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2024 3RD QUARTER RISK ASSESSMENT AND ACTION PLAN AREA OF RISK ACTION REQUIRED RESPONSIBILITY TARGET DATE COMPLETED? UDS DOCUMENTATION- CLINICAL MEASURES Providers must be reminded of the importance of not only carrying out the necessary screening for each patient, but also about the importance of documenting all clinical measures in the correct areas of the chart so they can be tracked. Clinical Compliance Officer Medical Director March 2025 Providers were trained on the mandatory clinical measures again as well as how and where to document them within the system. Since the 1st quarter goal was not met, a “cheatsheet” was created to provide more support. Assessment completed on 10/10/2024 tgr 1. Purpose & Goals To assess the accuracy and completeness of provider documentation of UDS clinical measures to reduce risk of incomplete care, noncompliance with reporting requirements, and potential malpractice exposure related to under-documented patient services. 2. Risk Analysis • Findings: Incomplete & inconsistency in documentation of UDS clinical measures. • Severity of Risk: High • Causes Identified: o Providers lack of understanding the importance of required data. o Variability in provider documentation habits • Impact: o Clinical: Potential for missed follow-up on key health indicators o Financial: UDS reporting affects grant compliance and funding o Reputational: Quality metrics are publicly reported o Regulatory: HRSA compliance risk 3. Risk Evaluation The documentation gaps identified in Q3 pose a high-priority risk to the health center due to their potential clinical, regulatory, and financial consequences. Cheat sheets were created for provider support: • Risk Severity: High Inaccurate or incomplete documentation of UDS clinical measures can compromise patient care continuity, affect the center's ability to meet HRSA quality benchmarks, and jeopardize future funding tied to performance metrics. • Likelihood of Recurrence: High The issue was observed in over half of the sampled charts, indicating that this is a widespread concern among providers rather than an isolated incident. • Necessary Actions: o Conduct targeted training to address the knowledge gap in proper documentation procedures. o Standardize protocols to ensure uniform EHR usage across providers. o Implement ongoing audits to monitor improvement and compliance. o Real-Time Documentation, encourage providers to complete documentation during or immediately after the patient visit to avoid errors from memory lapses. o Promote a Culture of Quality, embed the importance of accurate documentation into staff meetings and daily huddles. o Develop an Error Reporting Mechanism process to report documentation issues confidentially. • Associated Costs: The intervention is low-cost and primarily involves staff time planning and conducting training, creating documentation checklists, and reviewing charts. No external consultants or software upgrades are required at this time. • Risk Priority Ranking: This issue is considered high priority due to its direct link to: o Patient safety and Care Quality (e.g., missed screenings or follow-ups) o Reputational risk (e.g., poor publicly reported UDS outcomes) o Regulatory/Legal (e.g., HRSA site visits and FTCA eligibility) o Financial impact (e.g., penalties or funding reductions based on inaccurate reporting, payment denials or recoupments after payer audits) As such, the center has prioritized immediate action with ongoing monitoring to prevent recurrence. 4. Action Plan To address the identified documentation issues and mitigate associated risks, the following action plan was developed: • Strategy Development: Identified documentation gaps were directly addressed by designing focused interventions aimed at improving provider compliance with UDS reporting requirements. Positive reinforcement strategy options to be utilized through team celebrations, peer acknowledgements, personalized appreciation, or incentives and rewards to foster a culture of excellence and dedication. • Training Programs: Cheat sheets were created to assist the providers on how to accurately and consistently document clinical measures in the designated areas of the EHR. Refresher training sessions will be scheduled quarterly or as needed. • Ongoing Monitoring and Continuous Improvement: The QI team will track trends in documentation accuracy and evaluate the effectiveness of interventions using Plan-Do-Study-Act cycles. Adjustments to training, procedures, or tools will be made based on audit findings and staff input. 5. Monitoring & Review • Ongoing Monitoring: The Compliance Team will conduct monthly chart audits to monitor provider adherence to updated documentation protocols. Audit results will be logged, tracked, and compared over time to detect trends or areas of persistent noncompliance. • Review and Update: Audit of checklists will be reviewed quarterly by the Risk Management Committee and reported to the Medical Director. Any new risks or incidents will trigger an immediate review of the risk assessment framework. • Feedback Loop: Providers will receive individualized feedback based on audit results. Trends will be shared during clinical staff meetings to foster group learning. Feedback from providers about barriers to documentation will be collected and used to improve both training materials and EHR workflows. The cycle will be repeated using Plan-Do-Study-Act cycles. 6. Documentation and Reporting Risk assessment findings and progress updates are shared with the following key stakeholders: • Medical Director – reviews audit outcomes and approves corrective actions. • Quality Improvement (QI) Committee – will receive quarterly summaries and oversees follow-up on action items. • Governing Board – provided with a quarterly risk management summary report, which includes key findings, implemented actions, and outcomes. • FTCA Review – this risk assessment, along with supporting documentation, is maintained for inclusion in the annual FTCA deeming application and any audit request from HRSA or the Department of Justice.