Survey Expectations for Meeting Minutes

By Cyndi Newman, MSHL, BSN, RN, Senior Clinical Review Specialist 

Cyndi Newman is an ACHC Senior Clinical Review Specialist for office-based surgery and ambulatory surgery centers. She has over 30 years of experience as a registered nurse, surveyor, and risk manager. Cyndi is passionate about quality patient care and the collaborative nature of accreditation. 

Posted: September 8, 2026

ACHC Standards for office-based surgery (OBS) practices require the governing body to establish bylaws or policies that define its structure and responsibilities. For an accreditable practice, maintaining meeting minutes is one of these responsibilities and applies regardless of practice size or complexity.  

During a survey for ACHC OBS Accreditation, these minutes will be one of the first things your surveyor requests to review as part of an evaluation of your practice’s planning and implementation of services.  

Minutes should identify actions, decisions made, follow-ups needed, and who is responsible for implementing those activities. Governing body minutes—even when that body consists of only one individual—ensure that practice leadership is actively engaged in the oversight of patient safety, quality assurance, infection control, and credentialing.  

Incomplete or vague meeting minutes fail to show that the compliance and governance are effective. This could lead to future disputes among members, duplication of efforts, and even increased liability risk.  

Keep minutes clear

Meeting minutes should be clear, concise, and structured. They should include attendance, key topics discussed or considered, decisions made, and action items assigned. Consistency in format and timely completion support reliability and usability, including ease of reference.

At a minimum, meeting minutes should include:

• Meeting date and time.
• Meeting attendance and absences.
• Items discussed/considered.
• Decisions made and actions to implement them.
• Follow-ups needed and the party responsible.
• Goals achieved.
• Signatures of governing body members or chair.
• Date of the next scheduled meeting.

Continuity matters

In a small practice, governing body meeting minutes represent risk management and documentation of decisions made. In a large practice, governing body membership may change over time, and detailed meeting minutes help the new members understand past decisions and identify items that need further attention.

Recent observations made by ACHC Surveyors include:

• The minutes are only an agenda, failing to document attendance and deliberations leading to action. Example: “QAPI Plan reviewed.”
• The minutes are not legible.
• Minutes lack the name of the individual responsible for follow-up and a timeline for completion.
• There is no continuity reflected; documentation does not demonstrate that follow-up was completed between meetings.
• Minutes were not available upon surveyor request.

Best meeting practices

Good meetings drive better documentation. The following are tips for structuring governing body meetings to support compliance:

• Set aside time for meeting preparation.
• Be consistent with meeting frequency.
• Allow enough time to cover all agenda items.
• Send clear communication on meeting date and time.
• Be factual and focus on outcomes and decisions.
• Write the minutes during or soon after the meeting while they are fresh.
• Make sure all tasks and assignments are followed up and recorded at the next meeting.
• Ensure minutes are accessible when needed and by more than one individual.

Key takeaways

Accurate and detailed governing body meeting minutes are a foundational element of strong and effective governance. Minutes are not merely administrative records. They should document a moment in time for future recall. Show the deliberations and decisions made by the governing body, and they become an essential tool that supports compliance, accountability, and quality improvement.

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