3900, Quality Management

Revision 22-2; Effective April 1, 2022

Contractors must use internal quality assurance and quality improvement (QA/QI) systems and processes to monitor HHSC FPP services. Contractors must have a quality management (QM) program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care. 

Contractors should integrate QM concepts and methods into the structure of the organization and day-to-day operations. 

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

  • The client;
  • Systems and processes;
  • Measurement; and
  • Teamwork.

The QM program must be developed and implemented in such a way that provides for ongoing evaluation of services. Contractors 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.

Contractors must have a QM program individualized to their organizational structure and based on the services provided. The goals of the quality program should ensure availability and accessibility of services, quality and continuity of care.

Contractors who subcontract for the provision of services must also address how quality will be evaluated and how compliance with HHSC policies and basic standards will be assessed with the subcontracting entities.

An important part of the QM program is the QM committee, whose membership consists of key leadership of the organization, including the executive director or chief executive officer, medical director and other appropriate staff, where applicable, must annually review and approve a quality work plan for the organization.

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.

Minutes of the discussion, actions taken by the committee and a list of the attendees must be maintained and made available during QA/QI reviews.

The comprehensive quality work plan must:

  • Include clinical and administrative standards by which services will be monitored;
  • Include the process for credentialing and peer review of clinicians;
  • Identify individuals 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.

Although each organization’s QM 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;
  • Annual review of facilities to maintain a safe environment, including an emergency safety plan;
  • Annual review of prescriptive authority agreements (PAAs), policies, clinical protocols and standing delegation orders (SDOs) to ensure they are current; and
  • Performance evaluations to include primary license verification, drug enforcement administration and immunization status to ensure they are current.

HHSC contractors 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 subcontracting entities including:

  • Annual license verification (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 for subcontractor staff.

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.