Form 4a NHHCIA NCC Financial Performance Measures

Financial Performance Measures, Required and Optional Sample

The Financial Performance Measures forms below are for reference only. Starting with the Required and Optional Financial Performance Measures Forms submitted with the FY 2021 limited competition application, add two new rows (as seen in red in the table below) to provide numeric data to date and a narrative explanation of progress in relation to the goal. Do not edit any information previously included in the FY 2021 form. In your progress report, you must include all Required Financial Performance Measures and any Optional Financial Performance Measures that you included in your FY 2021 limited competition application.

OMB No.: 0915-0285. Expiration Date: 3/31/2023

DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration NATIVE HAWAIIAN HEALTH CARE SYSTEM Required Financial Performance Measures		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
1. Required Focus Area – NHHCIA Program Grant Cost Per Total Patient (Grant Costs)
Performance Measure	Ratio of total NHHCIA grant funds per patient served in the measurement calendar year
Is this Performance Measure Applicable to your Organization?	Yes
Target Goal Description
Numerator Description	Total NHHCIA grants drawn-down for the period from January 1 to December 31 of the measurement calendar year
Denominator Description	Total number of patients
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
Projected Data (by End of Period of Performance)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration NATIVE HAWAIIAN HEALTH CARE SYSTEM Optional Financial Performance Measures		FOR HRSA USE ONLY
		Grant Number	Application Tracking Number
2. Optional Focus Area – Total Cost Per Total Patient (Costs)
Performance Measure	Ratio of total cost per patient served in the measurement calendar year
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
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: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
Projected Data (by End of Period of Performance)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
3. Optional Focus Area – Medical Cost Per Medical Visit (Costs)
Performance Measure	Ratio of total medical cost per medical visit in the measurement calendar year
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Total accrued medical staff and other medical cost after allocation of overhead, excluding lab and x-ray cost
Denominator Description	Medical visits, excluding nurse visits
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
Projected Data (by End of Period of Performance)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments
4. Optional Focus Area – Financial Viability
Performance Measure	Non-Federal Matching Funds (percentage of matching funds included in the total project budget)
Is this Performance Measure Applicable to your Organization?	[_] Yes [_] No
Target Goal Description
Numerator Description	Non-Federal Matching Funds
Denominator Description	Total Budget
Baseline Data	Baseline Year: Measure Type: Numerator: Denominator: Calculated Baseline:
Numeric Progress Since August 1, 2021	Provide recent data to demonstrate ongoing progress toward goal.
Narrative Progress Since August 1, 2021	Provide narrative description to explain recent data provided.
Projected Data (by End of Period of Performance)
Data Source & Methodology
Key Factor and Major Planned Action #1	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #2	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Key Factor and Major Planned Action #3	Key Factor Type: [_] Contributing [_] Restricting Key Factor Description: Major Planned Action Description:
Comments

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 3/31/2023. 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].

5