Standards Resource Library
This page is dedicated to answering questions for free and charitable clinics might have on the standards. If there is a resource you believe should be on this page, please email it to [email protected] with an explanation.
WAFCC Standards Documents
Standards of Excellence (Download PDF)The WAFCC Standards of Excellence are designed to promote and describe best practices which maximize access to healthcare and improve the overall quality of care for the uninsured, undeserved, economically and socially disadvantaged, and vulnerable populations, along with defining factors which facilitate organizational competence in free and charitable clinics (FCCs) in Wisconsin.
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Standards of Excellence Self Assessment (Download PDF)Related to the WAFCC Standards of Excellence, this self-assessment tool allows you to calculate if the Standards are “met", “partially met”, “not met” or “not applicable”. Additionally, in the comments section you can list any resources, training, or assistance you might want from the WAFCC to help you achieve the Standards.
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Resources, Clarifications, & FAQs
Clarifications & FAQs
Governance, Administration, & Management (GAM) FAQS
Standard#2: GAM1a: Does a clinic need to change their mission statement in order to comply with GAM1a, Optimal Evidence stating that "at least one of the healthcare needs in the Mission Statement is identified in the most recent CHNA"?
A: The CHNA talks about preventative care, which encompasses primary care and education. A mission is rarely changed and should be short and to the point.
Standard#2: GAM1a: For the required evidence, it indicates to have a “section of documentation verifying community healthcare service need”. What type of documentation is needed for this Standard?
A: Meeting minutes supporting review of mission is sufficient or enough evidence. The mission statement should also be highlighted to identify community health service need or this part of the mission statement identified in the minutes. The source of the identified community health service need should be identified too – i.e. the CHNA or similar type document.
Standard#2: GAM1a: For the Optimal evidence, what is the relevance of the CHNA to the mission statement of our organization? In other words, our mission reflects the knowledge that may come from multiple sources - not just the CHNA. Why does the mission statement to meet the optimal evidence have to come from the CHNA?
A: The Community Needs Health Assessment (CNHA) is a requirement of health systems – PPACA March 2012 “Each tax exempt hospital is required to conduct a Community Health Needs Assessment.” This is a useful document for FCCs to review. It identifies current, relevant community needs; not perceived needs or previous needs, but needs the local health systems have identified. The needs they are documenting they are willing to support. We encourage FCCs to invite their hospital to present the CHNA to their board to better understand how the clinic meets the current needs of the community. Review of the CHNA and incorporation into the mission keeps the mission relevant and engages the local health system in the clinics mission and services. This is an optimal Standard.
Standard#6: GAM1c: Why is it necessary to have meeting minutes to validate approval of Conflict of Interest policy? How can our clinic be in compliance with optimal, but not required?
A: There should be minutes with the approval of the by-laws and the Conflict of Interest policy. By-laws and the conflict of interest policy should be periodically reviewed for their relevance and to ensure new board members all understand them. If you cannot easily locate these minutes, please make it an agenda item at your next board meeting; review the item and the Standard is satisfied. Annual review of the Conflict of Interest policy should occur with the annual signing of the conflict of interest disclosure. There is increasing pressure on nonprofits to be transparent. This should not just occur at the committee level, although, the governance committee may review the policy first and make recommendations to the board to keep as-is or with changes. At every board meeting a standing agenda item should be disclosed of any conflicts with items on the agenda or new conflicts in general. This is best practice. Optimal builds on required; meaning having both would be the best. Sometimes, optimal can be achieved without having met the first, as they can be two separate concepts/evidence relating to the Standard.
Standard#15: GAM2a: What is the WAFCC looking for proof? – visual review that our poster is displayed?
A: Yes, WAFCC looks for visual proof of the poster. Generally, federal workplace posters must be displayed or posted in conspicuous places where they are easily visible to all employees — the intended audience. The FMLA, EEO, and EPPA posters are also required to be placed where they can be seen by applicants for employment/volunteers.
Standard#15: GAM2a: What is the relevance of eLaws First Step Poster Adviser? Our off-site payroll and MRA provide us with posters. We do not use eLaws.
A: The relevance of the eLaws First Step Poster adviser is evidence for the awarding of the Standard. Although you have a vendor provide your posters, this is a check-and-balance, whereby we know the Standard is achieved. A level of evidence must be established, and this is how WAFCC has chosen to have clinic demonstrate that all their current posters are in compliance. The simple reliance on a vendor is not evidence that the posters have been reviewed for validity.
Standard#17: GAM2a: Why is it important to complete periodic background checks? Our clinic’s policy is to conduct the background check at the time of recruitment and hire. We do not conduct periodic background checks at this time due to the time and resources needed.
A: Inadequate due diligence the healthcare sector harms not only an organization, but its patients and sector’s reputation, as well. It is recommended by most risk management and human resource organizations; that best practice is conducting periodic screening of employees to maintain a dependable healthcare workforce free of unlawful behavior. When clinics screen an applicant at the time of recruitment and their criminal record is clean, it does not necessarily mean that their record remains that way. This is especially important in safety-net healthcare where employees work with vulnerable populations (avoiding harm and for patient and staff safety). Periodic background screening is important for legal liability and to minimize risk and uncover red flags (manage the area of risk of accidents, employee theft, workplace violence, etc.). Some employers may not regularly re-screen but instead require employees/volunteers "self-report" if there are any arrests or convictions that may impact their jobs. This “Self-report” then becomes a part of the annual review, etc. process.
Standard#17&20: GAM2b: For the required evidence Does a clinic need to do a payed background check?
A: A background check using only CCAP, also known as Wisconsin Circuit Court Access satisfies the required evidence. However, for the optimal evidence an extensive background check is necessary. This means that is necessary a multi-state background check and just not only Wisconsin.
Standard#22: GAM2b: Does a clinic need a program to track volunteer hours or an excel spread sheet is acceptable?
A: A clinic could do a Google form, or a manually-updated Excel spreadsheet form that shows the time that the volunteers check- in and check-out. If a clinic does the Google form of the spread sheet, this form should be organizing in such a way that can show the total number of work hours donate for the volunteers, then WAFCC will accept the spreadsheet. There are also free and low cost software’s that clinics uses for tracking their volunteer hours such as logistics, volunteer impact, gift works, etc. One of the purposes to go electronic is because a clinic can easily track how many hours a volunteer donates.
Standard#26: GAM2c: What is the Drug Supply Chain Security Act?
A: The Drug Supply Chain Security Act (DSCSA) outlines critical steps to build an electronic, inter-operable system to identify and trace certain prescription drugs as they are distributed in the United States. Virtually every hospital, pharmacy, clinic, physician and long-term care facility that dispenses prescription medicine in the US faces a set of DSCSA compliance requirements.
Standard#27: GAM3a: For the optimal evidence, the Standards states that “documentation of clinician’s review of medical history, including allergies, adverse drug reactions, medication list, and recent laboratory testing at every visit. What if our clinic is small and only open a few days a month, and then we do not have the ability to do this electronically because we do not have EMRs. What would those clinics without EMR do? Please provide clarity by illustrating a good example of documentation.
A: This is intentionally an “optimal” not “required” Standard. WAFCC believes that this Standard is an optimal best practice, and that FCCs should strive to do this. We recognize that not all FCCs have EMRs or the infrastructure for this, which is why it is “optimal” not “required”. However, it is important to understand what medications a patient is on, if there were any changes since their last visit to the clinic, and if they developed any allergies (ex: new drug on visit to emergency room, exposure to food allergen, etc.). Part of any H&P note at a physician visit includes current medications and allergies as part of the visit. If this information has been documented in full on a previous visit and has not changed, it would be acceptable to write that there is no change to medications or allergies from previous documentation. In another words, the history can be reviewed even without an EMR by just documenting in the patient file – “history and allergies reviewed and the date” or creating a cover form in the patient file to be initialed at each visit when the information is reviewed. Another example is creating a cover sheet that states "medications/allergies reviewed with no changes". WAFCC feels this is an optimal Standard for providing safe care (a goal of the Standards). We do acknowledge and understand that not all clinics are in a place to achieve the “optimal”, and that “optimal” Standards are more challenging. Optimal should be viewed as a goal.
Standard#29: GAM3a: What does "medication dispensing occurs in an uninterrupted work environment free of distractions" means?
A: It is important for medications to be dispensed in an environments where the patients are able to understand what is given to them and how to properly take the medication.
Standard#29: GAM3a: Please clarify what WAFCC means by "medication errors are reported to healthcare provider and addressed in a log to minimize patient harm"?
A: It is important for FCCs to have a process in place for reporting medication errors and recognizing them. A log, a medication incident report form, and medication error tracking form are examples of how FCCs address medication errors. FCCs should report all medication errors, regardless of whether the error results in an adverse drug event. Medication errors could include the wrong medication being dispensed to a patient, accidental omission of a prescription, prescribing medications that are expired, etc. These may be noticed by a provider, patient, volunteer. They are something that should be very rare/possibly not occur in a clinic, but it is important to be aware of the possibility and correct any errors that occur. We feel this is a practical and best practice. Addressing the issues of errors and working towards an environment that reduces errors is very practical (see the Institute of Medicine 1999 report “to Err is Human”). In 2016, it is estimated that 250,000 people died because of medication errors. This Standard addresses that statistic. Policies are in place in hospital and community pharmacies relating to these issues. Each time an error is made, the staff should be made aware and discuss ways to prevent future errors of the same kind. FCCs should have a policy in place to do this. Patients should be made aware if an error reaches the patient. Training the staff/volunteers to report errors, creating a form, addressing systemic errors, eliminating blame, and other obstacles to error reporting are practical things that can reduce errors and create a safer clinic for our patients. WAFCC feels this is a necessary Standard for providing safe care (a goal of the Standards).
Standard#29: GAM3a: Please clarify what you mean by pharmacy database system? For example, we have an Excel file – is this sufficient?
A: Yes, an Excel file could potentially satisfy the database system requirement.
Standard#35: GAM3D: If I am registered with VHCP do I need to enroll in the fund?
A: If your clinic employs a staff physician or CRNA's who work more than 240 hours a year in Wisconsin, then yes you are required to still have coverage through the Injured Patient’s family compensation fund. Assuming your clinic does not employ a physician and you are registered with VHCP then, no your clinic is under no legal obligation to maintain coverage through the fund. However it may still be advantage to gain coverage through the fund because it could lead to a reduction in your insurance premiums.
Standard#35: GAM3D: Who doesn’t have to participate in the Fund?
A: Doctors and CRNAs for whom Wisconsin in not their principal place of practice or who work less than 240 hours in a fiscal year.
Standard#35: GAM3D: Does the fund cover RN’s and dentists?
A: No, the fund covers physicians, and nurse anesthetist (CRNA).
Standard#35: GAM3D: Can my clinic be covered by the fund?
A: Yes, your clinic can be covered by the fund as well as medical directors.
Standard#35: GAM3D: If I run a Free and Charitable Dental Clinic does this fund apply to me?
A: If your FCC serves only dental patients then no, this fund would not apply to you, but your clinic has both a medical and dental clinic then this standard may still apply.
Standard#35: GAM3D: What is the current limit for primary medical malpractice coverage (in order to be enrolled in the fund.)?
A: Every physician and CRNA must purchase primary medical malpractice coverage at the levels defined in ch. 655, Wis. Stat. (currently $1,000,000 per occurrence/$3,000,000 annual aggregate)
A: The CHNA talks about preventative care, which encompasses primary care and education. A mission is rarely changed and should be short and to the point.
Standard#2: GAM1a: For the required evidence, it indicates to have a “section of documentation verifying community healthcare service need”. What type of documentation is needed for this Standard?
A: Meeting minutes supporting review of mission is sufficient or enough evidence. The mission statement should also be highlighted to identify community health service need or this part of the mission statement identified in the minutes. The source of the identified community health service need should be identified too – i.e. the CHNA or similar type document.
Standard#2: GAM1a: For the Optimal evidence, what is the relevance of the CHNA to the mission statement of our organization? In other words, our mission reflects the knowledge that may come from multiple sources - not just the CHNA. Why does the mission statement to meet the optimal evidence have to come from the CHNA?
A: The Community Needs Health Assessment (CNHA) is a requirement of health systems – PPACA March 2012 “Each tax exempt hospital is required to conduct a Community Health Needs Assessment.” This is a useful document for FCCs to review. It identifies current, relevant community needs; not perceived needs or previous needs, but needs the local health systems have identified. The needs they are documenting they are willing to support. We encourage FCCs to invite their hospital to present the CHNA to their board to better understand how the clinic meets the current needs of the community. Review of the CHNA and incorporation into the mission keeps the mission relevant and engages the local health system in the clinics mission and services. This is an optimal Standard.
Standard#6: GAM1c: Why is it necessary to have meeting minutes to validate approval of Conflict of Interest policy? How can our clinic be in compliance with optimal, but not required?
A: There should be minutes with the approval of the by-laws and the Conflict of Interest policy. By-laws and the conflict of interest policy should be periodically reviewed for their relevance and to ensure new board members all understand them. If you cannot easily locate these minutes, please make it an agenda item at your next board meeting; review the item and the Standard is satisfied. Annual review of the Conflict of Interest policy should occur with the annual signing of the conflict of interest disclosure. There is increasing pressure on nonprofits to be transparent. This should not just occur at the committee level, although, the governance committee may review the policy first and make recommendations to the board to keep as-is or with changes. At every board meeting a standing agenda item should be disclosed of any conflicts with items on the agenda or new conflicts in general. This is best practice. Optimal builds on required; meaning having both would be the best. Sometimes, optimal can be achieved without having met the first, as they can be two separate concepts/evidence relating to the Standard.
Standard#15: GAM2a: What is the WAFCC looking for proof? – visual review that our poster is displayed?
A: Yes, WAFCC looks for visual proof of the poster. Generally, federal workplace posters must be displayed or posted in conspicuous places where they are easily visible to all employees — the intended audience. The FMLA, EEO, and EPPA posters are also required to be placed where they can be seen by applicants for employment/volunteers.
Standard#15: GAM2a: What is the relevance of eLaws First Step Poster Adviser? Our off-site payroll and MRA provide us with posters. We do not use eLaws.
A: The relevance of the eLaws First Step Poster adviser is evidence for the awarding of the Standard. Although you have a vendor provide your posters, this is a check-and-balance, whereby we know the Standard is achieved. A level of evidence must be established, and this is how WAFCC has chosen to have clinic demonstrate that all their current posters are in compliance. The simple reliance on a vendor is not evidence that the posters have been reviewed for validity.
Standard#17: GAM2a: Why is it important to complete periodic background checks? Our clinic’s policy is to conduct the background check at the time of recruitment and hire. We do not conduct periodic background checks at this time due to the time and resources needed.
A: Inadequate due diligence the healthcare sector harms not only an organization, but its patients and sector’s reputation, as well. It is recommended by most risk management and human resource organizations; that best practice is conducting periodic screening of employees to maintain a dependable healthcare workforce free of unlawful behavior. When clinics screen an applicant at the time of recruitment and their criminal record is clean, it does not necessarily mean that their record remains that way. This is especially important in safety-net healthcare where employees work with vulnerable populations (avoiding harm and for patient and staff safety). Periodic background screening is important for legal liability and to minimize risk and uncover red flags (manage the area of risk of accidents, employee theft, workplace violence, etc.). Some employers may not regularly re-screen but instead require employees/volunteers "self-report" if there are any arrests or convictions that may impact their jobs. This “Self-report” then becomes a part of the annual review, etc. process.
Standard#17&20: GAM2b: For the required evidence Does a clinic need to do a payed background check?
A: A background check using only CCAP, also known as Wisconsin Circuit Court Access satisfies the required evidence. However, for the optimal evidence an extensive background check is necessary. This means that is necessary a multi-state background check and just not only Wisconsin.
Standard#22: GAM2b: Does a clinic need a program to track volunteer hours or an excel spread sheet is acceptable?
A: A clinic could do a Google form, or a manually-updated Excel spreadsheet form that shows the time that the volunteers check- in and check-out. If a clinic does the Google form of the spread sheet, this form should be organizing in such a way that can show the total number of work hours donate for the volunteers, then WAFCC will accept the spreadsheet. There are also free and low cost software’s that clinics uses for tracking their volunteer hours such as logistics, volunteer impact, gift works, etc. One of the purposes to go electronic is because a clinic can easily track how many hours a volunteer donates.
Standard#26: GAM2c: What is the Drug Supply Chain Security Act?
A: The Drug Supply Chain Security Act (DSCSA) outlines critical steps to build an electronic, inter-operable system to identify and trace certain prescription drugs as they are distributed in the United States. Virtually every hospital, pharmacy, clinic, physician and long-term care facility that dispenses prescription medicine in the US faces a set of DSCSA compliance requirements.
Standard#27: GAM3a: For the optimal evidence, the Standards states that “documentation of clinician’s review of medical history, including allergies, adverse drug reactions, medication list, and recent laboratory testing at every visit. What if our clinic is small and only open a few days a month, and then we do not have the ability to do this electronically because we do not have EMRs. What would those clinics without EMR do? Please provide clarity by illustrating a good example of documentation.
A: This is intentionally an “optimal” not “required” Standard. WAFCC believes that this Standard is an optimal best practice, and that FCCs should strive to do this. We recognize that not all FCCs have EMRs or the infrastructure for this, which is why it is “optimal” not “required”. However, it is important to understand what medications a patient is on, if there were any changes since their last visit to the clinic, and if they developed any allergies (ex: new drug on visit to emergency room, exposure to food allergen, etc.). Part of any H&P note at a physician visit includes current medications and allergies as part of the visit. If this information has been documented in full on a previous visit and has not changed, it would be acceptable to write that there is no change to medications or allergies from previous documentation. In another words, the history can be reviewed even without an EMR by just documenting in the patient file – “history and allergies reviewed and the date” or creating a cover form in the patient file to be initialed at each visit when the information is reviewed. Another example is creating a cover sheet that states "medications/allergies reviewed with no changes". WAFCC feels this is an optimal Standard for providing safe care (a goal of the Standards). We do acknowledge and understand that not all clinics are in a place to achieve the “optimal”, and that “optimal” Standards are more challenging. Optimal should be viewed as a goal.
Standard#29: GAM3a: What does "medication dispensing occurs in an uninterrupted work environment free of distractions" means?
A: It is important for medications to be dispensed in an environments where the patients are able to understand what is given to them and how to properly take the medication.
Standard#29: GAM3a: Please clarify what WAFCC means by "medication errors are reported to healthcare provider and addressed in a log to minimize patient harm"?
A: It is important for FCCs to have a process in place for reporting medication errors and recognizing them. A log, a medication incident report form, and medication error tracking form are examples of how FCCs address medication errors. FCCs should report all medication errors, regardless of whether the error results in an adverse drug event. Medication errors could include the wrong medication being dispensed to a patient, accidental omission of a prescription, prescribing medications that are expired, etc. These may be noticed by a provider, patient, volunteer. They are something that should be very rare/possibly not occur in a clinic, but it is important to be aware of the possibility and correct any errors that occur. We feel this is a practical and best practice. Addressing the issues of errors and working towards an environment that reduces errors is very practical (see the Institute of Medicine 1999 report “to Err is Human”). In 2016, it is estimated that 250,000 people died because of medication errors. This Standard addresses that statistic. Policies are in place in hospital and community pharmacies relating to these issues. Each time an error is made, the staff should be made aware and discuss ways to prevent future errors of the same kind. FCCs should have a policy in place to do this. Patients should be made aware if an error reaches the patient. Training the staff/volunteers to report errors, creating a form, addressing systemic errors, eliminating blame, and other obstacles to error reporting are practical things that can reduce errors and create a safer clinic for our patients. WAFCC feels this is a necessary Standard for providing safe care (a goal of the Standards).
Standard#29: GAM3a: Please clarify what you mean by pharmacy database system? For example, we have an Excel file – is this sufficient?
A: Yes, an Excel file could potentially satisfy the database system requirement.
Standard#35: GAM3D: If I am registered with VHCP do I need to enroll in the fund?
A: If your clinic employs a staff physician or CRNA's who work more than 240 hours a year in Wisconsin, then yes you are required to still have coverage through the Injured Patient’s family compensation fund. Assuming your clinic does not employ a physician and you are registered with VHCP then, no your clinic is under no legal obligation to maintain coverage through the fund. However it may still be advantage to gain coverage through the fund because it could lead to a reduction in your insurance premiums.
Standard#35: GAM3D: Who doesn’t have to participate in the Fund?
A: Doctors and CRNAs for whom Wisconsin in not their principal place of practice or who work less than 240 hours in a fiscal year.
Standard#35: GAM3D: Does the fund cover RN’s and dentists?
A: No, the fund covers physicians, and nurse anesthetist (CRNA).
Standard#35: GAM3D: Can my clinic be covered by the fund?
A: Yes, your clinic can be covered by the fund as well as medical directors.
Standard#35: GAM3D: If I run a Free and Charitable Dental Clinic does this fund apply to me?
A: If your FCC serves only dental patients then no, this fund would not apply to you, but your clinic has both a medical and dental clinic then this standard may still apply.
Standard#35: GAM3D: What is the current limit for primary medical malpractice coverage (in order to be enrolled in the fund.)?
A: Every physician and CRNA must purchase primary medical malpractice coverage at the levels defined in ch. 655, Wis. Stat. (currently $1,000,000 per occurrence/$3,000,000 annual aggregate)
Optimizing The Patient Care Experience (OPC) FAQs
Standard#51: OPC1c: How should I confirm that a clinic maintains a tracking process for diagnostic tests and referrals without a EMR? Can you please provide a good example to prove that the Standards is being achieved as written?
A: If a clinic does referrals or order lab work, they should have a process in place for tracking this. If a clinic does not do referrals or order lab work – this Standard would not apply to them and they would select “not applicable”. WAFCC understands that tracking referrals adds an additional level of work to any clinic, but it is very important to ensure that our patients are receiving optimal care and have access to specialists. At XX’s student run clinic, they don't utilize an EHR for this process since they are referred to outside clinics/hospitals. They use a secure website that is HIPPA compliant and have a spreadsheet to document if a patient has seen the specialist or not. This can be done via communication with the patient (i.e. calling to see if they were able to go to their appointments) or with the provider's office. Patients aren't always the best advocates for their own care, so it's important that we, as providers, act as their advocates and ensure that their needs are being met.
Standard#51: OPC1c: How does the clinic know if the patient completed the referral?
A: Some clinics have a referral log sheet that a volunteer completes, and then documents in the patient’s paper chart. An FCC should have a policy in place for how they conduct referrals and follow-up on them.
Standard#51: OPC1c: How does the clinic know when labs are performed and how does that information get into the patient's paper chart?
A: Similar to the referral log, some clinics have a lab log. Also, some clinics have a process for when a lab is faxed to the clinic – a process for the nurses/providers to review and follow-up on that lab and document the patient’s paper chart. This is a necessary standard for continuity of care (a goal of the standards). Documentation of the policy is sufficient.
Standard#57: OPC2c: We have a definition of “high risk” patients, but I don’t have the sense we have it documented in a way that would be considered sufficient proof of documentation. So, I think we are partially meeting the Standard, but want clarification on what is good proof in a document – is this a policy or some other type of document?
A: Regarding evidence, it could be a policy, procedure, or a direction on where to find the information (i.e. in the red binder labeled Processes in the ED office, on the shelf - - or in Google Drive under the process folder – the file called XXX). You might have a log, the slides, or the agenda from when the volunteers were trained, or make it part of the on boarding process. We tried to leave the Standards open enough that individual clinics could achieve them in a way that bests fit their clinic.
A: If a clinic does referrals or order lab work, they should have a process in place for tracking this. If a clinic does not do referrals or order lab work – this Standard would not apply to them and they would select “not applicable”. WAFCC understands that tracking referrals adds an additional level of work to any clinic, but it is very important to ensure that our patients are receiving optimal care and have access to specialists. At XX’s student run clinic, they don't utilize an EHR for this process since they are referred to outside clinics/hospitals. They use a secure website that is HIPPA compliant and have a spreadsheet to document if a patient has seen the specialist or not. This can be done via communication with the patient (i.e. calling to see if they were able to go to their appointments) or with the provider's office. Patients aren't always the best advocates for their own care, so it's important that we, as providers, act as their advocates and ensure that their needs are being met.
Standard#51: OPC1c: How does the clinic know if the patient completed the referral?
A: Some clinics have a referral log sheet that a volunteer completes, and then documents in the patient’s paper chart. An FCC should have a policy in place for how they conduct referrals and follow-up on them.
Standard#51: OPC1c: How does the clinic know when labs are performed and how does that information get into the patient's paper chart?
A: Similar to the referral log, some clinics have a lab log. Also, some clinics have a process for when a lab is faxed to the clinic – a process for the nurses/providers to review and follow-up on that lab and document the patient’s paper chart. This is a necessary standard for continuity of care (a goal of the standards). Documentation of the policy is sufficient.
Standard#57: OPC2c: We have a definition of “high risk” patients, but I don’t have the sense we have it documented in a way that would be considered sufficient proof of documentation. So, I think we are partially meeting the Standard, but want clarification on what is good proof in a document – is this a policy or some other type of document?
A: Regarding evidence, it could be a policy, procedure, or a direction on where to find the information (i.e. in the red binder labeled Processes in the ED office, on the shelf - - or in Google Drive under the process folder – the file called XXX). You might have a log, the slides, or the agenda from when the volunteers were trained, or make it part of the on boarding process. We tried to leave the Standards open enough that individual clinics could achieve them in a way that bests fit their clinic.
Fostering Community Relationships (CR) FAQS
Standard#59: CR1: For the required evidence, what constitutes relevant information?
A: This standard and required evidence is intentionally written broadly to allow an FCC to determine first of all their target population (OPC1a) and then to define what information they need from the health system relevant to that population. For example, many FCCs want to know when their patients visit the ED or have an inpatient hospital admission.
Standard#59: CR1: What type of process is WAFCC looking for?
A: Relationship/referral network/partnership is evidence that there is communication between the clinic and health system. Another example is documentation of the communication between the clinic and health system such as documentation of email between organizations, an agenda, minutes of the meetings, etc.
Standard#66: CR3b: Standard states “documentation in patient’s medical record at each clinic visit regarding interval ED or inpatient use” This is a process that our clinic had not considered. Please provide clarity by explaining and providing a good example of documentation.
A: It is important to know if patients were seen in the ED or urgent care since they were last in your clinic in order to provide quality care. Part of caring for our patients is teaching them proper use of the healthcare system.. It is important that FCCs have processes in place to ask patients about their recent visits to health care providers outside of the FCC, in particular ER/ED rooms. This helps the FCCs to understand the patient’s health and issues/problems the patient might forget to mention or new medications that patient is on. The clinic should then document in the patient paper or EMR chart that ED visits were reviewed. This could be a cover sheet in the patient file, medical history and allergies reviewed, and ED/ER reviewed. If there is no change to the history, there could be a box to check on the paper chart for each visit that states "patient has not seen emergency providers since last visit".
A: This standard and required evidence is intentionally written broadly to allow an FCC to determine first of all their target population (OPC1a) and then to define what information they need from the health system relevant to that population. For example, many FCCs want to know when their patients visit the ED or have an inpatient hospital admission.
Standard#59: CR1: What type of process is WAFCC looking for?
A: Relationship/referral network/partnership is evidence that there is communication between the clinic and health system. Another example is documentation of the communication between the clinic and health system such as documentation of email between organizations, an agenda, minutes of the meetings, etc.
Standard#66: CR3b: Standard states “documentation in patient’s medical record at each clinic visit regarding interval ED or inpatient use” This is a process that our clinic had not considered. Please provide clarity by explaining and providing a good example of documentation.
A: It is important to know if patients were seen in the ED or urgent care since they were last in your clinic in order to provide quality care. Part of caring for our patients is teaching them proper use of the healthcare system.. It is important that FCCs have processes in place to ask patients about their recent visits to health care providers outside of the FCC, in particular ER/ED rooms. This helps the FCCs to understand the patient’s health and issues/problems the patient might forget to mention or new medications that patient is on. The clinic should then document in the patient paper or EMR chart that ED visits were reviewed. This could be a cover sheet in the patient file, medical history and allergies reviewed, and ED/ER reviewed. If there is no change to the history, there could be a box to check on the paper chart for each visit that states "patient has not seen emergency providers since last visit".