Form 33 HRSA EHBs Action Plan

OMB No.: XXXX-XXXX. Expiration Date: XX/XX/20XX

HRSA EHBs ACTION PLAN

Complete the following information related to the health center’s diabetes performance improvement actions identified during the site visit. Return the “Prepare Action Plan” section to the HRSA Project Officer within 15 calendar days from receipt. The Diabetes Action Plan involves a year-long monitoring period. Health Centers will utilize the “Resolve Action Plan” section for progress updates and resolution. Please contact the HRSA Project Officer with any questions related to the Diabetes Action Plan. For systems questions, please contact Health Center Program Support.

Prepare Action Plan (Shared between Health Center and HRSA Staff)
This information is pre-populated by HRSA. H80CSXXXXX Health Center Name: Tracking #: APXXXXXX Project Director: Project Period: Budget Period: Project Officer: Duns #: BCHMIS ID: Action Plan Source Site Visit Report link: Site Visit Dates: Site Visit Report Sent On: Action Plan Created On: Action Plan Created By: Action Plan Submission Due Date: Action Plan Type:
Update Finding
Finding Category	Performance Improvement Area (PIAs)
Finding	Clinical
Description
Person(s) Responsible Provide the name of the person responsible for the action plan implementation. This could be the Project Director/Chief Executive Officer (CEO), the Chief Medical Officer (CMO) or the Quality Improvement Director.
Target/Due Date (mm/dd/yyyy) Enter the date one year from the current date.
Intervention/Action Enter the three performance improvement actions that were identified during the site visit root cause analysis discussion – review of UDS diabetes measure and contributing and restricting factors. Note: If the HRSA Project Officer has pre-populated the Intervention/Action field, update the actions, if needed, and ensure that each action is specific, measurable, achievable, results-focused, and time-bound.
Supporting Documents – HRSA Staff (minimum 0 - maximum 10)
Supporting Documents – Grantee OPTIONAL (minimum 0 - maximum 10)
Resolve Action Plan – This Task Remains with the Health Center During the Action Plan Monitoring Period.
This information is pre-populated by HRSA. H80CSXXXXX Health Center Name: Tracking #: APXXXXXX Project Director: Project Period: Budget Period: Project Officer: Duns #: BCHMIS ID: Action Plan Source Site Visit Report link: Site Visit Dates: Site Visit Report Sent On: Action Plan Created On: Action Plan Created By: Action Plan Submission Due Date: Action Plan Type:
Update Finding
Resolve Action Plan – Progress Notes (Shared between Health Center and HRSA Staff)
Add Progress Note: On a quarterly basis, provide a brief narrative update on the status of performance improvement actions. Also include current UDS diabetes measure data. You may utilize attachments for progress updates. Note: HRSA Staff will utilize the Progress Notes feature to provide feedback on reported progress.	Progress Note #1
	Progress Note #2
	Progress Note #3
	Progress Note #4
Supporting Documents – HRSA Staff (minimum 0 - maximum 10)
Supporting Documents – Grantee OPTIONAL (minimum 0 - maximum 10)
Resolution After the fourth quarterly progress update is submitted to HRSA, complete the resolution field. Answer the following questions: Were all the action steps completed? Why or why not? What had the greatest impact on improving patient diabetes control, and improving the UDS diabetes measure? You may utilize attachments to supplement resolution information.

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].