Featured Articles: Risk and Compliance

Making the Most of an Operational Site Visit

Thursday, November 13, 2014   (0 Comments)
Posted by: Krista Chuscavage
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By Candace J. Chitty, RN, MBA, CPHQ, PCMH CCE, President & CEO, Quality First Healthcare Consulting, Inc., www.Qfhc.com


Sooner or later every health center will receive notice from the Health Resources and Services Administration (HRSA) that it is time for an operational site visit (OSV).  In the midst of the never-ceasing day-to-day activities in which health centers must engage, the OSV is often not viewed as a positive opportunity to present accomplishments and best practices, self-assess readiness and/or performance against the HRSA 19 program requirements, and tap into the expertise of the consultant team for technical assistance.  


This is an opportunity missed.   It is true that the consultant team is first tasked with assessing health center compliance with the program requirements, but during that assessment opportunities may arise that allow health center staff and the Board of Directors (BOD) to receive technical assistance specific to needs.  Most consultants on the team have many years of experience in working at health centers or providing services to health centers.  As a result of that experience, combined with the knowledge gained when doing OSVs across the country, consultant team members bring invaluable knowledge and best practices directly to you.


How best can your health center prepare for the site visit?  I call it the 3 P’s:


Positive Approach




Positive Approach:  The OSV experience can be what you make it. It can be viewed positively or negatively by health center staff and the BOD.  The approach a health center takes impacts the overall tone of the OSV and drives the OSV experience.  Be careful not to set your OSV performance expectations too high, leading to a sense of disappointment or failed efforts by staff when perceived expectations are not achieved.   The numbers of requirements that have multiple components to them make it challenging to meet.  Realistically you may have areas in which program requirements are not met, so it is important to manage expectations.  Recognizing this and setting the tone with staff that areas not met are learning opportunities to improve the overall quality of care will open dialogue with the OSV team and foster a collaborative learning environment.  This encourages the team to provide technical assistance while on site and set in play actions for improvement.


Planning:   Prior to the OSV, health centers are introduced to and have the opportunity to speak with the OSV team and project officer for the purpose of pre-visit planning.  This is your opportunity to ask questions about the site visit in order to plan a successful visit.  Key considerations include:


  • Ask what staff the OSV team will want to spend time with, and schedule staff availability accordingly.
  • If you have more than one location, ask how many locations the team wants to visit.
  • Work with the OSV team to schedule time to meet with the BOD.  Coordinate the best times to propose to the OSV team for this meeting (e.g., mornings, lunch, evening, etc). 
  • Plan to have BOD members and health center staff, particularly senior leaders, at the entrance and exit conferences.


Preparation:   Prior to the site visit the OSV team will send a document list. These documents are important and viewed as evidence of compliance with the program requirements.  It is important to gather and organize them for ease of review by the team during the visit.  If these documents are in electronic format they do not have to be printed and placed in binders.  Most consultants prefer documents in electronic format such as on a USB drive or via an Intranet/Internet shared file system when available.  Paper documents and/or electronic documents should be well organized and available at the start of the site visit on the first day.

  • Prepare for the entrance conference. 
  • Communicate to all staff the purpose, goals and objectives of the OSV.
  • Prepare a short 10-15 minute presentation for the entrance conference.  This is your time to express important information about the health center to the OSV team.  Key points of interest to consider including are:

ü  Brief overview of organization including site locations, unique and/or innovative services

ü  Major accomplishments, accreditations, recognitions, etc.

ü  Board of Directors (members, expertise, officers, etc.)

ü  Performance (clinical, financial, etc. measurement results)

ü  Challenges (environment, internal, economic, etc.)

ü  Future Strategic Directions

ü  HRSA Grants awarded and progress made

  • Reserve an adequate location for the OSV team to work when onsite.  The team usually prefers to co-locate in a common location with appropriate space for document review, with Internet & telephone access, and electrical outlets for charging laptops.

I wish you a successful and value-added experience when you have your next OSV.



NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.

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