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Documentation Required to Demonstrate Compliance with Chapter 10 – Quality Improvement/Assurance
In accordance with the guidance provided in “Chapter 10 – Quality Improvement/Assurance” (Chapter 10 – QI/QA) of the Health Resources and Service Administration (HRSA) Health Center Program Compliance Manual, health centers must develop and maintain an ongoing Quality Improvement/Assurance (QI/QA) system. The system must include monitoring of clinical services and clinical management metrics, the completion of quarterly assessments, and must maintain the confidentiality of patient information.
Although the QI/QA section of the HRSA Health Center Site Visit Protocol (QI/QA Site Visit Protocol) contains a checklist of documentation the health center is required to provide during an Operational Site Visit (OSV), in some cases there is a lack of clarity with regards to exactly what documentation will meet the compliance standard. Below is the list of documents included in the Site Visit Protocol checklist, with some examples of specific documentation that should be provided.
Although all of the above should be referenced in a high-level manner in the QI/QA Plan, the health center should provide individual policies for items 1 4. Items 5 and 6. can be fulfilled by providing the annual QI Workplan that references the specific clinical services and clinical management metrics, process for data collection, monitoring/reporting frequency and accountable parties.
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).