Evaluation of the Health Center’s Quality Program

As health centers continue to deal with the repeated surge in COVID-19 cases, clinical performance measures continue to decline.  Regardless of what other challenges health centers are encountering, the Health Services and Resources Administration (HRSA) expects health centers to maintain continuous compliance with all health center program requirements, including Quality Improvement.  

A key component of a successful Quality Improvement Program is an annual evaluation.  How do you do this and what do you do with the results?  At the end of each year, health centers should evaluate the effectiveness of the current Quality Improvement Program.  This can be accomplished by doing the following:

  • Evaluate the effectiveness of the Quality Improvement Program structure to identify any needs to improve how work gets accomplished.  Document gaps!
  • Evaluate the quality activities that were implemented to determine if goals were met.  Document why or why not!
  • Evaluate the clinical services and clinical management metrics selected to determine if they are adequate and appropriate enough to assess the care being provided.  Document why or why not!
  • Formulate recommendations that will facilitate development of the Quality Plan for the subsequent year.  


The annual evaluation should be a separate document that provides a summary of the previous year’s quality activities and responses to the above.  This document is presented to the Board of Directors at the end of each calendar year. The results of the annual evaluation will be used as the catalyst for annual review and revision of the Quality Plan. Resources for Quality Improvement Program development can be found at ECRI | Trusted Voice in Healthcare and Clinical Quality Improvement | Bureau of Primary Health Care (hrsa.gov).

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