Initiating End of the Year Clinical Quality Improvement Efforts

Initiating End of the Year Clinical Quality Improvement Efforts

As the end of the year approaches, Federally Qualified Health Centers (FQHCs) are presented with a vital opportunity to assess and enhance the delivery of quality care.  This time provides health centers with the chance to reflect, strategize and implement improvements that will elevate operational efficiency and patient outcomes in the upcoming year. Below are some best practices to consider when initiating end-of-the-year quality improvement efforts.

  • Reflect on Both Achievements and Challenges – Evaluate the existing Quality Improvement (QI) Program to identify and address any potential areas of non-compliance with Health Resources and Services Administration (HSRA) Health Center Program Requirements. Review clinical services and clinical management metrics including, but not limited to, clinical outcomes, patient satisfaction scores and employee feedback. 
  • Engage Essential Stakeholders – A strong QI Program is the result of collaborative efforts.  Engage clinical staff from all services in scope, administrative staff and community representatives, when possible, to participate in discussions and brainstorming sessions.  This will facilitate the collection of various perspectives that can assist in the identification of areas of oversight. 
  • Prioritize Areas in Need of Improvement – Identify specific areas that require prompt attention such as enhancing patient access, reducing patient wait times, improving care coordination and continuity of care, and implementing new workflows to facilitate better documentation and communication. 
  • Set Clear Goals and Objectives – Develop goals to address areas in need of improvement that are Specific, Measurable, Achievable, Relevant and Time-bound (SMART).  For example, aim to improve colorectal cancer screening scores by 5% and increase patient satisfaction scores by 20% in the first quarter of the upcoming year.  
  • Leverage Quality Improvement Tools – Tools such as Plan-Do-Study-Act (PDSA) cycles and Root Cause Analysis (RCA) can help to streamline processes, as well as promote continuous improvement by allowing for the evaluation of changes and adjustments based on real-time feedback and data. 
  • Plan for the Next Year – Initiate planning for the next year through the documentation of an Annual Quality Improvement Program Evaluation. The annual evaluation is a separate document that provides a summary of the previous year’s quality activities and outlines opportunities for continuous improvement. Share this document with stakeholders, including the Board of Directors, and utilize the results to modify the health center’s QI Plan.  


Additional resources for QI Program development can be obtained at ECRI | Trusted Voice in Healthcare and Clinical Quality Improvement | Bureau of Primary Health Care (

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