Form 1 Financial Performance Measures

OMB No.: 0915-0285     Expiration Date: 10/31/2013

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration

FINANCIAL PERFORMANCE MEASURES

FOR HRSA USE ONLY

Grant Number

Application Tracking Number

Project Period Date

Focus Area: Costs

Performance Measure: Total cost per patient
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Total accrued cost before donations and after allocation of overhead.
Denominator Description	Total number of patients.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Costs

Performance Measure: Medical cost per medical encounter
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Total accrued medical staff and medical other cost after allocation of overhead (excludes lab and x-ray cost).
Denominator Description	Non-nursing medical visits (excludes nursing (RN) and psychiatrist visits).
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Financial Viability

Performance Measure Description: Change in Net Assets to Expense Ratio (Note: Net Assets = Total Assets – Total Liabilities).
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Ending Net Assets - Beginning Net Assets.
Denominator Description	Total Expense.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Financial Viability

Performance Measure: Working Capital to Monthly Expense Ratio
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Current Assets - Current Liabilities.
Denominator Description	Total Expense / Number of Months in Audit.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Financial Viability

Performance Measure: Long Term Debt to Equity Ratio
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Long Term Liabilities.
Denominator Description	Net Assets.
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

Focus Area: Other

Performance Measure:
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description
Denominator Description
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data (by End of Project Period)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting [_] Not Applicable Key Factor Description: Major Planned Action Description:
Comments

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