10.4 Quality Assurance

Part II: Guidelines for Client Services and Clinic Management


Delegate agencies must develop a quality assurance system that provides for the continued development and evaluation of their clinical and educational services and performance.

The quality assurance system must include written protocols and operating procedures and include the following:

  1. An approved health care plan that is based on an on-going community needs assessment specifying all services to be routinely provided by the delegate, as well as the additional services provided for specific population groups.
  2. A tracking system that identifies clients in need of follow-up and/or continuing care.
  3. Medical audits to determine conformity with the program guidelines, standards and current acceptable medical practice that are conducted on an on-going basis. The medical audits should include:
    • A review of a reasonable number of randomly selected medical records by the medical director at least once a month.
    • A review of a minimum of 20 medical records, per clinic site per month, by the quality assurance personnel. A minimum of five medical records from each clinician should be reviewed at this time.
    • Medical audits should address completeness and accuracy of the medical record
    • Topic-specific audits are strongly recommended.
  4. Annual performance evaluations for all family planning program staff, including the medical director.
  5. Ongoing peer review by the medical director of all physicians and mid-level practitioners is recommended. This should include evaluation of both clinical skills and documentation practices. Re-certification in a relevant area of practice constitutes evidence of maintaining current skills in the field.
  6. Annual update of clinic procedures and clinician protocol manuals reflecting current acceptable medical practices.
  7. Infection control policies and procedures reflecting CDC recommendations and current acceptable medical practice.
  8. A periodic patient flow analysis.
  9. Periodic client satisfaction surveys for input on services provided both on-site and by referral. Satisfaction must be evaluated annually at a minimum, with programmatic changes responsive to client feedback, as indicated.
  10. Regularly scheduled staff meetings, with minutes, to update and/or review medical or service delivery topics.
  11. Equipment maintenance checks and calibration of equipment conducted on a regular basis.
  12. Laboratory audits, including but not limited to the following:
    • Evidence of internal compliance with periodic laboratory proficiency testing procedures, according to the level of CLIA certification and/or tests being performed;
    • An annual review of credentials of contracted laboratories;
    • An annual pap test results audit, reviewing results of ACS or higher (refer to FPAR, Table 9 instructions); and
    • Routine monitoring for the accuracy of laboratory testing equipment and materials via the running of control tests; and
    • Evidence of staff skills in test performance.
  13. Annual review of educational materials used in both the clinic setting and community education activities.
  14. Annual review of all forms used by the delegate for completeness and applicability.
  15. Routine monitoring of critical incident/occurrence reports.
  16. Annual review of adequacy of provider liability insurance coverage.
  17. CPR certification of clinic staff, as appropriate.
  18. Documentation that drugs and supplies are checked routinely.
  19. A process for monitoring the reliability and accuracy of the local client data system and that the data system assures program performance, quality care, and maximizes program revenues. The following components should be monitored:
    • Missing user data
    • Coding error editing
    • Data outcome
  20. Annual external financial audit.
  21. Ongoing and systematic documentation of the quality assurance activities.

Delegate agencies should have a quality assurance committee in place. This committee should meet monthly/quarterly to discuss quality assurance issues and to make recommendations for corrective action when deficiencies have been noted.

  • If a formal quality assurance committee is in place, minutes should be kept of all quality assurance committee meetings.
  • An in-house nursing or medical advisory committee may assume the function of the quality assurance committee.

[Back to Section 10.0 for Navigation]