A Ryan White clinical quality management (CQM) program is the quality structure HRSA's HIV/AIDS Bureau requires of Ryan White HIV/AIDS Program (RWHAP) Part A, B, C and D recipients under Policy Clarification Notice (PCN) 15-02: a written plan, performance measures, quality improvement activity and oversight of subrecipients. This page is for recipients, subrecipients and HIV service organizations that are implementing an award, bringing subrecipients into a recipient's program, or giving an existing quality effort an operating structure. Integral Healthcare Solutions (IHS) builds the clinical quality management plan and oversight procedures to PCN 15-02; your HIV clinicians choose the measures.

Last reviewed: October 2026.

What is a Ryan White clinical quality management program?

The governing text is HRSA HIV/AIDS Bureau, "Clinical Quality Management Policy Clarification Notice (PCN) #15-02," updated September 1, 2020, which replaced Policy Notice 11-04 (PCN 15-02). HRSA's RWHAP policy notices index still lists 15-02 with a companion FAQ document (HRSA policy notices). The PCN cites Title XXVI of the Public Health Service Act, sections 2604(h)(5), 2618(b)(3)(E), 2664(g)(5) and 2671(f)(2). Your notice of award terms sit on top of it.

The PCN applies to "Health Resources and Services Administration (HRSA) HIV/AIDS Bureau (HAB) Ryan White HIV/AIDS Program (RWHAP) Parts A, B, C, and D" (PCN 15-02). It names three parts of a CQM program: "These necessary components are Infrastructure, Performance Measurement and Quality Improvement."

The core document is the plan. PCN 15-02 describes it as "A clinical quality management plan that describes all aspects of the CQM program including infrastructure, priorities, performance measures, quality improvement activities, action plan with a timeline and responsible parties, and evaluation of the CQM program" (PCN 15-02).

The PCN also sets working expectations:

• Measures: "Recipients should identify at least two performance measures for the RWHAP service categories ... where greater than or equal to 50% of the recipients' eligible clients receive at least one unit of service."
• Data: "Recipients should have an established process to collect and analyze (e.g. calculate the numerator, denominator, and percentage) performance measure data at least quarterly."
• Improvement: "Recipients should conduct quality improvement activities within at least one funded service category at any given time."

Who needs it and what triggers it

Any RWHAP Part A, B, C or D recipient is covered, and the obligations reach subrecipients through the recipient. The PCN says "It is the responsibility of the RWHAP recipient to work directly with their subrecipients to provide overall direction and to implement, monitor and exchange any needed data for performance measure data and/or quality improvement activities" (PCN 15-02). Common triggers:

• A new or changed award. The award terms set the recipient's obligations, and the CQM plan has to match them.
• Adding or integrating subrecipients. "Recipients need to ensure that their subrecipients that provide services have the capacity to contribute to the recipient's CQM program, have the resources to conduct CQM activities in their organizations, and implement a CQM program in their organizations, as identified in the written agreements between the recipient and subrecipient" (PCN 15-02).
• A quality effort that runs without a written plan, a quarterly data process or a documented improvement project, which are the elements the PCN describes.
• Budget review for Part A and Part B, where CQM costs are capped (see the cost section below).

How IHS helps

IHS works through a fixed process against the text of PCN 15-02 and your award:

1. Gap assessment. IHS compares your current quality program with each element of PCN 15-02, using questionnaires on measures, committees and subrecipients.
2. Document and evidence mapping. Each PCN element is tied to the document or record that shows it, including where subrecipient agreements carry the CQM duties.
3. Drafting. IHS drafts the clinical quality management plan, a committee charter and minutes templates, a measure ownership table, the subrecipient oversight procedure and quality improvement project templates. Clinical content goes to your HIV clinicians to review and approve.
4. Mock review. IHS runs a mock site-visit review of the plan, the data process and the records against the PCN.
5. Readiness support. IHS revises the drafts after the mock review and helps your team keep the records current.

What you supply: the award terms, current measures and data, the HIV clinicians who select clinical measures, and your subrecipient agreements.

The limit: measure selection and care standards are your clinicians' call. Award type changes the obligations (Part A and B carry a cost cap that Parts C and D do not), so the scope follows your actual award.

What to have ready

Gather these before the first working session. Each item ties to PCN 15-02 (updated September 1, 2020, HRSA) or to your award.

• Your notice of award and its terms, which govern alongside the PCN.
• Your current clinical quality management plan, or notes toward one, checked against the PCN's list: "infrastructure, priorities, performance measures, quality improvement activities, action plan with a timeline and responsible parties, and evaluation of the CQM program."
• A description of your CQM infrastructure (committee, roles, meeting records), the first of the PCN's three "necessary components."
• Service category utilization data, so you can see which categories reach "greater than or equal to 50% of the recipients' eligible clients."
• Your current performance measures, at least two for each such category.
• Your process to "collect and analyze ... performance measure data at least quarterly," with the last four quarters of results if you have them.
• Records of current quality improvement activity, since the PCN expects it "within at least one funded service category at any given time."
• Each written subrecipient agreement, read for the CQM capacity, resources and program duties the PCN says those agreements identify.
• How you exchange performance and improvement data with subrecipients, the recipient responsibility the PCN describes.
• For Part A and Part B, a breakdown of CQM costs against the cap, with grant administration activities such as "monitoring of subrecipients, and compliance with audit requirements" kept separate, since the PCN says they are "not CQM activities."

Bring what you have to the introductory call; gaps in this list are what the gap assessment is for.

How CQM compares with quality assurance and grant administration

PCN 15-02 separates CQM from two neighboring activities.

A recipient that already runs a quality program for another purpose, such as a health center quality program, may choose to house CQM inside it. PCN 15-02 does not describe that as a pathway; this is IHS's reading as of October 2026, and the PCN's elements still apply either way.

What it costs

HRSA does not publish a fee schedule for a CQM program on the pages we reviewed; fees depend on scope. RWHAP is a grant program, and PCN 15-02 sets a spending limit rather than a fee: "For RWHAP Part A and Part B recipients, these requirements include a cap on CQM costs not to exceed the lesser of 5 percent of the amount received under the grant or $3 million. RWHAP Part C and Part D recipient CQM costs must be reasonable" (PCN 15-02). Verify current limits with HRSA and your award terms.

IHS scopes each engagement after a free introductory call.

What this is not

• It is not a HRSA determination. IHS cannot grant, predict or influence a site-visit or monitoring outcome.
• IHS does not submit anything to HRSA or your project officer. IHS drafts; your organization submits.
• It is not clinical direction or legal advice. Your HIV clinicians choose the measures and care standards, and award questions go to your counsel and grants staff.

Frequently asked questions

What does HRSA require in a Ryan White clinical quality management (CQM) program?

PCN 15-02 names three components: "These necessary components are Infrastructure, Performance Measurement and Quality Improvement" (PCN 15-02). It also expects at least two performance measures in qualifying service categories, quarterly data analysis and ongoing quality improvement activity.

What must a Ryan White clinical quality management plan include?

The PCN says the plan "describes all aspects of the CQM program including infrastructure, priorities, performance measures, quality improvement activities, action plan with a timeline and responsible parties, and evaluation of the CQM program." IHS drafts the plan for your team and clinicians to approve.

How many performance measures does a Ryan White recipient need, and for which service categories?

"Recipients should identify at least two performance measures for the RWHAP service categories ... where greater than or equal to 50% of the recipients' eligible clients receive at least one unit of service" (PCN 15-02). Your clinicians select which measures.

How often must CQM performance measure data be collected and analyzed?

At least quarterly. The PCN says recipients "should have an established process to collect and analyze (e.g. calculate the numerator, denominator, and percentage) performance measure data at least quarterly."

How much of a Part A or Part B award can be spent on CQM?

PCN 15-02 caps Part A and Part B CQM costs at "the lesser of 5 percent of the amount received under the grant or $3 million." For Parts C and D, "CQM costs must be reasonable." Check the current limit against your award terms.

Is subrecipient monitoring a CQM activity or grant administration?

Grant administration. The PCN appendix lists activities such as "monitoring of subrecipients, and compliance with audit requirements" as "not CQM activities." Subrecipients' own CQM capacity is still part of the recipient's CQM program.

What CQM responsibilities flow down to subrecipients, and how should our subrecipient agreements say it?

Recipients "need to ensure that their subrecipients that provide services have the capacity to contribute to the recipient's CQM program, have the resources to conduct CQM activities in their organizations, and implement a CQM program in their organizations, as identified in the written agreements between the recipient and subrecipient" (PCN 15-02). IHS drafts the oversight procedure; contract language goes to your counsel.

Does PCN 15-02 apply to Part C and Part D recipients?

Yes. Its scope line covers RWHAP "Parts A, B, C, and D." The cost cap differs: Parts A and B are capped, while Part C and D CQM costs "must be reasonable."

What is the difference between quality assurance and quality improvement in Ryan White programs?

PCN 15-02 treats quality improvement as one of the three CQM components and describes quality assurance separately: "Site visits and chart reviews are examples of commonly used quality assurance activities." A CQM program needs the improvement activity, not only the reviews.