Preparing For the Site Visit Performance Analysis Section

With the new Site Visit process, health centers will have the clinical reviewer walk-through a “Performance Analysis” exercise (Performance Analysis section of the HRSA Site Visit Protocol (SVP)). So grab a snack and the note-taking implement of your choice—you’ll want to learn all about Performance Analysis.

Performance Analysis isn’t considered a Program Requirement, but it will take place during the Operational Site Visit. And yes, your FQHC needs to be ready for it. Typically, the Clinical reviewer will lead the process.

The moment the reviewer shows up to conduct the Performance Analysis should not be the first time you look at this data. Well before the day of your site visit, you should assemble a large team to prepare for exercise. Review the relevant metrics and come up with relevant solutions so you are well-prepared.

The reviewer will be assessing several metrics closely, including your health center’s Diabetes Control metrics, and will compare them to the state and national data.

Let’s walk through what the Performance Analysis process looks like:

Step 1: Reviewing the Goal

First, the reviewer will review your health center’s goal for the Diabetes Control measure (or any other metric that’s under review).

Then, the reviewer will look at how you’re actually doing with the measure, and what your trends look like. Help the reviewer out by providing some kind of visual that clearly illustrates the trend. There’s no need for you to break out the graph paper—tools such as RegLantern’s UDS Dash provide pretty visuals with much less fuss.

Step 2: The Root Cause Analysis

Once the reviewer is done admiring your slick visuals, they will want to really dive deep into things via a Root Cause Analysis. The reviewer will discuss the findings at some length with your staff.

Some basic questions that you can expect to be covered during the analysis:

  • What are contributing factors (that aid in improving the metric)?
  • What are the restricting factors (that present barriers to improvement)?
  • What are you currently doing to remove those barriers?
  • What interventions have you put into place so far?

The general purpose of this analysis is to identify the root causes behind the trend and prioritize the factors—both internal and external—that are contributing to your current performance. If you can do that, you’re showing your dedication to continuous improvement.

Tip: Prepare for the Root Cause Analysis ahead of time by holding a mock session with your staff.

Step 3: Spreading the Culture

Reviewers get that your metrics might not be 100% terrific. But they will be looking to assess whether your health center is nurturing a culture of continuous quality improvement.

You can surpass your reviewers’ expectations by being fully prepared to discuss how your health center responds to metric changes. Try to offer specific examples of how you responded to an outcome change in the past.

Also, expect reviewers to ask for documents relevant to quality improvement for the metric under review. In the case of the Diabetes Control metric, prepare documents that pertain to healthcare performance improvement in diabetes control. This may include materials on staff training or patient interventions. QI/QA reports or other internal analyses of your performance can also help make your case.

Remember: Reviewers aren’t looking for a mythical perfect health center. They just want to see that you’re actively taking steps to get better.

Performance Analysis: Illustrating a Culture of Continuous Compliance

The Performance Analysis may not be a Program Requirement, but don’t forget about it in the process of preparing for a site visit. Indirectly, your center’s future funding is somewhat influenced on how well you’re able to improve outcomes over time.

For best results (and for the sake of your own sanity), we recommend working to build a culture of continuous HRSA compliance. This framework shifts your health center’s focus from getting through operational site visits to being ready for an Operational Site Visit (OSV) at any time.

Does the thought of a HRSA Operational Site Visit or Performance Analysis exercise make you feel a little queasy? For help, contact RegLantern. We’re happy to provide a free quote for a Mock Site Survey or a subscription to our HRSA Continuous Compliance web-based tools. With a little help, your community health center will be super-prepared for any reviewer who walks through your doors…all the time!