(A) Each HCF shall establish a quality assessment and performance improvement program designed to systematically monitor and evaluate the quality of patient care, pursue opportunities to improve patient care, and resolve identified problems.
(B) Each HCF shall develop a written plan that describes the quality assessment and performance improvement program's objectives, organization, scope, and mechanism for overseeing the effectiveness of monitoring, evaluation, improvement and problem-solving activities.
(C) The quality assessment and performance improvement program shall do all of the following:
(1) Monitor and evaluate all aspects of care including effectiveness, appropriateness, accessibility, continuity, efficiency, patient outcome, and patient satisfaction;
(2) Establish expectations, develop plans, and implement procedures to assess and improve quality of care and resolve identified problems;
(3) Establish expectations, develop plans, and implement procedures to assess and improve the health care facility's governance, management, clinical, and support processes;
(4) Establish information systems and appropriate data management processes to facilitate the collection, management, and analysis of data needed for quality assessment and performance improvement and to comply with the applicable data collection requirements of Chapter 3701-83 of the Administrative Code;
(5) Document and report the status of the quality assessment and performance improvement program to the governing body every twelve months;
(6) Document and review all unexpected complications and adverse events, whether serious injury or death, that arise during an operation or procedure; and
(7) Hold regular meetings, chaired by the medical director of the HCF or designee, as necessary, but at least within sixty days after a serious injury or death, to review all deaths and serious injuries, and report findings. Any pattern that might indicate a problem shall be investigated and remedied, if necessary.
(D) Each HCF shall implement a program for proactive assessment of high-risk activities related to patient safety and to undertake appropriate improvements.
(E) Each HCF shall report to the director, in a manner and interval prescribed by the director, the data specified in the applicable rules of Chapter 3701-83 of the Administrative Code.
Five Year Review (FYR) Dates: 02/16/2016 and 02/15/2021
Promulgated Under: 119.03
Statutory Authority: 3702.12, 3702.13
Rule Amplifies: 3702.30
Prior Effective Dates: 1/13/1996, 9/5/02, 6/1/06, 4/24/11