GOVERNING BOARD MEETING AGENDA BUILDER

GOVERNING BODY MEETING AGENDA
Welcome to the Governing Body Agenda Builder! Our goal is to help ensure a more effective and organized Governing Body meeting.
- This tool is designed to help you create a comprehensive, well-structured agenda for your upcoming Governing Body meeting.
- Use it as a checklist to ensure no required items are overlooked.
How to use this form:
- Proceed through each section, and skip any that do not apply to your meeting.
- For each agenda item you’d like to include, provide a brief summary or description.
- For items not included in your meeting, be sure to leave those sections blank.
- Use the Other Business section for any additional items not covered elsewhere.
- Clicking Save will send you an email link so you can return later to finish if needed.
After Submission:
- A copy of your completed agenda will be emailed to the address provided.
- Need to make edits? Your emails will contain a link to come back to your agenda. You will receive a new emailed agenda after re-submission.
- Use this printout as your official Governing Body Meeting Agenda, and remember to attach any supporting documents as appropriate.
- You will receive an email assigning you to the Governing Body Meeting Minutes Builder with your PRE-FILLED agenda items to make documenting the activities easier!
Questions:
- If you need assistance or have questions, please save your progress and contact support@almss.com.
Please enter your access code to access the form:*
If you do not have an access code, please contact support at 770-325-0140, for assistance.** Please note: passcode is case-sensitive **
Name of Facility or Governing Body:*
Date of meeting:*

MonthDayYear
Type of Governing Board Meeting

AnnualQuarterlyInterimOther
Prior meeting date:

MonthDayYear
Agenda prepared by:*

First NameLast Name
Email address of preparer:*
this email address will receive the completed agenda

Governance
Contracts:
- New or Updated Contracts: List the contracts presented for approval
- Annual Meeting: All contracts should be presented for review. Tip: Attach a separate list of contracts to the meeting agenda and minutes rather than list them in the agenda.
- Examples:
  - The following contracts are presented for review: _____
  - The list of contracts presented for review is attached.
Contract(s) Discussion/Review:
Credentialing and Re-Credentialing:
- New Appointments or Re-Appointments: List the applicant files presented for approval.
- Example:
  - The following applicant files are presented for review: ____
Credentialing Discussion:
Facility Policies:
- New or Updated Policies: List the policies presented for approval
- Annual Meeting: All policies should be presented for review. Tip: Attach a separate list of specific policies to the meeting agenda and minutes rather than list them in the agenda.
- Examples:
  - The following policies are presented for review: ___
  - The list of policies presented for review is attached.
Policy Discussion:
Peer Review:
- Be sure to include both Random and Focused Peer Review activities as applicable.
- Peer Review activities done for credentialing/recredentialing do not need to be listed separately here.
- Example: The following peer review activities are presented for review: ___
Peer Review Discussion:
Accreditation and Regulatory Updates:
- The Governing Body must be informed of any regulatory and accreditation activities and accreditation compliance status annually.
- Examples:
  - The facility is in compliance with all current regulatory and accreditation standards, and the annual attestation has been submitted to the accrediting body. Our current accreditation term will expire March 2028.
  - The facility is due for re-accreditation in June 2026 and is reviewing all standards in comparision with facility processes.
  - The facility underwent its re-accreditation survey in January 2025. It submitted a Plan of Correction which was accepted and is attached for review.
Accreditation and Regulatory Discussion:
Facility Goals and Objectives Progress Review:
- The Governing Body must evaluate the progress of meeting facility goals and objectives at least annually.
- This should include items such as: Quality Care; Cost Effectiveness; Culture of Safety; Patient Outcomes; etc.
- Example: The progress on the following goals and objectives are presented for review...
Goals and Objectives Progress Discussion:
Credentialing Coordinator Appointment:
- Example: The following Credentialing Coordinator appointment request is presented for approval:
Credentialing Coordinator Appointment:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

HIPAA and Privacy
HIPAA and Privacy Activities:
- Be sure to include any breaches in HIPAA or privacy
- Example: The following HIPAA or Privacy activities are presented for review...
HIPAA or Privacy Discussion:
Privacy Officer/Coordinator Appointment:
- Example: The following Privacy Officer appointment request is presented for approval:
Privacy Officer Appointment:
Medical Records Coordinator Appointment:
- Example: The following Medical Records Coordinator appointment request is presented for approval:
Medical Records Coordinator Appointment:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Infection Control
Infection Control Plan:
- Annual Review: The Governing Body must review the Infection Control Plan annually or in the event of any updates.
- Example: The Infection Control Plan presented for review is attached.
Infection Control Plan Review Discussion:
Infection Control Risk Assessment:
- Annual Review: The Governing Body must review the Infection Control Risk Assessment annually or in the event of any updates.
- Example: The Infection Control Risk Assessment presented for review is attached.
Infection Control Risk Assessment Discussion:
Infection Control Activities:
- Include any infections/complications reported
- Examples:
  - No infections were reported this period.
  - The following Infection Control activities are presented for review: ___
Infection Control Discussion:
Infection Control Audit Activities:
- Be sure to include quarterly Hand Hygiene and Safe Injection Audit results.
- Example: The following audits are presented for review: ___
Infection Control Audit(s) Discussion:
Infection Control Coordinator Appointment:
- Example: The following Infection Control Coordinator appointment request is presented for approval:
Infection Control Coordinator Appointment:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Life Safety and Emergency Preparedness
Emergency Operations Plan Review:
- Annual Review: The Governing Body must review the Emergency Operations Plan annually or in the event of any updates.
- Example: The Emergency Operations Plan presented for review is attached.
Emergency Operations Plan Review Discussion:
Emergency Preparedness and Life Safety Activities Review:
- Include results of:
  - Drills
  - Tabletop Exercises
  - Safety Survey
  - Life Safety Testing Results
- Example: The following Life Safety and Emergency Preparedness testing and activities are presented for review: ___
Life Safety and Emergency Preparedness Discussion:
Safety Officer Appointment:
- Example: The following Safety Officer appointment request is presented for approval:
Safety Officer Appointment:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Medication Safety
Pharmacy Audit Review:
- Example: The quarterly Pharmacy Audit report is presented for review.
Pharmacy Audit Review/Discussion:
Medication Safety Issues:
- Include any medication recalls, shortages, etc.
- Example:
  - The following Medication has been reported by the FDA to be in shortage:___. We have reached out to our supplier who has provided the facility with the following workaround:___.
  - The following medication has been recalled: ___. Facility supply of this medicaiton has returned per manufacturer instructions.
Medication Safety Discussion:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

OSHA
Exposure Control Plan Review:
- Annual Review: The Governing Body must review the Exposure Control Plan annually or in the event of any updates.
- Example: The Exposure Control Plan presented for review is attached.
Exposure Control Plan Review Discussion:
Staff Injuries or Exposure Review:
- Include any injuries, needlesticks, or other exposures reported
- Examples:
  - No staff injuries were reported this period.
  - The following staff injuries are presented for review: ___
Staff Injury Discussion:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Patient Rights
Complaint, Grievance and Patient Satisfaction Activity Review:
- Example:
  - Patients reported satisfaction with care. No complaints or grievances reported during this period.
  - The following complaint was reported by a patient: ___.
Complaint/Grievance/Patient Satisfaction Discussion:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Patient Emergency Preparedness
Patient Emergency Preparedness Activity Review:
- Discuss the results of patient emergency response drills (Code, MH)
- Example: The following Patient Emergency Preparedness activities are presented for review: ___
Patient Emergency Preparedness Discussion:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Quality Improvement & Risk Management
Quality Improvement Plan Review:
- Annual Review: The Governing Body must review the Quality Improvement Plan annually or in the event of any updates.
- Example: The Quality Improvement Plan presented for review is attached.
Quality Improvement Plan Review Discussion:
Risk Management Plan Review:
- Annual Review: The Governing Body must review the Risk Management Plan annually or in the event of any updates.
- Example: The Risk Management Plan presented for review is attached.
Risk Management Plan Review Discussion:
Quality Improvement Study Review:
- Example: The following Quality Improvement study is presented for review: ___
Quality Improvement Study Discussion:
Adverse Events, Trends, and Near Misses Review:
- Examples:
  - There were no Adverse Events or Near Misses reported this period.
  - The following Adverse Events, Trends and Near Misses are presented for review: ___
Adverse Events, Trends and Near Misses Discussion:
Benchmarking Report Review:
- Example: The benchmarking report for 2nd quarter is presented for review.
Benchmarking Report Discussion:
Quality Coordinator Appointment:
- Example: The following Quality Coordinator appointment request is presented for approval:
Quality Coordinator Appointment:
Risk Management Coordinator Appointment:
- Example: The following Risk Management Coordinator appointment request is presented for approval:
Risk Management Coordinator Appointment:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Radiology and Laser Safety
Radiology and/or Laser Safety Activities Review:
- Be sure to include the review of: Badge Exposure Reports and Physicist Reports
- Example: The following Radiology/Laser Safety activity is presented for review: ___
Radiology/Laser Safety Discussion:
Laser Safety Officer Appointment:
- Example: The following Laser Safety Officer appointment request is presented for approval:
Laser Safety Officer Appointment:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Staffing
Staffing Activities and/or Changes
- Example: The following staffing activities/changes are presented for review: ___
Staffing activities/changes Discussion:
Staff Education and Training
- Example: The following staffing training, orientation, and competencies have been completed: ___
Staff Education and Training Discussion:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Financial
Financial and/or Capital Equipment Activities:
- Include any proposed capital equipment needs/activity
- Example: The following financial/budget activities are presented for review: ___
Financial Activities Discussion:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Other Business
Other Business:
- Include any other items for discussion that was not covered elsewhere in the agenda
Other Business Discussion:
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.

Submit Agenda
You’re almost done! Before submission, please review the following:
- Ensure every agenda item to be included has a brief description of the activities or items to be discussed in the associated free-text areas.
- Use the “Additional Items / Other Business” field for any remaining topics.
- Not quite ready to finalize your agenda? Click SAVE to get an email with a link to continue at a later time. Be sure to save that email as your entry will not be saved in our system until you click Submit.
- Once ready, click Submit below.
After submission:
- Your agenda will be compiled and sent to you by email to the address provided.
- Be sure to distribute the agenda — along with attachments — sufficiently in advance of the meeting, per your organization’s bylaws or governance policy.
Want to use our Governing Body Meeting Minutes Builder - PREFILLED with your agenda items?
Use your custom link in the emailed agenda to easily write your meeting minutes!

Thank you for using this builder tool!
If you need assistance or have questions, please save your progress and contact support@almss.com or call 770-325-0140.
Should be Empty:

GOVERNING BODY MEETING AGENDA

Welcome to the Governing Body Agenda Builder! Our goal is to help ensure a more effective and organized Governing Body meeting.

How to use this form:

After Submission:

Questions:

Governance

Contracts:

Credentialing and Re-Credentialing:

Facility Policies:

Peer Review:

Accreditation and Regulatory Updates:

Facility Goals and Objectives Progress Review:

Credentialing Coordinator Appointment:

HIPAA and Privacy

HIPAA and Privacy Activities:

Privacy Officer/Coordinator Appointment:

Medical Records Coordinator Appointment:

Infection Control

Infection Control Plan:

Infection Control Risk Assessment:

Infection Control Activities:

Infection Control Audit Activities:

Infection Control Coordinator Appointment:

Life Safety and Emergency Preparedness

Emergency Operations Plan Review:

Emergency Preparedness and Life Safety Activities Review:

Safety Officer Appointment:

Medication Safety

Pharmacy Audit Review:

Medication Safety Issues:

OSHA

Exposure Control Plan Review:

Staff Injuries or Exposure Review:

Patient Rights

Complaint, Grievance and Patient Satisfaction Activity Review:

Patient Emergency Preparedness

Patient Emergency Preparedness Activity Review:

Quality Improvement & Risk Management

Quality Improvement Plan Review:

Risk Management Plan Review:

Quality Improvement Study Review:

Adverse Events, Trends, and Near Misses Review:

Benchmarking Report Review:

Quality Coordinator Appointment:

Risk Management Coordinator Appointment:

Radiology and Laser Safety

Radiology and/or Laser Safety Activities Review:

Laser Safety Officer Appointment:

Staffing

Staffing Activities and/or Changes

Staff Education and Training

Financial

Financial and/or Capital Equipment Activities:

Other Business

Other Business:

Submit Agenda

You’re almost done! Before submission, please review the following:

After submission:

Want to use our Governing Body Meeting Minutes Builder - PREFILLED with your agenda items? Use your custom link in the emailed agenda to easily write your meeting minutes!

Thank you for using this builder tool!

Want to use our Governing Body Meeting Minutes Builder - PREFILLED with your agenda items?
Use your custom link in the emailed agenda to easily write your meeting minutes!