Section 11.1: IDHS Comprehensive Program Review Components

Part III: Program Evaulation and Monitoring


  1. Clinical Review:
  2. Administrative Desk Audit:
  3. Delegate Agency Grant Application:
  4. Required Reporting:
  5. Client Visit and Services Data Monitoring:
  6. Technical Assistance Visits:

The IDHS comprehensive program review of delegate agencies consists of six major components. Each component utilizes standardized review processes and/or review instruments. The elements of the family planning program that are reviewed correspond directly to the guidelines issued in this manual. Questions on the review instruments are posed to be answered in the affirmative and any negative responses indicate delegate noncompliance with a particular guideline.

Clinical Review:

The MCH Nurse Consultants conduct annual onsite clinical reviews for Title X compliance utilizing designated audit tools. The Nurse Consultants evaluate all clinical services, including certain personnel and financial sections that relate to client services. The evaluation/audit instruments include:

  • Family Planning Delegate Agency Clinical Review Criteria
  • Family Planning Delegate Agency Clinical Review Tool
  • Medical Chart Audit/CVR Billable Services Audit Tool
  • Illinois Title X Family Planning Clinic Infertility Prevention Project Chlamydia and Gonorrhea Screening Criteria Chart Audit Tool (as required)
  • Sterilization Audit Tool (if applicable)
  • Separation of Title X Family Planning and Abortion Services (when applicable)

(Refer to Appendix P for the IDHS Family Planning Delegate Agency Clinical Review Criteria and Tools).

Administrative Desk Audit:

The IDHS's administrative review process for delegate agencies is conducted to ensure all other requirements not evaluated during the clinical audit and grant application process are being met. These include:

  • Community Education Plan;
  • Personnel Management, including the orientation outline specific to family planning, current job descriptions, and personnel policies; and
  • Financial Management, including charges, billing and collection policies; cash handling policies; fiscal policies and chart of accounts.

The Administrative Desk Audit procedures outline a tiered schedule (6 months, 2, 3, or 4 years) for audits based on compliance with program requirements. (Refer to Appendix Q for the Administrative Desk Audit).

Delegate Agency Grant Application:

The IDHS requires an annual grant application that includes:

  • Signed Title X Assurance of Compliance
  • Provider Directory Information
  • Clinic(s) Schedule
  • Services Provided Checklist
  • Organizational Requirements
  • Information and Education Committee
  • Geographic Service Area
  • Needs Assessment, when applicable
  • Health Care Plan, when applicable
  • Work Plan
  • Sterilization Waiver Letter, if applicable
  • Schedule of Discounts
  • Sliding Fee Scale
  • Financial Status Baseline Report (Budget)
  • Revenue Analysis of Patient Fees
  • Cost Center Report
  • Cost Analysis

Required Reporting:

As outlined in Section 6.7, Required Reporting, delegates must submit required reports for review by IDHS staff on an annual or semi-annual basis. Included in these required reports are the following, which are considered key elements for program evaluation:

  • Community Education/Outreach Report
  • Equipment Inventory Report
  • Family Planning Annual Report (FPAR)
  • Family Planning Staff Training Attendance Report
  • Financial Status Report (FSR)
  • Information & Education Committee Meeting Minutes
  • Sterilization Semi-Annual Report (if applicable)
  • Work Plan Semi-Annual Progress Report

All of the above listed grant application documents and plans, along with all of the annual and semi-annual reports, are used for delegate program evaluation by the IDHS staff and for Federal reporting compliance. Refer to Appendix A for all Grant Application Required Materials and Appendix H for Required Reports.

Client Visit and Services Data Monitoring:

The IDHS data reporting system contributes to service site monitoring by providing detailed reports on the client population and the services provided. From these data reports, IDHS staff determines if services are meeting the needs of the community and meeting the approved service objectives of the delegate agencies. Specifically, the IDHS reviews the data reported for the Family Planning Annual Report, as well as data from the IDHS Program Objectives Monitoring Report and the IDHS User, Visit and Extended Exam Comparison Report such as:

  • Total unduplicated users;
  • Low income users;
  • Medicaid clients;
  • Adolescents; and
  • STD and HIV education/counseling encounters.

Minimally, the IDHS reviews these data every six months, at the mid point and the end of the program year. Delegate agencies are also responsible for data monitoring and should evaluate the quality of their data input quarterly.

Technical Assistance Visits:

IDHS provides onsite technical assistance to any Title X funded site. Most often, technical assistance is provided to improve operations and assure compliance with guidelines. But technical assistance may also be provided to meet the specific request or need of a particular site or delegate agency.

The focus of technical assistance visits generally fits into the following four categories:

  • a) Clinical Operations: including assistance with medical policies, standards or procedures, standing orders, clinic staff orientation, implementation of new clinical services, clinical in-service training, client scheduling, patient flow, clinic efficiency, etc.
  • b) Management Development: including assistance with training of new site managers, staff scheduling, personnel issues, data analysis, facility management, operational efficiency, cost effectiveness and outreach planning.
  • c) Data Operations: including assistance with pertinent systems enhancements, software changes, and training on FPAR reporting and CVR completion.
  • d) Finance: including assistance with budget preparation, billing and collections, cash management, cost analysis and fee schedule development and inventory management and control.

IDHS program and field staff conduct the technical assistance visits. IDHS also utilizes professionals outside of the department through the availability of the Title X Technical Assistance support.


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