Background: Little research has been conducted to describe the factors and practices associated with the effectiveness of rural hospital governing boards. Aim: To identify activities and characteristics of the governing boards of small rural hospitals that are related to hospital success. Methods: We surveyed 89 rural hospital board chairs in Washington, Alaska, and Idaho about how they spent their time and how they were organized. We asked experts familiar with 74 hospitals with less than 100 beds to rate them in several key areas. Results: The eight activities of boards associated with “strong” hospitals included: one or more board retreats per year, annual review of mission and goals, lower percentage of time monitoring budget, use of board committees, clear recruitment plan to attract desirable board members, funds for continuing education of board members, owned or leased ownership, and larger hospital average daily census. In addition, the “strong” hospitals were found to have higher daily census than the “weak” hospitals (higher among hospitals with less than 100 beds). Conclusions: As long as the governance of rural hospitals is in the hands of volunteer boards, researchers and policy makers should assist these boards in identifying the most efficient and effective ways for them to spend their limited time and resources. Funded by HRSA’s ORHP.