Article produced for the MidWest Clinicians Network

What does this mean for community health centers from a reporting perspective?  As outlined by “Chapter 21 – Federal Tort Claims Act (FTCA) Deeming Requirements” of the Health Resources and Services Administration (HRSA) Compliance Manual (Chapter 21: Federal Tort Claims Act) and the FTCA Health Center Policy Manual (FTCA Policy Manual), the health center’s Risk Management Program must address the following:

• The completion of quarterly Risk Management assessments by the health center, with the reporting of these results to key management and the board of directors on a quarterly basis.
• Reporting to the board of directors and key management staff on Risk Management activities and progress in meeting goals a minimum of annually. 
• Reporting of Risk Management metrics on a quarterly basis.  Minimally these include, but are not limited to the following:

o   Patient Complaints and Grievances

o   Near Misses

o   Patient and Employee Incidents

o   Patient and Employee Adverse Events

o   Sentinel Events

Neither HRSA, nor FTCA defines the format in which Risk Management reports must be presented.  Industry standard best practices for presenting Risk Management reports include the following:

• Present data in a format that is appropriate for the composition of the board – Some people are more visual, while others are more narrative.
• Simplify the presentation of data – Sometimes less is more.
• Ensure the reports facilitate discussion and management decision making by the board of directors.
• Ensure discussion of these reports is clearly documented in meeting minutes.

It is important to remember there are a significant number of other requirements related to Risk Management that are not listed above.  Additionally, although the review of Chapter 21 – FTCA Deeming Requirements during an Operational Site Visit does not factor into compliance, the responses submitted by the reviewer will be included in the final report and sent to FTCA for review.  The FTCA Program then utilizes this information to support deeming decisions and identify the need for additional technical assistance in this area. 

Additional resources for Risk Management initiatives can be found by accessing the Institute for Healthcare Improvement (IHI – Institute for Healthcare Improvement) and ECRI (ECRI | Trusted Voice in Healthcare).