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Presenting Quality Data to the Board
What Questions to Ask
Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com
Jennifer Genua-McDaniel, BA (Hons), CHCEF
Genua Consulting, LLC
jgenua@genuaconsulting.com
Disclaimers
 This presentation is not endorsed by Management Strategists
Consulting Group (MSCG).
 This presentation is not endorsed by Health Resources Services
Administration (HRSA) or the Bureau of Primary Health Care
(BPHC).
 Not employed by MSCG or BPHC.
 Independent Consultants who are contracted to conduct
Operational SiteVisits (OSV), provideTechnicalAssistance and
assist health centers with preparation for their OSV.
 This information should not be considered legal advice.
Agenda
 Overview of HRSA Clinical Quality Requirements,Relative to the
Board of Directors
 The Board’s Role in Receiving Clinical Quality Data
 The Health Center’s Role in Presenting Clinical Quality Data
 Factors to ConsiderWhen Gathering and Presenting Clinical
Quality Data
 Methodologies for Presenting Clinical Quality Data
 Question and Answer Session
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Overview of HRSA Clinical Quality
Requirements, Relative to the Board of
Directors
 HRSA requirements for clinical quality reporting are
outlined in the Health Center Program Compliance
Manual & SiteVisit Protocol (SVP).
◦ https://bphc.hrsa.gov/programrequirements/compliancemanual/in
dex.html
◦ https://bphc.hrsa.gov/programrequirements/svprotocol.html
 Chapter 5- Clinical Staffing
 Chapter 10- Quality Improvement/Assurance
 Chapter 18- Program Monitoring and Data Reporting
Systems
 Chapter 19- Board Authority
Chapter 5: Clinical Staffing
The health center must utilize staff that are qualified by
training and experience to carry out the activities of the center
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Chapter 5: Clinical Staffing
A reminder about Credentialing and Privileging…….
The Health Center Must:
 Have Credentialing and Privileging Policies and Procedures.
 Have the documentation outlined in the HRSA Credentialing and
Privileging File Review Resource to attest all licensed and certified
staff have the required credentials.
 Conduct Peer Review between providers within the same specialty.
 Consider Peer Review results in the reappointment process.
 Have appropriate credentialing and privileging language in contracts
for Column II and Column III services.
Chapter 5: Clinical Staffing
 Board approval of Credentialing and Privileging of
Licensed and Certified Staff is no longer required per the
Compliance Manual
 Consider the requirements for FTCA Coverage
 Credentialing and Privileging Policies and Procedures
must be reflective of current practice
Chapter 10: Quality Improvement/Assurance
Health center has an ongoing Quality Improvement/Quality Assurance
(QI/QA) Program which:
 Has board approved policies
 Includes clinical services and management
 Maintains confidentiality of patient records
 Includes a designated individual to provide appropriate oversight
 Includes routine and regular assessment of service utilization and service
quality, i.e., Peer Review, Patient Satisfaction, Clinical Performance
Measures
 Identifies the need for and implementation of change, when necessary
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Chapter 10: Quality Improvement/Assurance
 Quality Improvement/Assurance Plan and Policies MUST be board
approved
◦ Document approval in the Board of Directors Meeting Minutes
 QI/QA Plan must be adopted or evaluated within the past 3 years
◦ Coincides with the SAC funding cycle
 Quality Improvement/Assurance assessments must be completed and
reported to the board of directors a minimum of quarterly
◦ Document discussion of results in the Board of Directors Meeting
Minutes
◦ Use results to facilitate management decision making
Chapter 10: Quality Improvement/Assurance
Key Language in this Requirement
The health center must have operating procedures that address
producing and sharing reports on QI/QA to support decision making
and oversight by key management staff and by the governing board
regarding the provision of health center services
Chapter 18: Program Monitoring and Data
Reporting Systems
Health center has systems in place which accurately collect
and organize data for program reporting, and support
management decision making
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Chapter 18: Program Monitoring and Data
Reporting Systems
Key Language in this Requirement
 Must be systems in place to collect and organize data
required for UDS and Clinical / Financial Performance
Measures.
 Information from data reporting must be used to support
management decision making.
Chapter 18: Program Monitoring and
Data Reporting Systems
Chapter 18: Program Monitoring and Data
Reporting Systems
 Patient Service Utilization
◦ Number of Patients Seen vs Scheduled
◦ Provider Productivity
 By Specialty
◦ New Patients vs Established Patients
◦ **VirtualVisits**
◦ Patients seen by location sites
 Don’t forget special populations (if FQHCs have designation)
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Chapter 18: Program Monitoring and Data
Reporting Systems
Trends and Patterns in Patient Population
◦ Based on community happenings
 Covid-19/Flu
 Immunizations
◦ Service Lines and Method of Service Delivery
 Tele-health and virtual visits
 Additional Clinical/Non-Clinical lines of businesses
◦ Additional Service Sites
 Based on capacity and demand
Chapter 18: Program Monitoring and Data
Reporting Systems
 Clinical Performance
◦ Clinical Performance Measures
 UDS, HEDIS, PCMH
 Diabetes measures-focus and action plans
 Financial Performance
◦ Balance Sheet/Statement of Financial Position
 Accounts Receivable
 Accounts Payable
 **Days cash on Hand**
 Liquidity
 Required fiscal measures required by HRSA
Chapter 18: Program Monitoring and Data
Reporting Systems
Operational Performance
• Implementation of virtual care/tele-health
• Workflow changes to organization
 Gap analysis to determine staffing ratio
• Patient satisfaction/grievances
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Chapter 19: Board Authority
Health Center governing board maintains appropriate authority
to oversee the operations of the center, including (specific to
clinical quality reporting):
• Evaluation of progress in meeting annual and long-term goals (Clinical,
Financial and Operational)
• Involvement in long term strategic planning through the receipt of
appropriate information (i.e., QA/QI data, Patient Satisfaction data)
Chapter 19: Board Authority
Key Language in this Requirement
These activities must be documented in the Board of Directors
Meeting Minutes.
Chapter 19: Board Authority
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Chapter 19: Board Authority
 Achievement of Project Objectives
◦ Strategic Plan
◦ HRSA grant (Notice of Funding Award[NOFA]
 Covid-19 funding released this week
 Reporting requirements
 Quality funding reporting requirements
 Service Utilization Patterns
◦ Patient trends
◦ Discussed in Slide 13
Chapter 19: Board Authority
 Quality of Care
◦ Clinical measures tracked
◦ Risk Management measures
 Needle stick injuries, HIPAA training
 PPE training for all staff
 Efficiency and Effectiveness of Health Center
◦ Financial Measures
◦ Billing and Collection rates
 Chart closure times affects timeliness of billing
 Patient Satisfaction/Grievances
Presenting Clinical Quality Data
The Health Center’s Role
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Health Center Should:
 Determine who will facilitate the QI discussion at Board
Meetings.
 Develop a reporting schedule for all clinical services and
clinical management metrics.
 Present a monthly Quality Report and engage in active
discussion.
 Present data in a format that is appropriate for the skill
set of the Board (i.e., visual vs. narrative).
Health Center Should:
 Develop a training schedule to educate Board Members
on metrics, including all UDS clinical performance
measures.
 Ensure all discussion and decisions made are clearly
documented in meeting minutes.
 Encourage Board Members to ask questions!
Board Document Example
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Receiving Clinical Quality Data
The Board’s Role
Board Members Should:
 Anticipate a QI report will be presented and discussed
at each meeting.
 Request training and education on the information
being discussed.
 Make sure data is presented in a format that is
appropriate for all members (i.e., dashboard vs.
narrative).
Board Members Should:
 Review previous meeting minutes to ensure QI
discussion is recorded.
 Consider the results of QI metrics in the strategic
planning process.
 Get involved in discussion when QI data is presented. If
you don’t understand………Ask Questions!
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Factors to Consider -
Gathering and Presenting Clinical
Quality Data
 Background, skill set and culture of the Board
◦ Primary language, education and professional background
◦ Learning style of the Board
 The method/frequency of data collection and reporting
 Who will present the data?
◦ Presentation style, engagement of the Board
 In what format will the data be presented?
 TrainingTools
◦ HRSA Quality Toolkit, PDSA Cycle Sheet, Operational SiteVisit Guide
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Strategies for
Gathering and Presenting
Clinical Quality Data
 Have a plan for data collection
◦ What, How,When,Why and How Much
 Consider multiple data collection methods
◦ Electronic Medical Record, Surveys, Chart Audits,
 Standardize the process
 Make sure data is reliable
 Act on it!
Summary
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Bar Chart
 Report results in a format that is easy to understand
 Show trends
 Discuss results
 Ask Questions!!
◦ What, How,When,Why and How Much
 Address training needs
 Identify strategies for improvement
 Document, Document, Document in Meeting Minutes
Additional Resources
• Health Resources and Services Administration (Quality Toolkit)
https://www.hrsa.gov/quality/toolbox/
• National Association of Community Health Centers
http://www.nachc.org/
• Health Center Resource Clearinghouse
https://www.healthcenterinfo.org/
• ECRI Institute (Free for Health Centers)
https://www.ecri.org/
• Health Center Program Compliance Manual and SVP
https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html
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Questions & Answers
Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com
Jennifer Genua-McDaniel BA (Hons), CHCEF
Genua Consulting, LLC
jgenua@genuaconsulting.com
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Reporting quality data to the board of directors

  • 1. 3/23/2020 1 Presenting Quality Data to the Board What Questions to Ask Michelle Layton BSN, MBA Infidium Healthcare Solutions, LLC michellel@infidiumhs.com Jennifer Genua-McDaniel, BA (Hons), CHCEF Genua Consulting, LLC jgenua@genuaconsulting.com Disclaimers  This presentation is not endorsed by Management Strategists Consulting Group (MSCG).  This presentation is not endorsed by Health Resources Services Administration (HRSA) or the Bureau of Primary Health Care (BPHC).  Not employed by MSCG or BPHC.  Independent Consultants who are contracted to conduct Operational SiteVisits (OSV), provideTechnicalAssistance and assist health centers with preparation for their OSV.  This information should not be considered legal advice. Agenda  Overview of HRSA Clinical Quality Requirements,Relative to the Board of Directors  The Board’s Role in Receiving Clinical Quality Data  The Health Center’s Role in Presenting Clinical Quality Data  Factors to ConsiderWhen Gathering and Presenting Clinical Quality Data  Methodologies for Presenting Clinical Quality Data  Question and Answer Session 1 2 3
  • 2. 3/23/2020 2 Overview of HRSA Clinical Quality Requirements, Relative to the Board of Directors  HRSA requirements for clinical quality reporting are outlined in the Health Center Program Compliance Manual & SiteVisit Protocol (SVP). ◦ https://bphc.hrsa.gov/programrequirements/compliancemanual/in dex.html ◦ https://bphc.hrsa.gov/programrequirements/svprotocol.html  Chapter 5- Clinical Staffing  Chapter 10- Quality Improvement/Assurance  Chapter 18- Program Monitoring and Data Reporting Systems  Chapter 19- Board Authority Chapter 5: Clinical Staffing The health center must utilize staff that are qualified by training and experience to carry out the activities of the center 4 5 6
  • 3. 3/23/2020 3 Chapter 5: Clinical Staffing A reminder about Credentialing and Privileging……. The Health Center Must:  Have Credentialing and Privileging Policies and Procedures.  Have the documentation outlined in the HRSA Credentialing and Privileging File Review Resource to attest all licensed and certified staff have the required credentials.  Conduct Peer Review between providers within the same specialty.  Consider Peer Review results in the reappointment process.  Have appropriate credentialing and privileging language in contracts for Column II and Column III services. Chapter 5: Clinical Staffing  Board approval of Credentialing and Privileging of Licensed and Certified Staff is no longer required per the Compliance Manual  Consider the requirements for FTCA Coverage  Credentialing and Privileging Policies and Procedures must be reflective of current practice Chapter 10: Quality Improvement/Assurance Health center has an ongoing Quality Improvement/Quality Assurance (QI/QA) Program which:  Has board approved policies  Includes clinical services and management  Maintains confidentiality of patient records  Includes a designated individual to provide appropriate oversight  Includes routine and regular assessment of service utilization and service quality, i.e., Peer Review, Patient Satisfaction, Clinical Performance Measures  Identifies the need for and implementation of change, when necessary 7 8 9
  • 4. 3/23/2020 4 Chapter 10: Quality Improvement/Assurance  Quality Improvement/Assurance Plan and Policies MUST be board approved ◦ Document approval in the Board of Directors Meeting Minutes  QI/QA Plan must be adopted or evaluated within the past 3 years ◦ Coincides with the SAC funding cycle  Quality Improvement/Assurance assessments must be completed and reported to the board of directors a minimum of quarterly ◦ Document discussion of results in the Board of Directors Meeting Minutes ◦ Use results to facilitate management decision making Chapter 10: Quality Improvement/Assurance Key Language in this Requirement The health center must have operating procedures that address producing and sharing reports on QI/QA to support decision making and oversight by key management staff and by the governing board regarding the provision of health center services Chapter 18: Program Monitoring and Data Reporting Systems Health center has systems in place which accurately collect and organize data for program reporting, and support management decision making 10 11 12
  • 5. 3/23/2020 5 Chapter 18: Program Monitoring and Data Reporting Systems Key Language in this Requirement  Must be systems in place to collect and organize data required for UDS and Clinical / Financial Performance Measures.  Information from data reporting must be used to support management decision making. Chapter 18: Program Monitoring and Data Reporting Systems Chapter 18: Program Monitoring and Data Reporting Systems  Patient Service Utilization ◦ Number of Patients Seen vs Scheduled ◦ Provider Productivity  By Specialty ◦ New Patients vs Established Patients ◦ **VirtualVisits** ◦ Patients seen by location sites  Don’t forget special populations (if FQHCs have designation) 13 14 15
  • 6. 3/23/2020 6 Chapter 18: Program Monitoring and Data Reporting Systems Trends and Patterns in Patient Population ◦ Based on community happenings  Covid-19/Flu  Immunizations ◦ Service Lines and Method of Service Delivery  Tele-health and virtual visits  Additional Clinical/Non-Clinical lines of businesses ◦ Additional Service Sites  Based on capacity and demand Chapter 18: Program Monitoring and Data Reporting Systems  Clinical Performance ◦ Clinical Performance Measures  UDS, HEDIS, PCMH  Diabetes measures-focus and action plans  Financial Performance ◦ Balance Sheet/Statement of Financial Position  Accounts Receivable  Accounts Payable  **Days cash on Hand**  Liquidity  Required fiscal measures required by HRSA Chapter 18: Program Monitoring and Data Reporting Systems Operational Performance • Implementation of virtual care/tele-health • Workflow changes to organization  Gap analysis to determine staffing ratio • Patient satisfaction/grievances 16 17 18
  • 7. 3/23/2020 7 Chapter 19: Board Authority Health Center governing board maintains appropriate authority to oversee the operations of the center, including (specific to clinical quality reporting): • Evaluation of progress in meeting annual and long-term goals (Clinical, Financial and Operational) • Involvement in long term strategic planning through the receipt of appropriate information (i.e., QA/QI data, Patient Satisfaction data) Chapter 19: Board Authority Key Language in this Requirement These activities must be documented in the Board of Directors Meeting Minutes. Chapter 19: Board Authority 19 20 21
  • 8. 3/23/2020 8 Chapter 19: Board Authority  Achievement of Project Objectives ◦ Strategic Plan ◦ HRSA grant (Notice of Funding Award[NOFA]  Covid-19 funding released this week  Reporting requirements  Quality funding reporting requirements  Service Utilization Patterns ◦ Patient trends ◦ Discussed in Slide 13 Chapter 19: Board Authority  Quality of Care ◦ Clinical measures tracked ◦ Risk Management measures  Needle stick injuries, HIPAA training  PPE training for all staff  Efficiency and Effectiveness of Health Center ◦ Financial Measures ◦ Billing and Collection rates  Chart closure times affects timeliness of billing  Patient Satisfaction/Grievances Presenting Clinical Quality Data The Health Center’s Role 22 23 24
  • 9. 3/23/2020 9 Health Center Should:  Determine who will facilitate the QI discussion at Board Meetings.  Develop a reporting schedule for all clinical services and clinical management metrics.  Present a monthly Quality Report and engage in active discussion.  Present data in a format that is appropriate for the skill set of the Board (i.e., visual vs. narrative). Health Center Should:  Develop a training schedule to educate Board Members on metrics, including all UDS clinical performance measures.  Ensure all discussion and decisions made are clearly documented in meeting minutes.  Encourage Board Members to ask questions! Board Document Example 25 26 27
  • 10. 3/23/2020 10 Receiving Clinical Quality Data The Board’s Role Board Members Should:  Anticipate a QI report will be presented and discussed at each meeting.  Request training and education on the information being discussed.  Make sure data is presented in a format that is appropriate for all members (i.e., dashboard vs. narrative). Board Members Should:  Review previous meeting minutes to ensure QI discussion is recorded.  Consider the results of QI metrics in the strategic planning process.  Get involved in discussion when QI data is presented. If you don’t understand………Ask Questions! 28 29 30
  • 11. 3/23/2020 11 Factors to Consider - Gathering and Presenting Clinical Quality Data  Background, skill set and culture of the Board ◦ Primary language, education and professional background ◦ Learning style of the Board  The method/frequency of data collection and reporting  Who will present the data? ◦ Presentation style, engagement of the Board  In what format will the data be presented?  TrainingTools ◦ HRSA Quality Toolkit, PDSA Cycle Sheet, Operational SiteVisit Guide 31 32 33
  • 12. 3/23/2020 12 Strategies for Gathering and Presenting Clinical Quality Data  Have a plan for data collection ◦ What, How,When,Why and How Much  Consider multiple data collection methods ◦ Electronic Medical Record, Surveys, Chart Audits,  Standardize the process  Make sure data is reliable  Act on it! Summary 34 35 36
  • 13. 3/23/2020 13 Bar Chart  Report results in a format that is easy to understand  Show trends  Discuss results  Ask Questions!! ◦ What, How,When,Why and How Much  Address training needs  Identify strategies for improvement  Document, Document, Document in Meeting Minutes Additional Resources • Health Resources and Services Administration (Quality Toolkit) https://www.hrsa.gov/quality/toolbox/ • National Association of Community Health Centers http://www.nachc.org/ • Health Center Resource Clearinghouse https://www.healthcenterinfo.org/ • ECRI Institute (Free for Health Centers) https://www.ecri.org/ • Health Center Program Compliance Manual and SVP https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html 37 38 39
  • 14. 3/23/2020 14 Questions & Answers Michelle Layton BSN, MBA Infidium Healthcare Solutions, LLC michellel@infidiumhs.com Jennifer Genua-McDaniel BA (Hons), CHCEF Genua Consulting, LLC jgenua@genuaconsulting.com 40 41