Piloting the Engaging Health Centers in Compliance and Excellence Site Visit (HCCESV)

“Change is inevitable. Growth is optional.” - John Maxwell

The Bureau of Primary Health Care is piloting a new Virtual Operational Site Visit (vOSV) format called Engaging Health Centers in Compliance and Excellence Site Visit (HCCESV). A select group of Health Centers will have their scheduled vOSV converted to this format to evaluate the difference.

As Health Centers, we uphold high standards through Quality Assurance and Quality Improvement. HRSA is doing the same thing and trying changes. Just as with our own PDSA cycles, the change may be adopted, adapted, or abandoned. In this post, we’ll take a few moments to:

• Set the backdrop for the change

• Explain the change

• Provide a few tips on how to grow through this change

vOSV Backdrop

Since the COVID-19 pandemic, HRSA updated OSV to adopt to a virtual visit (vOSV) and updated the Site Visit Protocol (SVP) in 2021 and 2022. While HRSA maintained the 3-day format, the biggest changes were Health Centers now provide all related documents two weeks in advance. In most cases, this has provided Site Visit Reviewers more time to review documents and reduced the amount of time needed for the interviews for the staff. For vOSVs we have conducted, the Exit Conference has been moved up on Day 3 because of the reduced amount of time needed to review and interview.

What’s the Difference?

With that backdrop, HRSA is piloting the HCCESV program to determine the ability to reduce the number of days for the vOSV from three to one by implementing several steps. Before we discuss the differences, here is what is staying the same:

• There are 3 reviewers (Clinical, Governance/Admin, Fiscal)

• The reviewers will use the Site Visit Protocol to evaluate compliance

• The required documentation is aligned to the Site Visit Protocol

• All documents are to be uploaded 2 weeks beforehand

• The Notice of the OSV Date, the Pre-OSV call, Entrance Conference, Exit Conference and Compliance Resolution Opportunity all remain unchanged

The key differences being tested are:

• Moving the Presentation by the Health Center to the pre-OSV

• Introduction of a Cultivation and Support Period

• Replacing interviews with narrative statements for the 14 Desktop Review chapters

• Requiring prepared samples beforehand in place of on-screen reviews

• Reviewing 14 chapters through a Desktop Review and 4 chapters through the Virtual Site Review

• Only having the Governance Reviewer at the Board meeting

• Condensing the vOSV from three days to one

Health Center Presentation

Currently, Health Center’s provide an overview during the Entrance Conference. In the new model, this presentation will be conducted during the pre-OSV call. This provides an opportunity for the Reviewers and Federal Representative to be introduced to the Health Center ahead of time, and meet staff that will participate in the Cultivation and Support activities over the coming weeks.

Cultivation Period

The Cultivation Period starts after the pre-OSV call for two weeks. During this period, the reviewers will schedule with the Health Center staff to discuss documentation, what is required, and ideas on how to improve performance. During this time the Fiscal and Clinical Reviewers will conduct a Form 5A discussion with the Health Center prior to evaluating it for compliance.

Document Submission

After the Cultivation Period concludes (2 weeks after the pre-OSV call, and 2 weeks before the vOSV), all documents are due to be uploaded. This now includes narrative responses to typical questions to replace interviews, and all samples are prepared in advance.

Desktop Review and Virtual Site Review

Chapters from the Compliance Manual are separated into Desktop Review and Virtual Site Review Chapters (as you see below). With the submitted documents, the Reviewers will begin to assess compliance for the Desktop Review chapters.

Desktop Review

· Chapter 3 Needs Assessment

· Chapter 6 Accessible Locations and Hours of Operation

· Chapter 7 Coverage for Medical Emergencies During and After Hours

· Chapter 8 Continuity of Care and Hospital Admitting

· Chapter 10 Quality Improvement and Quality Assurance

· Chapter 11 Key Management Staff

· Chapter 12 Contracts and Sub-Awards

· Chapter 13 Conflict of Interest

· Chapter 14 Collaborative Relationships

· Chapter 15 Financial Management and Accounting Systems

· Chapter 16 Billing and Collections

· Chapter 17 Budget

· Chapter 18 Program Monitoring and Data Reporting Systems

· Chapter 20 Board Composition

Virtual Site Review

· Chapter 4 Required and Additional Services

· Chapter 5 Clinical Staffing

· Chapter 9 Sliding Fee Discount Program

· Chapter 19 Board Authority

Board Meeting

The Board Meeting will now be conducted with the Governance/Admin Reviewer only. Previously, the Clinical and Fiscal Reviewers attended, but this has been streamlined, since the Governance/Admin Reviewer typically takes lead for this meeting already.

Timeline

Finally, the biggest change is that the HCCEV will be one day of Virtual Site Review instead of three. Below is a chart of the overall timeline and tasks to provide a comparison.

Time Frame	Current vOSV (2022)	HCCESV (Pilot)
1-6 months in advance	- Notice of OSV date	- No Change
4 weeks in advance	- Pre-OSV Call	- Pre-OSV Call - Health Center Presents - Cultivation and Support Period Begins - Reviewers coordinate education sessions with Health Center Staff
2 weeks in advance	- Documents Due - Reviewers may begin to review documents for compliance	- Documents Due - All sample documents are due - Narrative documents are due for Desktop Review - Reviewers begin Desktop Review
Day 1	- Entrance Conference - Health Center Presentation - Begin Interviews - Begin Document Review - Sample records may be reviewed live - Health Center may submit any final documentation	- Entrance Conference - Interviews for Ch 4, 5, 9, 19 - Board meeting with Governance Reviewer Only - No screen share samples allowed - Exit Conference
Day 2	- Continue Interviews - Continue Document Review - Board Meeting with all reviewers	- NONE
Day 3	- Finalize Interviews - Finalize Document Review - Exit Conference	- NONE
2-4 weeks after	- Health Center receives the Report - Compliance Resolution Opportunity (CRO) begins	- No Change
14 days after report	- CRO ends	- No Change
Within 90 days	- Final Report and accepted changes based on CRO OR - A condition is placed for resolution	- No Change

Growing through Change

John Maxwell notes that “Change is Inevitable. Growth is Optional.” As these types of changes come, we as Health Center staff and Reviewers have an opportunity to embrace these opportunities to grow ourselves and develop our staff. Here are two points to keep in mind, if you are selected to participate in this process:

1. This is a Test. HRSA is openly telling Health Center staff and Reviewers that this is a pilot. There have been no official indications that this is anything more than a test. With that in mind, be observant about how this helps and hinders your ability to demonstrate your compliance. Be ready with feedback for HRSA after the process. You will make this better for all of us by being honest about the time it takes, the fairness of the process, and the degree to which this actually helps.

2. Use this to promote Continual Compliance. This process requires your team to be ready all of the time. Use this as an opportunity to re-orient staff to the requirements of the OSV and set a schedule for continuous compliance. RegLantern offers Continuous Compliance support as a part of a subscription as well as Mock Reviews and Continuous Compliance Reviews. Let us know how we can help.