1. Professional Liability History/Additional Information: Supplemental Information and ECRI Institute Resources

2. HRSA Clinical Risk Management Resources Homepage

3. Before You Fill Out the Application… Have the following items with you:  If you’ve had a professional liability claim filed against your center and/or employees within the past 5 years, a document listing and summarizing the allegations  HRSA Program Assistance Letter (PAL) 2012-02: Calendar Year 2013 Requirements for Federal Tort Claims Act (FTCA) Medical Malpractice Coverage for Health Centers (access at http://www.bphc.hrsa.gov/policiesregulations/policies/pal201202.html) http://www.bphc.hrsa.gov/policiesregulations/policies/pal201202.html

4. Components of Application Professional Liability History 1. Confirm whether you have had a professional liability claim filed against your center/employees within past 5 years. Additional Information 1. Specify professional organizations from which you have received accreditation, certification, or recognition. 2. List risk management training/continuing education completed by staff during the past 12 months. 3. Describe plans for risk management training/continuing education for the upcoming year.

5. Professional Liability History Once a health center reasonably anticipates litigation, it must preserve any documents related to the claimant. If the health center has had a claim filed within the past 5 years, it must attach a separate document listing each claim and including the following information for each claim:  Name of provider(s) involved  Area of practice/specialty  Date of occurrence  Summary of allegations  Status/outcome of claim

6. Additional Information: Accreditation/Recognition The Joint Commission accreditation for ambulatory care: http://www.jointcommission.org/accreditation/ambulatory_h ealthcare.aspx. http://www.jointcommission.org/accreditation/ambulatory_h ealthcare.aspx Accreditation Association for Ambulatory Health Care: http://www.aaahc.org http://www.aaahc.org Adjunct Medical Home Chapter (if applicable) National Committee for Quality Assurance Patient Centered Medical Home Accreditation: http://www.ncqa.org/tabid/631/default.aspx. http://www.ncqa.org/tabid/631/default.aspx  See “Resource Page: Patient-Centered Medical Home” on the Clinical Risk Management website: https://members2.ecri.org/Components/HRSA/Pages/PCMH.aspx. https://members2.ecri.org/Components/HRSA/Pages/PCMH.aspx

7. Additional Information: Training/Continuing Education Patient safety Infection control/hand hygiene Teamwork and communication Medication safety Fall prevention Fire safety Documentation Disaster planning Obstetrics safety

8. Education and Training Tools Bloodborne Pathogen Communication/Disclosure Hand Hygiene Risk Management/ Patient Safety Sharps Injury Prevention Cross-Contamination from Flexible Endoscopes

9. ECRI Institute’s e-Learn FTCA deemed health centers and free clinics have free access to e-Learn as part of the Clinical Risk Management Program membership Library of courses for continuing education credit In order to access e-Learn  Go to http://ecrilearning.ecri.orghttp://ecrilearning.ecri.org  Register using your course keys; create a username and password  After initial registration, log-in each time with your username and password

10. Clinical Risk Management Website http://www.ecri.org/Clinical_RM_Program Go to: http://www.ecri.org/clinical_rm_programhttp://www.ecri.org/clinical_rm_program Enter username and password under “Member Login” Don’t have a username and password? Contact us:  Clinical_rm_program@ecri.org Clinical_rm_program@ecri.org  (610) 825-6000 x5200

11. Professional Liability History FAQs Q: How many years does the claims history on the FTCA application need to go back? A: The Health Center should list all claims that occurred within the past five years. This includes FTCA claims and non-FTCA claims. The claims history should include the following for each case: Name of provider(s) involved Area of practice/Specialty Date of occurrence Summary of allegations Status and outcome of claim

12. Questions on Deeming/Application Process? Contact BPHC helpline at 1-877-974-BPHC (877-974-2742) or BPHChelpline@hrsa.govBPHChelpline@hrsa.gov  9:00AM to 5:30PM (ET) FTCA website: http://www.bphc.hrsa.gov/ftcahttp://www.bphc.hrsa.gov/ftca For EHB technical support (e.g., registration, username and password), contact HRSA Call Center at 1-877-464- 4772 or CallCenter@hrsa.gov.CallCenter@hrsa.gov  Monday-Friday (except federal holidays) 9:00AM to 5:30PM (ET)