Sample Program Evaluation - Rural health

1 Sample Program Evaluation The following is an example of a Program Evaluation policy developed by RHCs in Virginia. The process involves review of a sampling of charts for select diagnoses on a quarterly basis. The accompanying Quality Management Worksheets help to guide the reviewer through the process; identify the number of charts to be reviewed; list the diagnosis codes; and the compliance goals. Also included are worksheets for review of lab orders, to ensure the information flow is effective and efficient. A worksheet for patient education activities is included as well, to ensure that the patient leaves the visit prepared to continue treatment and/or recovery. Program Evaluation Prior to the commencement of operations as a Rural health Clinic and annually thereafter in February, following the close of the fiscal year in December, an Evaluation of the clinic's Program will be conducted by the clinic's Advisory Committee.

2 The Advisory Committee will be composed of the Medical Director, Nurse Practitioner, and the Practice Manager from the clinic and at least one representative of the community. The community representative(s) will be appointed by the Medical Director. The Advisory Committee will meet at least annually to review the accomplishments of the clinic in meeting the health care needs of the community. The Advisory Committee will be responsible for establishing and reviewing policies covering the scope and utilization of services, medical intervention, emergency care, personnel qualifications, clinical records, and quality assurance indicators with a resolution of identified problems. The clinic's Advisory Committee will advise the clinic on professional issues, evaluate the effectiveness and adequacy of the clinic's Program , and assist in evaluating necessary changes.

3 The Committee will identify the clinic's strengths and weaknesses from the previous year, especially related to utilization of staff and space, handling of patient load and meeting the needs of the community. It will set goals and objectives which will be evaluated the following year. Any corrective action will be outlined and reviewed in the following meeting. The action could include, but not be limited to, areas such as: Source: National Organization of State Offices of Rural health Page 2 Patient care Personnel ( , numbers and types of position, hours) Fiscal condition and accounting Revised policies and procedures Alterations to space and use of personnel or equipment Alterations to medical priorities Commitment to a different patient population Commitment to service enlargement or scale-down The Committee will identify suggested changes in operations as well as develop plans and timetables for corrective action to be taken.

4 The minutes of the meeting will be recorded and maintained as part of the clinic's administrative records. A written report, prepared by the Practice Manager, summarizing the findings of the Advisory Committee, will be submitted to the Medical Director. Components of the Evaluation The three main areas of Evaluation include: Utilization Review Medical Records Review Administrative Review Utilization Review Throughout the year, the Executive Director, Medical Director, Nurse Practitioner, and staff clinical personnel will review the utilization of services at the clinic, including the number of patients served and the volume of services. They will study the most frequently encountered medical problems that patients present with to the clinic and determine if their care was adequate, appropriate, and timely.

5 Special attention will be paid to pay-for-performance indicators recognized by Medicare. Source: National Organization of State Offices of Rural health Page 3 Medical Record Review The group of individuals identified above will conduct the medical record review on at least a quarterly basis. The review will focus on quantity, quality, and documentation for the past quarter. The record review will address the adequacy of patient and clinical medical records forms, including staff and legal needs and clinical pertinence. On at least a quarterly basis, the staff and Medical Director will review a Sample of 10% of charts seen during the quarter for at least three of the following diagnoses: headache, extremity injury, lab procedures, diabetes mellitus, congestive heart failure, hypertension, lacerations, patient education, and otitis media.

6 Additional diagnoses may be added from time to time as audit sheets are developed and pay-for-performance indicators are added within the practice. The Practice Manager will assure that audits of the charts are completed and present the results to the staff during periodic staff meetings and annually to the Advisory Committee. Any corrective action or policy changes will be initiated by the Medical Director at the time of the audit. The subsequent meeting will review the areas of improvement. Administrative Review The Advisory Committee will review the administrative areas such as personnel and fiscal services. All personnel are employees of [clinic name]. The clinic is responsible for conducting all training regarding safety, exposure control to bloodborne pathogens, and hazard communication.

7 These records will be reviewed to assure that all employees have completed required annual training. A review of personnel policies and job descriptions will be conducted in accordance with Clinic policies and review schedules. The Evaluation report should identify, however, suggested changes in such policies that are specifically needed to address clinic issues. Each month, the Practice Manager will generate reports which indicate the number of patient visits by CPT code, payor class, and provider. Also, the Practice Manager will review the Source: National Organization of State Offices of Rural health Page 4 number of hours the clinic was open and the number of hours worked by the physicians and nurse practitioner. This information will be analyzed to determine if minimum productivity standards are being met.

8 This information will be summarized as part of the report to the Medical Director. Source: National Organization of State Offices of Rural health Page 5 QUALITY MANAGEMENT Objective: Patients can expect appropriate care for any diagnosis as evidenced by the criteria noted below. The documentation should record pertinent facts, findings and observations about the individual's condition. Date of Review: _____ Medical Record Number: _____ Treating Physician/Non-physician Provider: _____ Date of Service: _____ Diagnosis _____ PHYSICIAN/NON-PHYSICIAN PROVIDER INDICATORS X NA Organization of the Medical Record Patient name found on each page. Entry date noted. Entry is legible.

9 Each entry is found in chronological order. Identity of provider is noted. Entry is signed by provider. If NP/PA, does supervising MD signature should appear as well. Overall, the medical record is found to be well organized. Papers are held in the folder by a clip and divider tabs are used where possible. History CC, Reason for visit noted. Onset of problem, character, duration, prior history noted. Past, family and/or social history noted. ( prior illness, surgeries, family diseases, current activities, etc.) Allergies noted Medications and dosage presently being taken by patient are noted Symptoms (or lack thereof) noted. ( headaches, angina, irritability, etc.)

10 Noted) Exam Vital signs noted - BP, Temp., HR, Resp., Ht., Wt. Review of Systems/Physical exam - Review ones applicable for diagnosis. (A notation of "abnormal" findings should be elaborated. "Normal" notation is sufficient.) - Constitutional symptom such as fever, wt loss - BP, WT, HT, etc., - Eyes - Optic disc, inspection of conjunctiva, lids, pupils, and irises, etc., - Ears, nose, mouth and throat - Tympanic membranes, mucous membranes, hearing assessment, etc., - Neck - Thyroid, overall appearance, etc., - Cardiovascular - Heart sounds, pulses, etc., - Respiratory - Breath sounds, assessment of respirations, etc., Source: National Organization of State Offices of Rural health Page 6 Quality Management - Diagnosis:_____ PHYSICIAN/NURSE PRACTITIONER INDICATORS X NA - Gastrointestinal - Exam of abdomen for masses, tenderness, stool samples, exam of anus and rectum, etc.