The Fundamentals of a Quality Improvement/Assurance Program

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, health centers must develop and implement a Quality Improvement/Assurance (QI/QA) Program.  The program must be applicable to all the services in scope that are listed on Form 5A and must address the monitoring of both clinical services and clinical management metrics.  To ensure compliance with HRSA Health Center Program Requirements and align with industry standard best practices, the health center’s QI/QA Program should include the following basics:

  • QI/QA Plan – Often referred to as the “QI/QA Policy,” the QI/QA Plan lays the foundation for the health center’s quality improvement initiatives.  Best practices support annual review of the plan, although HRSA Health Center Program Requirements only require review and approval every three years.  The QI/QA Plan must be approved by the health center’s Board of Directors.
  • QI/QA Workplan – Often referred to as the “QI Procedure” and “QI Project,” the QI/QA Workplan is a living, breathing document that reflects the organization’s quality activities for the current reporting period.  The QI/QA Workplan is frequently the driver for further analysis of specific metrics, as well as the implementation of Plan-Do-Study-Act (PDSA) cycles or a Root Cause Analysis (RCA). The QI/QA Workplan does not require approval by the health center’s Board of Directors.
  • QI/QA Policies – Although an overview of QI/QA Policies is typically included in the health center’s QI/QA Plan, to ensure compliance, the health center should develop individual QI/QA Policies in the following QI/QA and Risk Management areas:
    • Clinical Guidelines
    • Peer Review
    • Patient Satisfaction
    • Patient Complaints and Grievances
    • Incidents and Adverse Events

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). 

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