Section 11.2: Clinical Evaluation Methodology

Part III: Program Evaulation and Monitoring


The clinical evaluation methodology has both clinical and administrative components and includes a review of client records, policy and procedure manuals, and selected administrative documentation, as well as direct observation of clinical services. It is designed to establish the procedure and protocol for outside reviews and to assist the delegate agencies to conduct self-reviews of their own programs. The clinical evaluation should provide information about the strengths and weaknesses of the delegate agency's current operations, which can be used for ongoing management and service improvement.

Evaluation/Reporting Coordination:

IDHS Regional MCH Nurse Consultants will conduct the IDHS Family Planning Program Clinical Review annually.

  1. It is important that all of the clinical evaluation activities be conducted with minimal disruption of delegate agency project operations. The MCH Consultant should schedule the review four to six weeks in advance at a mutually agreeable time, date and location.
  2. Delegates will receive a confirmation letter along with all audit criteria and tools that will be used in advance of the clinical evaluation date.
  3. MCH Nurse Consultants should recognize that special circumstances may preclude an agency's exact adherence to an established program standard, and this should be noted in their comments. For example, a delegate agency may not be prescribing IUD/IUS onsite. This may be due to the untrained personnel; thus, an off-site clinician referral source must be identified in order for the agency to be in compliance with the Section 8.4 of the Title X guidelines.
  4. After the clinical evaluation activities are completed, an exit conference will be conducted to share preliminary or pertinent findings/comments with the delegate agency staff. Delegate agency personnel may provide immediate feedback to IDHS review team members regarding negative findings and any recommendations made as a result of the program review.
  5. The final written report will contain the completed indicators and required actions, along with recommendations for enhancing or improving practice, if indicated. The final report will be sent to the delegate agency within four weeks. As directed, the agency will respond with corrective action in writing within four weeks. MCH nurses may also provide additional technical assistance to assure compliance with the Title X or IDHS guidelines. The delegate agency will receive an acceptance letter from the Nurse Consultant approving the agency response to any required action.
  6. IDHS Program Coordinator (Clinical) will facilitate the IDHS internal approval processes for the program review documentation.
  7. Final approval of the program review resides with the Project Medical Director. This final approval may indicate the need for additional technical assistance or continued monitoring.

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