A quality improvement program build is the work of writing an organization's documented QI program: the QI program description, the annual QI work plan and the annual QI evaluation, with the committee structure and procedures that connect them. It is for plans, PBMs, pharmacies and provider organizations that must run a documented QI program. Integral Healthcare Solutions (IHS) drafts the program documents for your quality and clinical leaders to review and approve, mapped to each QI requirement in the texts that govern you.
Last reviewed: October 2026.
What is a quality improvement program build?
It is a set of program documents written to the QI requirement in whichever text governs the organization. The texts IHS works from, read in their current versions in October 2026:
- Medicare Advantage, 42 CFR 422.152: "Each MA organization that offers one or more MA plan must have, for each plan, an ongoing quality improvement program that meets applicable requirements of this section for the service it furnishes to its MA enrollees" (42 CFR 422.152(a)). The plan must "Create a quality improvement program plan that sufficiently outlines the elements of the plan's quality improvement program" (422.152(a)(1)).
- Medicaid managed care, 42 CFR 438.330: "The comprehensive quality assessment and performance improvement program described in paragraph (a) of this section must include at least the following elements: (1) Performance improvement projects in accordance with paragraph (d) of this section. (2) Collection and submission of performance measurement data in accordance with paragraph (c) of this section. (3) Mechanisms to detect both underutilization and overutilization of services" (42 CFR 438.330(b)).
- Hospitals, 42 CFR 482.21: "The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program" (42 CFR 482.21).
- Health centers, HRSA Health Center Program Compliance Manual, Chapter 10: Quality Improvement/Assurance: "The health center must have an ongoing quality improvement/assurance (QI/QA) system that includes clinical services and [clinical] management and maintains the confidentiality of patient records" (HRSA Compliance Manual, Chapter 10).
Accreditor standards (URAC, ACHC, NABP and others) sit in manuals the organization buys. This page does not quote them; IHS maps the build to the manual you hold.
The three core documents do different jobs. The QI program description states scope, authority, structure, committee, data sources and confidentiality. The annual QI work plan lists the measures, owners, targets and reporting dates for the year. The annual QI evaluation looks back at the year's results. For MA plans the evaluation is required: "For each plan, there must be in effect a process for formal evaluation, at least annually, of the impact and effectiveness of its quality improvement program" (42 CFR 422.152(f)(2)).
Who needs it and what triggers it
Any organization whose governing text requires a QI program needs it written down. Common triggers:
- A Medicare Advantage plan without a QI program plan that "sufficiently outlines the elements" of the program, or without an annual evaluation process (42 CFR 422.152).
- A Medicaid managed care plan whose program lacks one of the 438.330(b) elements: performance improvement projects, performance measurement data, or mechanisms to detect under- and overutilization (42 CFR 438.330(b)).
- A health center without "a board-approved policy(ies) that establishes a QI/QA program," or without "periodic QI/QA assessments on at least a quarterly basis" (HRSA Compliance Manual, Chapter 10, Demonstrating Compliance).
- A hospital whose QAPI program is not hospital-wide and data-driven as 42 CFR 482.21 states (eCFR).
- An organization preparing for an accreditor whose standards require a QI program.
How IHS helps
IHS drafts the program documents for your quality and clinical leaders to review and approve. The process:
- Gap assessment of your current QI documents against each governing text you name: contracts, regulations and accreditor manuals.
- Questionnaires that collect your operating facts: committee membership, data sources, current reports.
- Document and evidence mapping: a crosswalk from each QI requirement to the document and record that meets it.
- Drafting the QI program description; quality committee charter, agenda and minutes templates; the annual QI work plan; performance improvement project templates; procedures for data collection, complaint and incident trending, under- and over-utilization review, and corrective action; the annual QI evaluation template; board or governing-body reporting templates; and staff training material. Facts only you can supply are marked as open items.
- Mock review of the drafted program against the governing texts.
- Readiness support: a work plan for the first program year and training for committee members and staff.
What you supply
Your governing texts (contracts and the accreditor manuals you hold), current data and reports, committee roster and current policies.
Who decides what
Your clinical and quality leaders choose the measures and targets. Your committee runs the meetings. Your board approves the program where your governing texts or bylaws call for it.
The limit
IHS does not run the committee, collect or certify the data, or select clinical measures. The first annual evaluation needs a year of your own operating data, so the evaluation template is drafted at the start and completed by your staff at year end.
What to have ready
Gather what exists; missing items become part of the build.
- The list of texts that require your QI program: regulations, contracts and accreditor manuals. Each one sets its own elements (422.152, 438.330, 482.21, HRSA Chapter 10).
- For MA plans: your current QI program plan (42 CFR 422.152(a)(1)).
- For MA plans: your most recent formal evaluation of the program's impact and effectiveness (42 CFR 422.152(f)(2)).
- For Medicaid managed care: your current performance improvement projects (42 CFR 438.330(b)(1)).
- For Medicaid managed care: the performance measurement data you collect and submit (42 CFR 438.330(b)(2)).
- For Medicaid managed care: how you detect underutilization and overutilization today (42 CFR 438.330(b)(3)).
- For hospitals: the data sources your QAPI program draws on across the hospital (42 CFR 482.21).
- For health centers: the board-approved QI/QA policy and your QI/QA assessments completed on at least a quarterly basis (HRSA Compliance Manual, Chapter 10).
- Your quality committee roster and its last year of minutes.
Bring whatever you have to the introductory call; the gaps on this list are where the build starts.
How it compares
The QI requirement differs by governing text. One program can be written to meet several texts when the crosswalk shows which document carries each element. The table below compares the elements quoted on this page; it is not a full summary of any text.
| Text | Who it governs | Elements quoted on this page |
|---|---|---|
| 42 CFR 422.152 | Medicare Advantage organizations | An ongoing QI program for each plan; a QI program plan; formal evaluation at least annually. |
| 42 CFR 438.330 | Medicaid managed care plans | Performance improvement projects; performance measurement data; mechanisms to detect under- and overutilization. |
| 42 CFR 482.21 | Hospitals | An effective, ongoing, hospital-wide, data-driven QAPI program. |
| HRSA Compliance Manual, Chapter 10 | Health centers | An ongoing QI/QA system; a board-approved QI/QA policy; quarterly QI/QA assessments. |
| Accreditor standards (URAC, ACHC, NABP and others) | Organizations seeking that accreditation | Not quoted here; mapped from the manual you hold. See Accreditation Consulting. |
Building the QI program and earning accreditation are separate pieces of work: the build writes the program, and an accreditor decides whether an existing program meets its standards. See also the Program Development practice line.
What it costs
Fees depend on scope. IHS scopes each engagement after a free introductory call.
What this is not
- This page is not legal advice, and IHS does not give an opinion on which texts govern your organization. Your counsel does.
- IHS does not run your quality committee, collect or certify your data, or choose your clinical measures.
- IHS does not file anything with CMS, HRSA, a state or an accreditor, and does not guarantee any reviewer's finding. IHS drafts; your organization adopts the program and runs it.
Frequently asked questions
What has to be in a QI program description?
It sets out the program's scope, authority, structure, committee, data sources and confidentiality, and it has to cover the elements your governing text lists. For Medicare Advantage, 42 CFR 422.152(a)(1) requires a QI program plan that sufficiently outlines the elements of the plan's QI program. IHS drafts the description and maps each element to its source.
What is the difference between a QI program description, a QI work plan and an annual QI evaluation?
The program description sets the structure and rules of the program. The work plan lists the year's measures, owners, targets and reporting dates. The evaluation looks back at the year and judges the program's impact and effectiveness.
How often must a QI program be evaluated, and who approves the evaluation?
For Medicare Advantage, 42 CFR 422.152(f)(2) requires a process for formal evaluation, at least annually, of the impact and effectiveness of the QI program. For health centers, HRSA's Chapter 10 describes QI/QA assessments on at least a quarterly basis. Who approves the evaluation is set in your program description. HRSA's Chapter 10 calls for a board-approved QI/QA policy for health centers.
Who should sit on the quality committee, and what do its minutes need to show?
Your leaders name the members. IHS drafts a committee charter, agenda and minutes templates, laid out so the minutes record what each governing text asks the committee to review and decide.
How do we choose measures and performance improvement projects?
Your clinical and quality leaders choose the measures and targets. For Medicaid managed care, 42 CFR 438.330(b) requires performance improvement projects and the collection and submission of performance measurement data. IHS drafts the work plan and project templates those choices go into.
What QI requirements apply to a Medicare Advantage plan versus a Medicaid managed care plan?
42 CFR 422.152 requires each MA plan to have an ongoing QI program, a QI program plan and an annual formal evaluation. 42 CFR 438.330(b) requires Medicaid managed care programs to include performance improvement projects, performance measurement data, and mechanisms to detect both underutilization and overutilization of services.
What does HRSA expect a health center's QI/QA program to include?
Chapter 10 of the HRSA Health Center Program Compliance Manual requires an ongoing QI/QA system that includes clinical services and management and maintains the confidentiality of patient records. Its Demonstrating Compliance section lists a board-approved policy that establishes a QI/QA program and periodic QI/QA assessments on at least a quarterly basis.
How do we connect complaints, incidents and utilization data to the QI program?
IHS drafts procedures for data collection, complaint and incident trending, under- and over-utilization review, and corrective action, each feeding the committee's agenda and the annual evaluation. For Medicaid managed care, mechanisms to detect under- and overutilization are a required element under 42 CFR 438.330(b).
Can one QI program satisfy several accreditors and regulators at once?
One program can be written to several texts when an evidence map shows which document and record carries each requirement. IHS builds that map. Whether a reviewer accepts the program is decided by that reviewer.
How long does it take to build a QI program and run the first cycle?
The documents can be drafted before the program year starts, but the first annual evaluation needs a year of your operating data. IHS sets the drafting schedule in a work plan after the introductory call.