As outlined in “Chapter 10 – Quality Improvement/Assurance” (Chapter 10 – QI/QA) of the Health Resources and Service Administration (HRSA) Health Center Program Compliance Manual, the health center must implement and maintain a Quality Improvement/Assurance (QI/QA) Program that addresses clinical services and clinical management metrics.  A key component of the QI/QA Program is the QI/QA Committee, which is responsible for operationalizing the quality initiatives outlined in the health center’s QI/QA Plan. While the HRSA Health Center Program Requirements do not specifically state how frequently the QI/QA Committee should meet, for the purposes of Federal Tort Claims Act (FTCA) Deeming, the committee must meet a minimum of six times per year.  Although Industry standard best practice supports meeting on a monthly basis, the health center’s QI/QA Plan should state the QI/QA Committee meets a minimum of six times per year, to avoid the risk of non-compliance if a meeting is canceled. 

Additionally, to ensure compliance with HRSA Health Center Program Requirements, the QI/QA Program must demonstrate the completion of quarterly assessments.  The results of these quarterly assessments must be presented to the QI/QA Committee for review, and QI/QA Committee Meeting Minutes must demonstrate the development of corrective plans of action to improve performance.  Once presented to the QI/QA Committee, the results of quarterly assessments must be presented to the health center’s Board of Directors to facilitate active discussion and decision-making on the part of key management staff, as well as the Board of Directors. 

Standard metrics that should be reported a minimum of quarterly include, but are not limited to the following:

• Uniform Data System (UDS) Clinical Performance Measures
• Tracking metrics for hospitalizations, referrals and laboratory/diagnostic tests
• Patient Satisfaction
• Patient Complaints, Grievances, Incidents and Adverse Events

It is at the discretion of the health center as to whether to incorporate Risk Management Metrics and initiatives into the health center’s QI/QA Program or to maintain a separate Risk Management Program. 

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).