For Federally Qualified Health Centers (FQHCs), few events spark more urgency—and anxiety—than an HRSA Operational Site Visit (OSV). Conducted every three years, these visits are a cornerstone of the Bureau of Primary Health Care’s oversight, ensuring that FQHCs remain compliant with program requirements. But they’re not just audits—they’re opportunities to prove the impact of your organization and identify areas for improvement.

Why the OSV Matters

The OSV evaluates whether your health center continues to meet all 90+ elements of the HRSA Health Center Program Compliance Manual. Falling short in even a few areas can trigger follow-up actions, conditions on funding, or—in rare cases—more serious consequences. But the purpose of the visit isn't punishment. It's to ensure that patients, especially those in underserved communities, are receiving safe, equitable, and high-quality care.

How HRSA Approaches Peer Review Evaluation

Peer review is a required part of every FQHC’s Quality Improvement and Assurance Program. And yes—HRSA will look at it.

During the OSV, surveyors will typically examine a small sampling of peer review documentation. But here’s the catch: if those samples show incomplete processes, missing signatures, or peer reviews that appear overly general or biased, the reviewer may widen the sample. At that point, it becomes a risk—not just to your funding, but to the trust your leadership team has worked to build internally and externally.

Peer Review Red Flags During OSV

Here are common issues that can raise concerns during peer review evaluation:

• Missing documentation: No evidence of reviews conducted, or reviews missing required elements like reviewer qualifications or clinical findings.
• Inappropriate reviewer assignments: Internal reviews conducted by providers outside the reviewer’s scope or without subspecialty alignment.
• Lack of follow-up: No clear documentation of action taken on findings or integration into broader QI efforts.
• Bias indicators: Reviews completed exclusively by internal staff, often within the same department or under the same leadership, can trigger skepticism.

Strengthening Your Peer Review Program Before OSV

One strategy gaining traction among FQHCs is supplementing internal peer reviews with external, independent reviews—especially for high-risk specialties like OBGYN or when staffing turnover is high.

External reviews can:

• Demonstrate objectivity
• Ensure reviewers have matching subspecialty credentials
• Provide consistent methodology when internal bandwidth fluctuates
• Reduce administrative burden on clinical staff

Even one independent review per provider per year can serve as a validation tool for your internal program—and a reassuring signal to HRSA that your processes are defensible and well maintained.

Other Key Areas HRSA Will Review

While peer review is one slice of the OSV pie, it intersects with broader themes the site team will evaluate, including:

• QAPI Integration: How are peer review findings feeding into your Quality Assurance/Performance Improvement activities?
• Clinical staffing compliance: Are licensed providers being reviewed appropriately, and are protocols in place for mid-level oversight?
• Policies and procedures: Does your written peer review policy match actual practice?

Final Thoughts: Preparing with Confidence

Preparing for an OSV doesn’t mean overhauling your systems. It means being intentional, organized, and transparent. A well-run peer review program—with clean documentation, relevant insights, and external validation—signals that your organization takes both compliance and patient safety seriously.

The bottom line: HRSA reviewers want to see that you know what’s happening in your clinical trenches. If you can show that through thoughtful peer review, you’re already a step ahead.

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