3800, Quality Management

Revision 23-2; Effective Sept. 15, 2023

Grantees must use internal Quality Assurance/Quality Improvement (QA/QI) systems and processes to monitor PHC services. Grantees 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.

Grantees should integrate QM concepts and methodologies into the structure of the organization 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; and
  • teamwork.

The QM program must be developed and implemented in such a way 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 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  subgrantees.

The QM Committee, whose membership consists of key leadership of the organization, including the executive director or CEO, medical director, dental director and other appropriate staff, where applicable, annually reviews and approves the 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 and actions taken by the committee and a list of the attendees must be maintained.

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

  • be reviewed annually;
  • include clinical and administrative standards by which services will be monitored;
  • include a process for credentialing and peer review of clinicians;
  • identify individuals responsible for implementing monitoring, evaluating and reporting;
  • establish timelines for QM 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;
  • client satisfaction surveys;
  • 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 (SDOs) and clinical protocols; and
  • annual review of all policies and forms.
  • defining, reporting, tracking and follow-up of adverse outcomes;
  • annual performance evaluations to include primary license verification, valid Drug Enforcement Agency (DEA) number, as applicable, and other required licenses or certifications.


The review or revision date must be clearly noted on each policy, form, agreement, order, etc. used.

HHSC 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 subcontracting entities, including:

  • annual license verification (primary source verification);
  • clinical record review;
  • eligibility and billing review;
  • on-site facility review;
  • annual client satisfaction evaluation process; and
  • 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 committee and should be documented.