Program Monitoring and Data Reporting Systems

• One to two data-based reports generated by the health center for the governing board or key management staff from the past 12 months. For example, dashboards, board packets, reports provided to the Finance or Quality Improvement Committee, routine reports generated by the health center for key management staff. The reports must include information on:
  • Patient service utilization;
  • Trends and patterns in the patient population; and
  • Overall health center clinical, financial, or operational performance.

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.]

Site Visit Team Methodology

• Interview relevant health center staff tasked with data management, collection, or reporting. 

• Review the health center’s Electronic Health Records (EHR), practice management system, or other data collection systems or methods. This review may include a navigation of the systems or methods. 

• Gather input from Operational Site Visit team members on related data systems (for example, systems used to support Quality Improvement/Quality Assurance, Financial Management and Accounting, Billing and Collections).

Notes: 

• Assess and document findings related to financial management and accounting systems capacity in the Financial Management and Accounting Systems section.
• Assess and document findings related to quarterly Quality Improvement/Quality Assurance assessments in the Quality Improvement/Assurance section.
• Do NOT repeat those findings here.

Site Visit Findings

1. Does the health center have systems or methods in place to collect and organize data, including ensuring the integrity of such data, for the purposes of overseeing the health center project and for monitoring and reporting on program performance?

   Response is either: Yes or No

   If No, an explanation is required, including specifying any deficiencies in the health center’s methods or safeguards for ensuring the integrity of data.

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.

Site Visit Team Methodology

• Review the one to two health center data-based reports that include information on:
  • Patient service utilization;
  • Trends and patterns in the patient population; and
  • Overall health center clinical, financial, or operational performance.
• Interview health center key management staff and board members about the receipt and relevance of health center data-based reports.

Site Visit Findings

2. Do the health center’s program data reporting systems or methods result in the production of relevant reports that can inform and support internal decision-making and oversight by key management staff and the governing board? This includes the production of reports on: 
   • 2.1 Patient service utilization?

     Response is either: Yes or No

   • 2.2 Trends and patterns in the patient population?

     Response is either: Yes or No

   • 2.3 Overall health center clinical, financial, and operational performance?

     Response is either: Yes or No

   If No was selected for any of the above, an explanation is required.