Illinois Department of Human Services Family Planning Program

SFY2012 Delegate Site Visit TOOL

Agency: / Date(s) of Visit:
Clinic Site: / Nurse Consultant:
Scheduled Site Visit  / Unscheduled Site Visit 
Criteria / Addressed / Not Addressed / Completion Due Date / Comments
Corrective Action Plan Status Prior Review Date:
  1. Resolved

  1. Work in progress

  1. Unresolved

Work Plan
  1. Progress meeting objectives

Observation of Clinic Activities
May include:
  1. Clinician observation
b. Follow-up on corrective actions
for direct service delivery:
1. Front desk procedures
2. Intake process
3. Clinic flow
4. Client focused approach
5. Appointment length
6. Fee assessment
7. Clinician techniques
8. Client education/counseling:
Comprehensive and problem
encounters
9. Laboratory procedures [logs,
OSHA precautions, specimen
handling]
Clinical Management
May include review of polices/protocols and staff interviews:
  1. Client confidentiality
  1. Infection control
  1. Pharmaceutical
  1. Laboratory
  1. Medical records
  1. Appointment scheduling

Quality Assurance
May include:
  1. Internal chart review process
  1. Direct Client Interviews
  1. Medical Director chart review
  1. Work plan utilization as guide
for service delivery
Performance Indicators

a. At least 30% of unduplicated visits are adolescents (<20 years old)

b.Clinic has increased the number of males from previous year (Target 7%).

c.# of unduplicated IHW clients.

d.There is improvement in monthly service rates (unduplicated clients) from previous year

e.Monthly CVR error rate consistently less than 3%

f.14-day Chlamydia treatment rates are 79% or above*

g.30-day Chlamydia treatment rates are 94% or above*

h.14-day gonorrhea treatment rates are 74% or above*

i.30-day gonorrhea treatment rates are 89% or above*

j. All clinic sites are open and

serving clients. List closures.

k. The clinic‘s hours are conducive to clients’ needs. Assess appropriateness of clinic hours for the population served.

/ / *IDPH Timeliness to Treatment percentage goals for CY 2012
Other
May include:
  1. Old/new issues
  1. Staff changes

Revised 01/13/12Page 1