Changes in FTCA OB Risk Management Training Requirements

On April 13, 2023, the Health Resources and Services Administration (HRSA) released its updated version on the Health Center Program Site Visit Protocol (SVP).

Two key changes have raised the most questions among our health centers:

• “For FTCA-deemed health centers that only provide obstetrical services through contracts with provider organizations or formal written referral agreements, the health center is required to ensure that the risk management training plans, credentialing, and privileging of each of the provider organizations and referral providers include obstetrics.”

• “In addition, regardless of the provision of obstetrical services, if a FTCA-deemed health center has contact with reproductive age patients for other clinical services through FTCA-deemed providers (health center employees or individual contractor providers), the health center is required to include obstetrical training as part of the health center risk management training plan to demonstrate compliance.”

So, let’s talk about the three situations that would cause these changes to impact your FTCA-deemed health center.

1. You provide at least one OB Service (Prenatal, Intrapartum, or postpartum) through FTCA-deemed providers (Form 5A, Column I employees or Column II individual contractor providers):

   • You are required to include obstetrical training as part of the health center Risk Management Training Plan.

   • This is not a new requirement.

   • There is no specific guidance on which staff are required to complete this training and what topics might include. However, our recommendation is that health centers should perform an assessment of risk associated with the unique OB services the health center provides and select annual trainings based on those specific services. This risk assessment might include a review of incident reports or quarterly Risk Management Assessments from the past few years to determine what are the trends in related near misses, incidents, claims, or patient satisfaction complaints. From this review, the health center can determine key areas of risk and tailor the required OB trainings to lower the risk in those areas. Then, once the topics are determined, the health center can determine which staff play a role in each of these service areas and require those staff to receive this OB risk management training.

2. You have contact with reproductive age patients for any clinical services (through employees or individually contracted providers):

   • This is likely every FTCA-deemed community health center (so probably affects you!).

   • You are now required to include some type of obstetrical training in your Risk Management Training Plan.

   • Like the above situation, there is no specific guidance on which staff are required to complete this training and what topics might include. Again, our recommendation is that health centers should perform an assessment of risk associated with the unique high-risk services the health center may provide to “reproductive age patients” and select annual trainings based on those specific services. This risk assessment might include a review of incident reports or quarterly Risk Management Assessments from the past few years to determine what are the trends in related near misses, incidents, claims, or patient satisfaction complaints. From this review, the health center can determine key areas of risk and tailor the required OB trainings to lower the risk in those areas. Then, once the topics are determined, the health center can determine which staff play a role in each of these service areas and require those staff to receive this OB risk management training.

   • Example training topics: “Racial disparities in care of reproductive age patients”; “Effective diagnosis or pregnancy and referral to prenatal care”; “State-specific confidentiality regarding pregnancy in minors”; “Dangerous Medications in Pregnancy”; etc.

   • ECRI offers a free Clinical Risk Management Program to all HRSA-deemed health centers and LALs. Course topics include: Electronic fetal monitoring, Shoulder dystocia, Postpartum hemorrhage, Hypertension. For questions or registration assistance, contact ECRI at Clinical_RM_Program@ecri.org or (610) 825-6000, ext. 5200.

3. You provide obstetrical services through contracts with provider organizations or formal written referral agreements (Form 5A, Column II or III):

   • You are now required to ensure that the risk management training plans, credentialing, and privileging of each of the provider organizations and referral providers include obstetrics.

   • This note is applicable to health centers that provide obstetrical services through Column II and/or Column III, regardless of whether or not obstetrical services are also provided through Column I. The note should be interpreted as follows: For FTCA-deemed health centers that provide any obstetrical services through contracts with provider organizations or formal written referral agreements, the health center is required to ensure that the risk management training plans, credentialing, and privileging of each of the provider organizations and referral providers include obstetrics.

   • HRSA/BPHC Policy Department has noted this issue as a possible future update to the SVP to further clarify.

   • Health centers should be able to provide evidence of implementation, for example for training, items such as the following:

     1. Annual training plans,

     2. Training policies,

     3. Training documents, and

     4. Sample of monitoring and tracking reports for training activities.

   • While emails stating that training has been conducted can be useful for evaluating compliance, it is essential to support such statements with additional information that provides sufficient assurance of the implementation of training. Ultimately, it is up to the HRSA reviewer to evaluate the documentation or information provided and determine whether it provides enough assurance to confirm that the training is more likely than not, being implemented as required.

Another common question we have been receiving is, “Who is required to complete annual OB training at our health center to obtain or maintain FTCA deemed status? And, what types of training are acceptable?”

HRSA answers this question in its FTCA FAQ page in this way:

“The FTCA Program allows for flexibility in complying with training requirements, including annual OB risk management trainings.

When planning these trainings, health centers should consider the following:

Who must complete the OB training: The health center should consider each staff member's role, responsibilities, and their level of contact with OB patients and patients of reproductive age and childbearing age in determining the employee’s specific training needs. For instance, an OB provider would be required to undergo different OB training compared to a behavioral health provider who interacts with OB patients and/or patients of reproductive age and childbearing age.

Source of the training: Health centers may choose from various training sources, such as HRSA trainings, ECRI trainings, in-house trainings, or other public or private training resources.

Delivery method and format: Health centers have the flexibility to choose the delivery method and format of the OB training. Options may include in-person, virtual, or hybrid trainings. Additionally, health centers may utilize different training formats, such as lectures, videos, presentations, labs or online modules.

Content covered during OB training: Health centers can determine the specific content covered during each OB training session based on health center data, assessments, and other available information. For example, a health center may require applicable staff members to complete OB training focused on topics such as maternal mortality, post-partum depression, shoulder dystocia, pregnancy and diabetes, or pregnancy and obesity.

By considering these factors, health centers can tailor their OB training programs to effectively address the needs of their staff and meet the requirements for FTCA deemed status.”

When discussing these requirements, HRSA has advised that “ALL” or “ALL Staff” are required to complete OB training. For example, staff who bill, code, or do administrative work would generally not have to do OB training. However, these vary by case and will be assessed based on the specific roles and responsibilities of the staff member and the type of contact, if any, they have in terms of clinical care.

HRSA’s FTCA Step-By-Step Guide states: “Include obstetric training for ALL clinical staff who see prenatal patients, postpartum patients, and patients who are of reproductive age. Determine obstetric training based on the type of care and interaction with patients and keep in mind that training may vary based on these factors”. This is understood to mean that “all clinical staff” refers to all credentialed and privileged staff and includes Licensed Independent Practitioners (LIPs), Other Licensed or Certified Practitioners (OLCPs), and Other Clinical Staff (OCS).

NOTE (5/3/23): Per HRSA’s FTCA training on May 3, 2023, HRSA representatives noted that all health centers (who provide care to reproductive-age patients) must demonstrate that they have completed the appropriate OB risk management training and show documentation of assurances of OB risk management training for contracted organizations prior to submission of FTCA deeming/re-deeming applications.

NOTE (5/31/23): Blog updated per guidance provided from BPHC Policy, May 23, 2023.

NOTE (8/2/23): HRSA provided additional guidance on their FTCA FAQ page and this article was updated with this information.

NOTE (10/31/23): HRSA Policy responded to a Consultant question on 7/31/2023 providing additional guidance on whether “ALL” staff were required to receive OB risk management training annually.

NOTE (6/26/24): Added additional guidance from FTCA Step-By-Step Guide.