Revision 26-2; Effective Sept. 1, 2026

Quality Assurance and Quality Improvement (QA/QI) support the quality of clinical service delivery. Grantees must use internal QA/QI systems and processes to monitor PHC services. Grantees must have a Quality Management (QM) program tailored to their organizational structure and the services they provide. The goals of the quality management program should ensure availability and accessibility of services, quality and continuity of care. Grantees should integrate QM concepts and methodologies into the organization’s structure and day-to-day operations.

Grantees are expected to develop quality processes based on four core QM principles that focus on:

• the client
• systems and processes
• measurement
• teamwork

The QM program must be developed and implemented in a way that provides for the ongoing evaluation of services. Grantees should have:

• a comprehensive quality work plan for the internal review, measurement and evaluation of services,
• the analysis of monitoring data, and
• the development of strategies for improvement and sustainability.

Grantees who subcontract to provide PHC services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with subrecipients.

3810 QM Committee

Revision 26-2; Effective Sept. 1, 2026

The committee is an important part of the QM program. The committee’s membership consists of the organization’s key leadership, including the:

• executive director or CEO
• medical director
• dental director
• other appropriate staff where applicable

The committee must review and approve a quality work plan for the organization annually.

The QM Committee must meet at least quarterly to:

• receive reports of monitoring activities
• make decisions based on the analysis of data collected
• determine quality improvement actions to be implemented
• reassess outcomes and goal achievement

Meeting dates, a list of the attendees and minutes of the discussion and actions taken by the committee must be maintained.

3820 Comprehensive Quality Work Plan

Revision 26-2; Effective Sept. 1, 2026

The comprehensive quality work plan must:

• be reviewed annually
• include clinical and administrative standards to monitor services
• include a process for credentialing and peer review of clinicians
• identify personnel responsible for implementing, monitoring, evaluating and reporting
• establish timelines for quality management activities
• identify tools and forms to be used
• outline reporting to the QM Committee

3830 Quality Assurance Activities

Revision 26-2; Effective Sept. 1, 2026

Although each organization’s QM program is unique, the following activities must be undertaken by all agencies that provide client services:

• ongoing eligibility, billing and client record reviews to ensure compliance with program requirements and clinical standards of care;
• utilization review;
• defining, reporting, tracking and following up on adverse outcomes;
• client satisfaction surveys and reporting of survey data to HHSC in the frequency, manner and format defined by HHSC;
• annual review of facilities to maintain a safe environment, including an emergency safety plan;
• annual review and update of all prescriptive authority agreements (PAAs), including protocols, for mid-level providers;
• annual review of all standing orders (SOs) and clinical protocols;
• up-to-date performance evaluations to include primary license verification, valid Drug Enforcement Agency (DEA) number, as applicable, and other required licenses or certifications; and
• annual review of all policies and forms.

The review or revision date must be clearly noted on each policy, form, agreement and order that is in use.

3840 Subrecipient Quality and Compliance

Revision 26-2; Effective Sept. 1, 2026

Grantees who subcontract for the provision of services must also address how quality will be evaluated and how compliance with policies and basic standards will be assessed with the subrecipient. This includes:

• annual license verification or the primary source verification
• clinical record review
• eligibility and billing review
• utilization review
• on-site facility review
• annual client satisfaction evaluation process
• compliance with all abuse and neglect, and civil rights requirements

Data from these activities must be presented to the QM Committee. Plans to improve quality should result from the data analysis and reports considered by the QM Committee and should be documented.