Program Monitoring and Data Reporting Systems

Primary Reviewer: Fiscal Expert

Secondary Reviewer: Governance/Administrative Expert

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

Health Center Program Compliance Manual Related Considerations

Document Checklist for Health Center Staff

  • Sample of 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) that include information on:
    • Patient service utilization;
    • Trends and patterns in the patient population; and
    • Overall health center clinical, financial, or operational performance.

Demonstrating Compliance

Select each element below for the corresponding text of the element, site visit team methodology, and site visit finding questions.

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.]

Note

HRSA will assess whether the health center has demonstrated compliance in terms of submitting timely, accurate, and complete UDS reports based on internal HRSA UDS reporting information. No review of the portion of element “a” in brackets is required through the site visit.

Site Visit Team Methodology

  • Interview relevant health center staff tasked with data management, collection, or reporting.
  • Review health center’s Electronic Health Records (EHR), practice management system, or other data collections systems or methods, which may include participation in a Health Center Controlled Network. This may include a navigation of the systems or methods, if helpful.
  • Confer with Operational Site Visit team members for input on related data systems (for example, systems used to support Quality Improvement/Quality Assurance, Financial Management and Accounting, Billing and Collections).

Site Visit Findings

In responding to the question(s) below, please note:

Findings related to financial management and accounting systems capacity or quarterly Quality Improvement/Quality Assurance assessments are to be assessed and documented within the Financial Management and Accounting Systems requirement and Quality Improvement/Assurance requirement, respectively, and do NOT need to be repeated here.

  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 one to two samples of internal 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 regarding the receipt and relevance of health center data-based reports.

Site Visit Findings

  1. 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 would include, but is not limited to, the production of reports regarding:
    • Patient service utilization?

      Response is either: Yes or No

    • Trends and patterns in the patient population?

      Response is either: Yes or No

    • Overall health center clinical, financial, or operational performance?

      Response is either: Yes or No

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

 

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.