Determining the Appropriate Attendees for Clinical Operational Site Visit Sessions

The Health Resources and Services Administration (HRSA) employs the use of a structured agenda during an Operational Site Visit (OSV).  Although there can be some flexibility with regards to timing of the interviews, the standardized agenda outlines timeframes and the structure for the review of the Admin/Governance, Fiscal and Clinical Chapters of the HRSA Health Center Program Compliance Manual (Health Center Program Compliance Manual) and HRSA Health Center Program Site Visit Protocol (Health Center Program Site Visit Protocol).  

While the standardized agenda provides suggestions for the individuals who should attend each session, the responsibility of determining the attendees lies with the health center.  This can be a difficult task and varies based on the reporting structure and responsibilities of the staff within the organization.

Below are some tips to help determine the appropriate attendees for the Clinical Sessions:

• Chapter 4 – Required and Additional Health Services:  This session is facilitated by the Clinical Consultant, in collaboration with the Fiscal Consultant.  The structured agenda suggests this session be conducted with the Chief Executive Officer (CEO), Chief Medical Officer (CMO), Chief Operating Officer (COO) and “others.”  Attendees for this session should be any staff members involved in the completion of Form 5A, staff responsible for the management of contracts/referral arrangements for the services on Form 5A and clinical staff responsible for the referral tracking process.  Attendance at this session only by the CEO is strongly discouraged.
• Chapter 5 – Clinical Staffing: The structured agenda suggests this session be conducted with Human Resources (HR) and “others.”  Attendees for this session should be any staff member(s) involved in the development of the Credentialing and Privileging Policy, staff responsible for management of the credentialing and privileging process, as well as staff responsible for the organization of credentialing and privileging files.
• Chapter 7 – Coverage for Medical Emergencies During and After Hours:  The structured agenda suggests this session be conducted with the CMO, COO and “others.”   Attendees for this session should include a staff member(s) responsible for the management of clinical operations, those involved in the after-hours process and clinical staff responsible for coordination of after-hours tracking procedures.
• Chapter 8 – Continuity of Care and Hospital Admitting:  The structured agenda suggests this session be conducted with the CMO, COO and “others.”  Attendees for this session should include a staff member with knowledge of the health center’s hospital admitting arrangements, as well as an individual with knowledge of the health center’s hospital tracking process. 
• Chapter 10 – Quality Improvement/Assurance:  The structured agenda suggests this session be conducted with the CMO, Quality Assurance/Quality Improvement (QA/QI) Director, COO, Nursing Director and “others.”  Attendees for this session should include the CMO, the individual responsible for oversight of the QA/QI Program and staff members involved in the health center’s QA/QI procedures. This includes those staff members responsible for ensuring the completion of quarterly assessments.
• Chapter 21 – Federal Tort Claims Act:  The structured agenda suggests this session be conducted with the CMO, Quality Assurance/Quality Improvement (QA/QI) Director, COO, Nursing Director and “others.” Attendees for this session should include the individual responsible for oversight of the Risk Management Program, including the individual responsible for oversight of the Claims Management Process.  Additionally, this session should include staff members involved in the health center’s Risk Management Procedures.

It is important to reiterate the assigned staff members may vary by health center.  Questions regarding the appropriate attendees for clinical sessions should be directed to the Clinical Reviewer on the OSV team.