1. Structure
     a. Definition of quality

     b. Purpose (enhance health of patients, achieve vision of quality, establish excellence in processes, performance, decisions, etc.)

     c. Scope (primary care, dental, lab, administration, finance, etc.)

     d. Program accountabilities and responsibilities (governing board, CEO, providers, staff, medical director, director of quality, etc.)

     e. Organizational structure (governing board, board quality management committee, health center quality committee)

2. Components of Quality Management

     a. Quality assessment (suggestions for measures)

          - Indicator selection (UDS measures, patient satisfaction, access, quality of clinical care, cost, productivity, health status, outcomes, financials, coding, scheduling, etc.)

          - Indicator measurement

          - Indicator assessment

          - Indicator tracking

          - Indicator reporting (meeting minutes, report to board)
     b. Quality improvement
          - Model for Improvement (PDSA Cycle)
          - Chronic Care Model (healthcare system, community, self management support, delivery system design, clinical information systems, healthcare organization)
     c. Provider performance assessment and improvement
          - Clinical guidelines (evidence-based care)
          - Peer review and clinical guidelines audits
          - Provider performance improvement activity (integrate into overall quality program)
3. Additional considerations
     a. Utilization Management
     b. Credentialing, re-credentialing and privileging
     c. Risk Management (incident reports, sentinel events, infection control, lab quality control, patient safety, medication reconciliation)
     d. Health records (current, detailed, secure, enabiling of effective care, confidential, enabling of quality review, complete, systematic (use of registries/flow charts), accurate, reflective of all aspects of care, readily available to appropriate health care professionals, HIPAA compliant