Best Practices for Developing a Quality Improvement Workplan

“Chapter 10 – Quality Improvement/Assurance” (Chapter 10 – QI/QA) of the Health Resources and Service Administration (HRSA) Health Center Program Compliance Manual requires health centers to develop and implement a Quality Improvement/Assurance (QI/QA) Program.  One of the easiest ways to ensure compliance with HRSA requirements, as well as align with industry standard best practices, is to develop a Quality Management (QM) Workplan. 

The Quality Management Workplan is commonly referred to as the “QI Procedure” or “QI Project” that supports the quality initiatives outlined in the health center’s Quality Management Plan.  The QM Workplan is a working, functional document that is a reflection of the health center’s QM activities for the current reporting year and must include both clinical services and clinical management metrics. The QM Workplan is frequently the catalyst for a deeper analysis of specific metrics, which often results in the development and implementation of Plan-Do-Study-Act (PDSA) cycles. Industry standard best practices demonstrate highly functional and effective QM Workplans include the following:

  • Metric Definition – Define the metric, including both numerator and denominator, as well as any exclusions. 
  • Pre-defined benchmarks – Utilize state and national resources as a benchmark for developing goals and tracking progress.
  • Internal Goals – Develop internal goals that are realistic and attainable, yet still encourage forward progress.
  • Data Source – Identify the source and method of data collection to facilitate assignment of accountability.
  • Reporting Frequency – Identify the frequency of monitoring and reporting of data to outline a schedule of assessments, enable timely intervention and ensure compliance with HRSA requirements.


Although the QM Workplan does not require approval by the health center’s board of directors, best practices support review by board members to facilitate discussion regarding QM activities. Health centers can do a self-assessment of QI/QA compliance by following the guidance in the HRSA Health Center Compliance Manual (Chapter 10 – QI/QA) and completing the questions in the QI/QA section of the HRSA Site Visit Protocol (QI/QA – Site Visit Protocol). 

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