Quarterly Compliance Article – Basics for Developing a Quality Improvement / Quality Assurance Program

The Health Services and Resources Administration (HRSA) requires health centers to develop and implement a comprehensive board approved Quality Improvement/Quality Assurance (QI/QA) Program. To be effective and improve the performance of the health center’s clinical and operational systems, the QI/QA Program must have many components.  Industry standard best practices demonstrate the basic foundation of a high performing QI/QA Program consists of the following:

QI/QA Plan – The QI/QA Plan is an overarching organizational framework utilized by the health center to outline the organization’s clinical service and clinical management quality improvement initiatives.  The document encompasses all services in the health center’s scope of project and provides the mission, purpose, reporting structure, committee composition, goals and objectives and defines the role of the Board of Directors.  The QI/QA Plan is often referred to as the “QI/QA Policy”; therefore, requires approval by the health center’s Board of Directors.  The QI/QA Plan is typically reviewed annually, although is only required to be reviewed, revised and reapproved at least every three years. 

QI/QA Work Plan – The QI/QA Plan is a working document that reflects the health center’s specific quality activities for the current reporting year.  As with the QI/QA Plan, the QI/QA Work Plan must encompass both clinical service and clinical management metrics for all services in scope.  An effective QI/QA Work Plan should include the following:

  • Established metrics, including those that address any special populations served by the health center
  • Numerator and denominator
  • Pre-defined benchmarks
  • The goal included in the most recent Service Area Competition (SAC) Application
  • Source of data collection
  • Reporting frequency 

The QI/QA Work Plan is often referred to as the “QI/QA Procedure” or “QI Project”; therefore, the document does not require approval by the health center’s Board of Directors.  The document is meant to be fluid and change throughout the course of the year, depending on the progress made by the health center, as well as any new issues identified.  Using the QI/QA Work Plan, the health center can determine what metrics require the implementation of a Plan-Do-Study-Act (PDSA) or Root Cause Analysis (RCA) to determine the most effective methods for improving outcomes.  

QI/QA Policies – Although the QI/QA Plan outlines the framework for the organization’s quality initiatives, health centers should develop specific QI/QA Policies and Procedures to outline the process and ensure compliance in the following areas:  

  • Clinical Guidelines
  • Peer Review
  • Patient Satisfaction
  • Patient Complaints and Grievances
  • Incidents and Adverse Events


Some key points to remember include:

  • The Risk Management Committee can be managed as a sub-committee of the QI/QA Committee.  
  • Risk Management Metrics can be reported through the QI/QA Committee. 
  • The QI/QA Plan should state the QI/QA Committee meets a minimum of six times per year. Stating the QI/QA Committee meets monthly places the health center at risk for non-compliance if a meeting is missed.  There is no harm in meeting more frequently. 
  • QI/QA Meeting Minutes must reflect active discussion, include the identification of action items, and the assignment of responsibility and timelines. 
  • QI/QA Meeting Minutes must reflect the presentation and discussion of data to support the purpose of management decision making. 


To ensure compliance with HRSA Health Center Program Requirements, health centers should follow the guidance outlined in the HRSA Health Center Compliance Manual (Chapter 10 – QI/QA) and HRSA Site Visit Protocol (QI/QA – Site Visit Protocol).  Additional resources for Quality Improvement initiatives, as well as how to conduct a Plan-Do-Study-Act and Root Cause Analysis, can be found by accessing ECRI (ECRI | Trusted Voice in Healthcare).

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