance Committee on: [date]. Adopted by the Board of Directors on: [date]. Board Chair: [signature]. Board Secretary: [signature]. Effective date: upon adoption. No volunteers may begin work under this policy until the board has approved the establishment of the program under section 5.2.

References

Administrative requirements, 45 C.F.R. § 164.530 (2024).

Carver, J. (2006). Boards that make a difference: A new design for leadership in nonprofit and public organizations (3rd ed.). Jossey-Bass.

Health Resources and Services Administration. (2018). Health center program compliance manual. U.S. Department of Health and Human Services.

Studer, S. (2016). Volunteer management: Responding to the uniqueness of volunteers. Nonprofit and Voluntary Sector Quarterly, 45(4), 688-714. https://doi.org/10.1177/0899764015597786