The involvement of the Board of Directors is a critical component of a successful Quality Management Program. This webinar is for Health Center Grantees and their Board of Directors, and will provide strategies for presenting and discussing clinical quality data. Areas of focus will include the following: (1) The role of the Board of Directors in receiving clinical quality data. (2) The role of the Health Center role in presenting quality data (3) What factors to consider when gathering and presenting clinical quality data. (4) The manner in which clinical quality data should be presented.

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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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