Quarterly Compliance Article – Utilizing Benchmarks in Quality Improvement/Quality Assurance Programs

Quality Improvement/Quality Assurance (QI/QA) Programs are designed to continuously monitor and improve healthcare processes, with the ultimate goal of leading to better patient outcomes. In Community Health Centers (CHCs), where the focus is on providing services to vulnerable populations, the importance of these programs is increased. Through the development of a robust QI/QA framework, CHCs can not only meet the regulatory requirements monitored by the Health Resources and Services Administration (HRSA), but also address disparities, improve patient satisfaction, and facilitate the delivery of high-quality patient care. 


One key strategy to enhancing quality of care is the utilization of standard benchmarks.  These benchmarks serve as reference points or targets that CHCs can use to assess their performance and measure it against established industry standards. These benchmarks are typically evidence-based metrics that reflect best practices in healthcare. Some common areas where standard benchmarks are applied in CHC programs include:


  • Clinical Quality Measures – These measures evaluate the effectiveness, safety and efficiency of healthcare services.  Examples include, but are not limited to, hypertension, diabetes and coronary artery disease, as well as preventive care services.
  • Chronic Disease Measures – These measures evaluate adherence to clinical guidelines and the effectiveness of managing chronic conditions and comorbidities.
  • Screening and Prevention Measures – These measures help to ensure patients receive the necessary preventive care and screenings such as immunizations, various cancer screenings and well child visits. 
  • Access to Care Measures – These measures evaluate timely access to care for patients, appointment wait times and the availability of access to extended hours and after-hours care.
  • Patient Satisfaction Surveys – Surveys evaluate feedback received from patients to measure satisfaction with care, provider and staff communication, and the overall patient experience. 


Common state and national benchmarks utilized by CHCs include the following:


  • Uniform Data System (UDS) – UDS is the standardized reporting system utilized by HRSA that provides comprehensive data on the services provided by CHCs. UDS includes performance measures related to access to care, quality of care and financial performance.  Data is collected on an annual basis and released at the health center, state and national levels.
  • Healthy People 2030 Objectives – Healthy People is a set of national health goals and objectives often used by CHCs and included in Quality Improvement Programs. 
  • Centers for Medicare and Medicaid Services (CMS) Core Set Measures – CMS establishes core sets of metrics that CHCs report on to assess the quality of care provided to specific payor beneficiaries. Many of the aforementioned UDS metrics are aligned with CMS Core Set Measures. 


Utilizing benchmarks as a quality tool involves a conscious and continuous effort to do the following:


  • Measure outcomes;
  • Compare outcomes with other community health centers, as well as state and national averages;
  • Determine how outcomes were achieved; and
  • Use “lessons learned” to implement corrective plans of action and improve. 


To implement effective benchmarking, health centers must ensure data is useful, reliable and up-to-date. Additionally, it is important for CHCs to select benchmarks that are relevant to the target population, service delivery and organizational goals. Resources for benchmarks can be found at (HRSA UDS Data) and (Healthy People 2030). 

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