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Planning and Conducting Title X Program Reviews: A Toolkit for Family Planning Providers

Toolkit/Guide
Title X Program Management

Welcome to the Toolkit

Title X Program Requirement 8.7 states: “Grantees must ensure that the project is competently and efficiently administered.” One strategy for meeting this requirement is to conduct formal, comprehensive program reviews with subrecipient agencies. Reviews should be conducted on a rotating schedule (e.g., once every project period or every three years.) Title X grantees who contract with subrecipient agencies to provide Title X services should carry out formal program reviews as part of the subrecipient monitoring process.

This toolkit provides guidance, steps, and resources for Title X-funded grantees to conduct program reviews.

 

Illustration looking over a person's shoulder at a clipboard.

This toolkit includes resources, such as job aids, sample documents, and templates that Title X grantees can modify to conduct program reviews. Instructions for customization are provided in each of the sample documents. The resources in this toolkit support grantees in:

  • Planning for an on-site program review and conducting a desk review;
  • Conducting an on-site program review; and
  • Monitoring findings and closing out a program review.

The entire process is outlined in more detail in the Title X Program Review Timeline and Checklist. The first step should be to download and refer to the Title X Program Review Timeline and Checklist to guide the action steps below.

Action Steps Supportive Resources

Start by downloading the Title X Program Review Timeline and Checklist, a roadmap for the program review process from start to finish. Note that time timing of the tasks on the timeline and checklist is a summary of the more detailed information on the timeline and checklist.

 

Title X Program Review Timeline and Checklist

Grantee: An agency that receives Title X funds directly from the Office of Population Affairs (OPA)

Subrecipient: An agency that receives Title X funds from a grantee

Service site or “site”: A clinical care-providing location operated by a subrecipient or grantee that provides Title X-funded family planning services

Review team: Members of the grantee staff and/or consultants who work together to conduct the program review. Often, the team consists of a team lead/coordinator, and reviewers who focus on one or more review components (administrative, clinical, and fiscal).

 

Thoughtful preparation is imperative for a successful program review. A comprehensive review requires the involvement of administrative, financial, and clinical staff at the grantee, subrecipient, and service site levels. To ensure a smooth process, planning for a program review should start one year to six months before conducting the review itself. Preparation includes a “desk review” during which documents, shared by the subrecipient or available through the grantee, are reviewed in preparation for the on-site review. Follow the action steps below, referring to the Title X Program Review Timeline and Checklist and associated resources, to plan for a program review.

Action Steps Supportive Resources

Determine which subrecipients will be reviewed. Consider creating a schedule of comprehensive reviews of each subrecipient at least once every project period.

Determine the assessment tool to be used for the program review.

Title X Program Review Tool

Notify the subrecipient.

Title X Program Review Announcement Letter Template

Identify a program review team.

Collect subrecipient documents and forward them to team for desk review.

Title X Program Review Requested Documents List Template

Prepare for client medical records review. Meet with clinical reviewer to determine chart review methodology and content.

 

The on-site program review builds on information gleaned from the desk review. During the on-site program review, the review team seeks clarification on questions raised by the desk review, conducts observations, interviews staff, and reviews materials that are only available on-site. Follow the action steps below, referring to the Title X Program Review Timeline and Checklist and associated resources, to conduct an on-site program review.

Action Steps Supportive Resources

Conduct entrance meeting.

Title X Program Review Agenda Template

Review documents available on-site.

Title X Program Review Requested Documents List Template

Conduct subrecipient staff interviews to provide context for the documents reviewed and clarify questions of the reviewers.

Conduct facility/staff/client observations to verify policies are consistently implemented and clinical services are provided in a client-centered, non-coercive manner.

Conduct daily debrief meetings with subrecipient staff.

Conduct exit meeting.

 

Post-review activities are strengthened by the prompt and careful coordination of all review team members to write their sections for a compiled Program Review Report. Timely delivery of this report to the subrecipient agency goes a long way to demonstrate that the grantee values a mutually respectful partnership. Follow the action steps below, referring to the Program Review Timeline and Checklist and associated resources, to close out a program review.

Action Steps Supportive Resources

Complete the program review report.

Title X Program Review Report Template

Prepare the Corrective Action Plan (CAP).

Title X Corrective Action Plan (CAP) Template

Send the Program Review Report and CAP to the subrecipient.

Title X Program Review Report Cover Letter Template

Review the subrecipient’s CAP and response to the Program Review Report.

Monitor subrecipient progress on CAP.

Send program review close-out letter.

Title X Program Review Close-out Letter Template