Chapter 18: Program Monitoring and Data Reporting Systems

In this chapter:

• Authority
• Requirements
• Demonstrating Compliance
• Related Considerations

Authority

Section 330(k)(3)(I)(ii) of the PHS Act; 42 CFR 51c.303(j) and 42 CFR 56.303(j); and 45 CFR 75.342(a) and (b)

Requirements

• The health center must establish systems for monitoring program performance to ensure:
  • Oversight of the operations of the Federal award [or designation]-supported activities in compliance with applicable Federal requirements;
  • Performance expectations [as described in the terms or conditions of the Federal award or designation] are being achieved; and
  • Areas for improvement in program outcomes and productivity [efficiency and effectiveness] are identified.
• The health center must compile and report data and other information as required by HRSA, relating to:
  • Costs of health center operations;
  • Patterns of health center service utilization;
  • Availability, accessibility, and acceptability of health center services; and
  • Other matters relating to operations of the Health Center Program project, as required.
• The health center must submit required data and information to HRSA in a timely manner and with such frequency as prescribed by HRSA.

Demonstrating Compliance

A health center would demonstrate compliance with these requirements by fulfilling all of the following:

1. The health center has a system in place for overseeing the operations of the Federal award-supported activities to ensure compliance with applicable Federal requirements and for monitoring program performance. Specifically:
   • The health center has a system in place to collect and organize data related to the HRSA-approved scope of project, as required to meet HHS reporting requirements, including those data elements for Uniform Data System (UDS) reporting; and
   • The health center submits timely, accurate, and complete UDS reports in accordance with HRSA instructions and submits any other required HHS and Health Center Program reports.
2. The health center produces data-based reports on: patient service utilization; trends and patterns in the patient population;¹ and overall health center performance, as necessary to inform and support internal decision-making and oversight by the health center’s key management staff and by the governing board.

Related Considerations

The following points describe areas where health centers have discretion with respect to decision-making or that may be useful for health centers to consider when implementing these requirements:

• In fulfilling HRSA reporting obligations, the health center determines the type of data system(s) (for example, type of Electronic Health Record software, use of practice management system) it will utilize based on its needs and the size and complexity of the health center’s operations.
• The health center determines the number, format, and types of reports the system generates to support governing board and key management staff internal decision making.

Footnotes

^1. Examples of data health centers may analyze as part of such reports may include patient access to and satisfaction with health center services, patient demographics, quality of care indicators, and health outcomes.