PURPOSE: The Governing Body (Board of Regents) and the Student Health Services staff (clinical providers, nurses, and non-clinical administrative/clerical staff) of Western New Mexico University will demonstrate a commitment to providing quality patient care within the scope of available resources and the goals of this institution.

GOALS: The goal of the Quality Improvement (QI) Program is to monitor the appropriateness and quality of patient care. Monitoring will be accomplished by activities that:

  1. are planned, systematic, and ongoing
  2. are comprehensive
  3. are based on objective criteria that reflect current medical knowledge and clinical experiences
  4. are accomplished by the routine collection and periodic evaluation of data
  5. result in appropriate actions to resolve identified problems
  6. are updated to assure sustained improvements in care and performance
  7. are coordinated in such a way that the information derived is shared among the appropriate staff of this facility

SCOPE: The scope of the QI Program is comprehensive and problem oriented. It will include all departments, services, disciplines, and practitioners associated with the Student Health Services. The topics to be reviewed are:

  1. the quality and appropriateness of diagnostic and treatment procedures
  2. the quality, content, and completeness of medical record entries
  3. the clinical performances
  4. the use of medications
  5. patient satisfaction
  6. the quality control of laboratory and pharmacy services provided

Each QI unit will be responsible for identifying the important aspects of the patient care provided, for indicating quality and appropriateness of the important aspects of care, and for the establishment of thresholds that will be used to evaluate the indicators. All personnel are expected to participate in the QI activities.

ORGANIZATION: Refer to the flow chart.


1. Governing Body

  1. The governing body (the Board of Regents) shall have the responsibility of assuring the public of the goal of optimal quality of all care delivered within the Student Health Services.
  2. The governing body shall make the commitment to provide the financial support necessary for the Student Health Services in order to provide services that are required (e.g., resources, equipment and personnel).
  3. The governing body will receive reports from the appropriate parties according to the organizational plan on the findings of the Quality Improvement (QI) activities. The governing body will respond definitively, if necessary, to fulfill their responsibility of adherence to the QI program.
  4. The governing body delegates the authority and accountability for the QI program to the Director of Student Health Services.
  5. The governing body stipulates that the clinic staff and the Director work together in a cooperative manner to create and maintain an effective program.
  6. The governing body stipulates that the Director work together with the Safety/Infection Control/Quality Improvement Coordinator and Committee to create a unified program of Quality Improvement.
  7. The Vice-President for Student Affairs shall represent the governing body.


  1. The Quality improvement Committee shall be combined with the Safety unit and the Infection Control unit to form the Safety/Infection Control/Quality Improvement Committee. The Student Health Services Director shall appoint the chairperson and members of a sub-committee to review QI activities. The sub-committee shall consist of at least one representative from the clerical unit, the nursing unit and the clinical unit. The Director, on an annual basis, will review sub-committee membership and the chairperson position.
  2. The sub-committee shall meet monthly.
  3. The duties of the sub-committee are:
    1. to identify and coordinate all QI activities
    2. to conduct routine appraisals of all QI units and to make recommendations regarding QI activities
    3. to promote and assist, where needed, in developing standards of care within each QI unit
    4. to receive, evaluate and coordinate the reports of all QI units
    5. to share information between QI units in order to prevent duplication of effort
    6. to identify problems and set priorities for their resolution, if needed
    7. to insure that all available data sources are utilized in implementing the QI program
    8. to insure the appropriate utilization of all available methods of studying, assessing, and resolving perceived problems, both within the SICQI Committee and within the individual QI units
    9. to reappraise the QI plan at least annually for
      1. unity of organization and function
      2. comprehensiveness
      3. effectiveness in solving problems


  1. The Student Health Services Director appoints the QI Chairperson. The Director, on an annual basis, reviews this appointment.
  2. The duties of the QI Chairperson include the following:
    1. Maintains copies of all QI sub-committee minutes and all reports routinely obtained from the QI units. A copy of all monthly minutes will be sent to the Director of the Student Health Services.
    2. Maintains a master file of all Student Health Services QI activities.
    3. Attends clinical staff meetings, or sends a representative, when monitoring functions or QI activities are to be discussed.
    4. Assists the QI units in developing written indicators and thresholds used to assess problems as needed.
    5. Provides references and/or indicators and thresholds developed in outside organizations.
    6. Promotes concepts of QI through New Employee Orientation.
    7. Prepares data to review/evaluate Student Health Services professional staff as deemed necessary by the Student Health Services Director and/or the QI sub-committee.
    8. Promotes consistency in QI activities by developing a glossary of terminology used to describe studies or methods employed.
    9. Facilitates monthly reports by the QI units to the QI sub-committee.
    10. Collaborates with the Director in preparing semi-annual reports to be submitted to the Vice-President for Student Affairs.
    11. Provides the Director with a yearly rating of each employee regarding the employee’s compliance with the QI program/plan. This rating will be incorporated into the official yearly performance evaluation of each employee.


The Vice-President for Student Affairs will evaluate the program at least annually and direct the Student Health Services Director and SICQI Coordinator as to components that need to be instituted, altered or deleted.


Confidentiality of the QI activity records will be honored. All reports and communications regarding QI activities will be filed in the SICQI Coordinator’s office. These records will only be available to the Director, the QI sub-committee, and persons authorized by the Student Health Services Director.

The QI Plan of the Western New Mexico University
Student Health Services has been reviewed and
approved _______________________________.