2700, Quality Management

Revision 24-2; Effective Sept. 20, 2024

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 services. Grantees must be able to meet the management standards per 2 Code of Federal Regulations Part 200.

QA/QI processes are intended to:

• improve screening and diagnostic services;
• link structure and process and include standards, measurement and actions;
• identify and remedy root causes of quality problems;
• meet client needs; and
• focus on high-volume, costly, high-risk or problem-prone aspects of care.

These aims are achieved by assessing performance, making changes based on the assessment and monitoring improvement. Steps to QA/QI include:

• Quality monitoring – The BCCS performance indicators are designed specifically for this purpose and represent aspects of care that align with the purpose of the NBCCEDP.
• Quality assessment – Assessing quality provides organizations with an opportunity to measure performance against standards, such as targets or benchmarks. Quality assessment creates a bridge between monitoring and improvement by establishing a common understanding of the quality of services provided and identifying opportunities for improvement.
• Quality improvement – QI strives to find strategies that will institute a change and continuously improve quality.

A Quality Management (QM) program must be developed and implemented that provides for ongoing evaluation of services. Grantees should have a comprehensive 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 services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subrecipients.

The QM Committee, whose membership consists of key leadership of the organization, includes the executive director, chief executive officer or both; the medical director; and other appropriate staff where applicable, annually reviews and approves the quality work plan for the organization.

2710 Quality Management (QM) Committee

Revision 23-2; Effective Sept. 29, 2023

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; and
• reassess outcomes and goal achievement.

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

2720 Comprehensive Quality Work Plan

Revision 22-0; Effective August 15, 2022 

The comprehensive quality work plan, at a minimum, must:

• include clinical and administrative standards by which services will be monitored;
• include a process for credentialing and peer review of clinicians;
• identify those responsible for implementing, monitoring, evaluating and reporting;
• establish timelines for quality monitoring activities;
• identify tools and forms to be used; and
• outline reporting to the QM Committee.

2730 Quality Assurance Activities

Revision 25-3; Effective Sept. 1, 2025

Although each organization’s quality assurance program is unique, the following activities must be undertaken by all agencies providing client services:

• ongoing eligibility, billing and clinical record reviews to ensure compliance with program requirements and clinical standards of care;
• utilization review;
• tracking and reporting of 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) for mid-level providers;
• annual review of all standing delegation orders and clinical protocols used;
• annual review of all policies and forms;
• up-to-date performance evaluations that include primary license verification, Drug Enforcement Administration, and immunization status; and
• clearly noted review or revision date on each policy, form, agreement or order used.

2740 Subrecipient Quality and Compliance

Revision 25-3; Effective Sept.1, 2025

Grantees who subcontract with subrecipients to provide services must also address how quality is evaluated and how compliance with policies and basic standards is assessed with the subrecipient. This includes at a minimum:

• annual license and certification verification which is the primary source verification;
• clinical record review;
• billing and eligibility review;
• utilization review;
• facility on-site review;
• annual client satisfaction evaluation process; and
• child abuse training and reporting.

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 committee and should be documented.

2750 Clinical Quality Assurance

Revision 25-3; Effective Sept.1, 2025

Ambulatory Surgical Centers

Ambulatory surgical centers providing services must be Centers for Medicare and Medicaid Services (CMS) certified, state-licensed and Joint Commission-accredited, as applicable. Review the HHS Ambulatory Surgical Centers website for more information.

Mammography Quality Assurance

All grantees and subrecipients that provide mammography services must:

• possess a current Certification of Mammography Systems from each mammography unit who must be fully accredited or undergoing accreditation; and
• possess a current mammography facility certificate from the appropriate agency certifying compliance with the U.S. Food and Drug Administration Mammography Quality Standards, at 21 CFR Part 900.

The Mammography Radiation Control Program may be contacted for certification questions and information on inspection results, escalated enforcement or cease and desist status.

Cytology Quality Assurance

Grantees and subrecipients that provide screening and diagnostic cytology services must have current documentation that shows the agency meets all quality assurance standards required by the BCCS program under state and federal laws.

All cytology laboratories that provide services to grantees and subrecipients must:

• possess a current, unrevoked and unsuspended registration certificate issued by the U.S. Department of Health and Human Services per the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88) (42 U.S.C. Section 263a); and
• have a mechanism for expedited notification of Pap tests which are CIN III or greater, such that the clinic is notified by the next business day after the case is signed out.

Human Papillomavirus (HPV) Quality Assurance

Grantees must assure all HPV tests are:

• for high-risk oncogenic types; and
• FDA approved and clinically validated.

Utilization Review

To make sure clients receive high-quality care and funds are expended per program policies, BCCS performs utilization review of billed services. Grantees not in compliance with billing guidelines may be required to refund the BCCS program for services inappropriately billed.