The Misconceptions of the Operational Site Visit

If your health center is scheduled for an Operational Site Visit (OSV), the organization may be experiencing some concern.  Adequate preparation for an OSV requires time, resources, and attention to detail that can often be anxiety provoking.  Below are three misconceptions about OSVs that are important to remember, both during the preparation process and during the OSV itself. 

  1. MYTH – The OSV is meant to be punitive:  The OSV is NOT meant to be punitive and is NOT reflective of the quality of care provided by the health center.  The OSV is simply the process utilized by the Health Resources and Services Administration (HRSA) to provide oversight to the Health Center Program.  The goal is to provide an objective assessment and evaluation of the health center’s compliance with the statutory and regulatory requirements of the Health Center Program.  Additionally, the results of the OSV should be utilized by the health center to maintain continuous compliance. 
  2. MYTH – A “perfect” score translates into a “perfect” health center: The HRSA Site Visit Protocol (SVP) is the tool utilized by the HRSA OSV Review Team to measure health center compliance.  The tool assesses compliance with 93 elements in the areas of Administration/Governance, Clinical, and Fiscal.  The HRSA SVP evaluates the minimum level of compliance with the Health Center Program Requirements and does not address the implementation of industry standard best practices; therefore, just because a health center does not have any findings during an OSV does NOT mean there is no room for improvement.
  3. MYTH – Virtual Operational Site Visits (VOSVs) require less work than on-site OSVs: In most cases, VOSVs require MORE work than on-site OSVs due to, but not limited to, the following:
    1. All documentation must be named using the HRSA specific naming convention.
    2. All documentation must be uploaded into the HRSA specific Citrix ShareFile System two weeks in advance of the start of the VOSV.
    3. Sample patient records are required for various chapters and must be prepared in advance.  If loading these into the Citrix ShareFile, all Personally Identifiable Information (PII) must be redacted. 
    4. A sample of credentialing and privileging files must be prepared in advance.  If loading into the Citrix ShareFile, all PII must be redacted. 
    5. The health center site tour(s) are completed virtually, and it is essential the health center perform a practice session to identify the roles of staff and areas of limited connectivity.
    6. Members of the Board of Directors may have limited technology, potentially creating a barrier to attendance at the session conducted between the Operational Site Visit Review Team and the Board of Directors. 

In general, the VOSV requires more planning on the part of both the health center and the HRSA OSV Review Team, as any additional ad hoc conversations outside of scheduled sessions requires planning to virtually connect. 

Regardless of the process being utilized by the HRSA OSV Review Team to conduct the OSV, the health center should follow the guidance outlined in the HRSA Health Center Compliance Manual (Health Center Compliance Manual) and HRSA SVP (Health Center Site Visit Protocol) to complete a self-evaluation of compliance.  Additional resources to assist with both the VOSV and OSV can be found on the HRSA website (HRSA Site Visit Resources).

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