Whether preparing for your health center mock site visit or your actual HRSA Operational Site Visit (OSV), your FQHC will begin by gathering your documents. There are lists in the HRSA Site Visit Protocol as well as the HRSA Compliance Manual that can sometimes be a little confusing. One area in which we commonly get questions is in regards to the QI/QA Assessments.

QI/QA Assessments

When the Site Visit Protocol mentions “QI/QA Assessments” it’s often a little unclear as to what HRSA means. In some areas, these assessments are understood to be what we commonly refer to as “Peer Review” assessments. In other areas, these assessments are assumed to be reports on clinical performance metrics like the UDS metrics of Hypertension Control or Childhood Immunizations. So, what do we need to prepare?

Let’s review the different areas within the Site Visit Protocol that mention these assessments.

In the Clinical Staffing Chapter, the Site Visit Protocol asks, “Does the health center have criteria and processes for modifying or removing privileges based on the outcomes of clinical competence assessments?” (Chapter 5: Clinical Staffing, Element d.8.).

In the QI/QA Chapter, the SVP notes that health centers should submit for review:

  • QI/QA-related operating procedures or processes that address periodic QI/QA assessments
  • Sample of two QI/QA assessments from the past year and/or the related reports resulting from these assessments
  • Schedule of QI/QA assessments (Chapter 10: QI/QA, Documents For Review)

It then asks, “Based on the interview(s) and review of the job/position description(s) or other documentation, do the responsibilities of this individual(s) include ensuring QI/QA assessments are conducted?” (Chapter 10: QI/QA, Element b.3.)

Does the health center have operating procedures and/or related systems that address completion of periodic QI/QA assessments on at least a quarterly basis? (Chapter 10: QI/QA, Element c.4.).

Quarterly Assessments of Clinician Care (Peer Review)

Element d. is labeled “Quarterly Assessments of Clinician Care” and asks,

  • “Are the health center’s QI/QA assessments conducted by physicians or other licensed health care professionals (such as nurse practitioner, registered nurse, or other qualified individual) on at least a quarterly basis?” (Chapter 10: QI/QA, Element d.7.)
  • “Are these QI/QA assessments based on data systematically collected from patient records?” (Element d.8.).
  • “Do these assessments demonstrate that the health center is tracking and, as necessary, addressing issues related to the quality and safety of the care provided to health center patients (e.g., use of appropriate medications for asthma, early entry into prenatal care, HIV linkages to care, response initiated as a result of a recent adverse event)?” (Element d.9.)

And then finally, the SVP chapter named “Program Monitoring and Data Reporting” asks, “Based on your review of board minutes, other relevant documents, and interviews conducted with the Project Director/CEO and board members, were there examples of how the board evaluates the performance of the health center based on quality assurance/quality improvement assessments and other information received from health center management?” (Chapter 18: Program Monitoring and Data Reporting, Element c.7.).

Documentation of HRSA Compliance

So, after looking at all these areas, we recommend preparing the following documentation of your compliance:

  • JOB DESCRIPTION - Job Description of QI/QA Director whose responsibilities include ensuring QI/QA assessments are conducted (Chapter 10: QI/QA, Element b.3.). A best practice would be to simply take this language directly out of the SVP and include in the job description of whomever you indicate is in charge of your QI Program.
  • POLICY/PROCEDURE - A policy (possibly in the health center’s Credentialing and Privileging Policy) that describes the criteria and processes for modifying or removing privileges based on the outcomes of clinical competence assessments (Ch 5, d.8.). The health center should define and describe what those clinical competence assessments are and a best practice recommendation would be to tie these clinical competence assessments to “Peer Review” or the “Quarterly Assessments of Clinician Care”.
  • POLICY/PROCEDURE - Operating procedures and/or related systems that address completion of periodic QI/QA assessments on at least a quarterly basis (Chapter 10: QI/QA, Element c.4.). In Element c., the description seems to refer to assessments that inform the modification of the provision of health center services, as appropriate and producing and sharing reports on QI/QA to support decision-making and oversight by key management staff and by the governing board regarding the provision of health center services. There should also be language in the policy that clearly states that these assessments are shared with the Board of Directors so that the board may evaluate “the performance of the health center based on quality assurance/quality improvement assessments and other information received from health center management?” (Chapter 18: Program Monitoring and Data Reporting, Element c.7.).
  • POLICY/PROCEDURE - QI/QA-related operating procedures or processes that address periodic QI/QA assessments (Ch 10, Documents For Review). In Element d. Quarterly Assessments of Clinician Care, the SVP states this is one of the documents to be reviewed. This is generally assumed to be the Peer Review Policy. This policy should clearly state that, “The health center’s QI/QA assessments are conducted by physicians or other licensed health care professionals (such as nurse practitioner, registered nurse, or other qualified individual) on at least a quarterly basis?” (Chapter 10: QI/QA, Element d.7.); That “These QI/QA assessments are based on data systematically collected from patient records?” (Element d.8.); and, that “These assessments demonstrate that the health center is tracking and, as necessary, addressing issues related to the quality and safety of the care provided to health center patients (e.g., use of appropriate medications for asthma, early entry into prenatal care, HIV linkages to care, response initiated as a result of a recent adverse event).” (Element d.9.).
  • SAMPLE - Sample of two QI/QA assessments from the past year and/or the related reports resulting from these assessments (Ch 10, Documents For Review). In Element d. Quarterly Assessments of Clinician Care, the SVP states this is to be reviewed. So this is generally assumed to be the samples of peer review as outlined in the health center’s Peer Review Policy.
  • SAMPLE - Schedule of QI/QA assessments (Chapter 10: QI/QA, Documents For Review). In Element d. Quarterly Assessments of Clinician Care, the SVP states this is to be reviewed. So, this is generally assumed to be a schedule or calendar indicating when peer review is to be completed. A best practice recommendation would be to make a list or calendar indicating the dates of each quarterly assessment, the areas of service assessed (should cover all areas in-scope.

Please reference you’re the most recent version of the HRSA Compliance Manual (https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html) or the HRSA Site Visit Protocol (https://bphc.hrsa.gov/programrequirements/svprotocol.html).