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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:
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).