Form 18 Financial Performance Measures (track changes)

OMB No.: 0915-0285     Expiration Date: XX/XX/20XX

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: Ratio of tTotal cost per patient served in the measurement calendar year
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.
Progress Field (for Service Area Competition and non-competing continuation applications)
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data Goal (by December 31, 2018End 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: Ratio of total mMedical cost per medical encountervisit in the measurement calendar year
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Total accrued medical staff and other medical other cost after allocation of overhead, (excludinesg medical lab and x-ray cost).
Denominator Description	Non-nursing medical visits , excluding nurse visits(excludes nursing (RN) and psychiatrist visits).
Progress Field (for Service Area Competition and non-competing continuation applications)
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data Goal (by December 31, 2018End 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: Grant costsFinancial Viability

Performance Measure Description: Ratio of total BPHC section 330 grant funds per patient served in the measurement calendar yearChange 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	BPHC section 330 grants drawn-down for the period from January 1 to December 31 of the measurement calendar yearEnding Net Assets - Beginning Net Assets.
Denominator Description	Total number of patientsExpense.
Progress Field (for Service Area Competition and non-competing continuation applications)
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data Goal (by December 31, 2018End 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
Progress Field (for Service Area Competition and non-competing continuation applications)
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator:	Projected Data Goal (by December 31, 2018End 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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