2025 Compliatric Webinar Series - Presenting Data To the Board-Practical Strategies

1. www.compliantfqhc.com
Presenting Data to the Board: Strategies for
Community Health Center Leaders
COMPLIATRIC WEBINAR SERIES
Michelle Layton
Infidium Healthcare
Solutions
Jennifer Genua-McDaniel
Genua Consulting, LLC
Vance Farrow
VK Farrow Consulting

2. Disclaimers
https://hrsa.my.site.com/support/s/
This presentation is not endorsed by Management
Strategists Consulting Group (MSCG).
This presentation is not endorsed by Health Resources
and Services Administration (HRSA).
Not employed by MSCG or HRSA.
Independent Consultants who are contracted to
conduct Operational Site Visits (OSV) and provide
Technical Assistance.
This information should not be considered legal advice.
For specific questions, please contact your HRSA Point
of Contact or https://hrsa.my.site.com/support/s/

3. Agenda
Identify key clinical, financial and governance
data that supports the board’s oversight and
decision-making responsibilities
Best practices, strategies and tools to prepare
effective reports that support informed mission
driven decisions

4. Why Data Is Important
Supports informed
decision making
Equips the board to make
strategic evidenced
based decisions on
clinical, financial and
operational impact
Strengthens
oversight and
accountability
Supports the board’s role
in ensuring compliance
with HRSA and
operational performance
standards
Aligns strategy with
community needs
Data demonstrates how
well the health center is
meeting patient needs
and identified service
gaps
Tracks progress
toward goals
Performance metrics help
measure progress against
strategic goals and UDS
benchmarks
Builds trust and
transparency
Fosters relationship
between the board and
leadership

5. KEY DATA METRICS

6. Financial Metrics
Evaluate the performance
of the health center related
to financial performance
Fiscal measures Service utilization metrics

7. Financial Metric Examples
-HRSA Required Metrics-
Grant cost per total patient
The amount of federal funding used per
patient
Total cost per total patient
The cost to serve one patient
Medical cost per medical visit
The cost to provide care to one patient
for a medical visit

8. Financial Metric Examples
Revenue and
expenses
Amount of revenue that
came in monthly
Amount of monthly
expenses
Days in accounts
receivable
How many days does it
take to get money in
from payors
Days in accounts
payables
How many days does it
take to pay bills
Days cash on
hand
If your health center
couldn’t see any more
patients, how long can
you continue to be
open and pay staff?
Best
practice:
<60 days
Best
practice:
<30 days
Best
practice:
>90 days

9. HRSA Required
Clinical Metrics*
◦ UDS Clinical Performance Metrics
◦ Risk Management Metrics
◦ Patient Complaints
◦ Incidents and Events
◦ Tracking Metrics (Hospital, Referrals, Lab and
Diagnostic Test Tracking)
◦ Other Quality Metrics
◦ Patient Satisfaction
◦ Peer Review
*Please note: This list is not all-inclusive

10. Clinical and Risk Management Metric
Examples
Colorectal Cancer
Screening
Percentage of
adults 45-75
years of age who
had appropriate
screening for
colorectal
cancer
Chart Closure
Times
Percentage of
medical records
closed within 72
hours
Patient
Satisfaction
Number of
patients who are
aware of how to
access after-
hours care
Incidents
Percentage of
incidents
forwarded to the
QI Director within
24 hours

11. Governance Metric Examples
◦ 12 Monthly Meetings = 12 Opportunities to Get/Stay in Compliance
◦ Board minutes capture
◦ Attendance, key actions, decisions
◦ Establish a board calendar of meeting metrics
◦ An amalgamation of ALL components
◦ CLINICAL
◦ Payer Mix Graphic
◦ Provider/Patient Load Comparisons
◦ EHR Reporting Tools
◦ FISCAL
◦ Approval of Annual Budget & Audit Findings
◦ Sliding Fee Discount Program & Nominal Fee - Update per project period!!
◦ Billing & Collections Policy; waiving or reducing patient fees; refusal to pay (as applicable)…
◦ CONTRACTS!

12. Governance Metric Examples
◦ Required HRSA Policies – PROJECT PERIOD
◦ Bylaws – Review for HRSA amendments
◦ Corporate or Governing Documents
◦ Co-applicant Agreements (for public entity, co-applicant health centers)
◦ Important to review if there are any changes
◦ CEO evaluation
◦ Board evaluation…? Is your board reflective?
◦ Personnel Policies
◦ Conflicts of Interest
◦ Forms for board members, and employees

13. Governance Metric Examples
◦ STRATEGIC PLAN DEVELOPMENT & UPDATES
◦ Grant applications/updates
◦ Achievement of project objectives
◦ Service utilization patterns
◦ Needs assessment updates
◦ Quality of care
◦ Efficiency and effectiveness of the center
◦ Patient satisfaction surveys/grievances
◦ Feedback loops on improvements/changes
◦ Sites & hours of operations

14. CONSIDERATIONS
TO SUPPORT
DECISION MAKING
DATA

15. Questions to Ask?
How is information
given to me?
Is the information
provided clear and
what do the numbers
mean?
What are the goals to
meet
Is my health center
improving on
providing care?
Do I get my
questions
answered?
Is the data (finance,
clinical or
operational)
provided to me in a
report format or in a
graph?

16. Questions
to Ask?
Do board members receive a
clinical quality report every month?
Do board members receive training
on clinical metrics, including UDS
clinical performance measures?
Is active discussion regarding clinical
metrics recorded in meeting
minutes?
Are the results of quality metrics
considered in the strategic planning
process?

17. BEST PRACTICE
EXAMPLES OF DATA
PRESENTED

18. Financial
Dashboard
Example
◦ Easy to read
◦ One page
◦ Metrics chosen by
leadership and board
◦ Through discussions and in
finance committee
◦ Graph format with color

19. Clinical Dashboard Example
• Result = Data for December 2021
• Change compares December 2021 to November 2021 Data

20. Sample Clinical Dashboard – Q2 2025
Domain Key Metric Goal Current Status
Preventive Care Colorectal Cancer
Screening
65% 58%
Cervical Cancer
Screening
70% 68%
Chronic Conditions Diabetes (A1c ≤9%) 70% 66%
Hypertension Control
(<140/90)
65% 63%
Maternal Health Prenatal Care Entry (1st
trimester)
80% 78%
Postpartum Visit (within 60
days)
75% 70%
Access to Care Same-Day Appointment
Availability
85% 88%
No-Show Rate ≤15% 17%
Engagement Patient Satisfaction 85% 82%
Quick Insights
Strengths: Same-day access, hypertension control, breast cancer screening
Opportunities: No-show rates, diabetes control, colorectal screening
In Progress: Care navigation, home monitoring tools, portal outreach

21. Governance Dashboard Example

22. Resources
◦ Health Resources and Services Administration (HRSA) Health
Center Program Compliance Manual: Chapter 10 – Quality
Improvement/Assurance
◦ https://bphc.hrsa.gov/compliance/compliance-
manual/chapter10
◦ Health Ressources and Services Administration (HRSA) Health
Center Program Site Visit Protocol: Chapter 19- Board
Composition
◦ https://bphc.hrsa.gov/compliance/site-visits/site-visit-
protocol/board-authority
◦ ECRI
◦ ECRI
◦ Capital Link: Financial and Operational Performance Analysis
◦ https://www.caplink.org/fqhc-trends-2024

23. Additional Thoughts…
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