Date of Award


Degree Name

Nursing (D.N.P.)


College of Nursing

First Advisor

Dianne Conrad

Second Advisor

Patricia Thomas

Third Advisor

Heather Bunting


Federally Qualified Health Centers (FQHCs) have become a vital part of access to care for low socioeconomic status individuals. The federal government has allocated funds to be distributed to FQHCs via Medicare and Medicaid reimbursement based on insurance claims and through the Health Resources and Service Administration (HRSA) via grants and incentives based on Uniform Data System (UDS) reporting. Federally Qualified Health Centers must complete annual uniform data system (UDS) reporting on quality indicator metrics to receive grants and incentives from HRSA. The Health Resources and Service Administration (HRSA) funded health centers are expected to have ongoing quality assurance and improvement programs to improve patient care and outcomes. A local West Michigan clinic is one of a group of five clinics that qualified for FQHC status based on serving the homeless population in the area. They have been operating as a FQHC for several years, but updated to a new EHR platform in January 2016, utilizing the Athena Health EHR. The completion of an organizational assessment assisted in identifying a problem in the level of training staff members receive on the Athena Health EHR, quality indicator documentation, and UDS reporting. Creating a quality protocol that includes staff education regarding UDS reporting and electronic health record functionality has the potential to improve compliance with HRSA reporting. The Donabedian Model was utilized to view the phenomenon of interest regarding quality indicator metrics, documentation and reporting. The PARiHS framework guided the implementation of the quality indicator protocol that incorporated staff education and increased utilization of EHR functionality for improved quality documentation and reporting at this West Michigan FQHC.

Included in

Nursing Commons