(A) Each provider of a HCS shall establish a quality assessment and performance improvement program designed to:
(1) Systematically monitor and evaluate the quality of patient care provided;
(2) Pursue opportunities to improve patient care;
(3) Ensure compliance with the applicable quality standards set forth in this chapter; and
(4) Resolve identified problems.
(B) Each provider of a HCS shall develop a written plan for each HCS 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 the quality of care and resolve identified problems;
(3) Establish expectations, develop plans, and implement procedures to assess and improve the health care service'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 improvement;
(5) Internally document and report findings, conclusions, actions taken, and the results of any actions taken to the health care service's management and medical director;
(6) Document and review all unexpected complications and adverse events, being serious injury or death resulting from medical management, which arise during the provision of the service or during the hospital stay; and
(7) Hold regular meetings, chaired by the medical director of the HCS, or designee, as necessary, but at least within sixty days after a death or complication, to review all deaths and complications and to report findings. Any pattern that might indicate a problem shall be investigated and remedied, if necessary.
Five Year Review (FYR) Dates: 02/27/2017 and 03/01/2022
Promulgated Under: 119.03
Statutory Authority: 3702.11, 3702.13
Rule Amplifies: 3702.11, 3702.12, 3702.13 , 3702.14, 3702.141, 3702.15, 3702.16, 3702.18, 3702.19, 3702.20
Prior Effective Dates: 3/1/1997, 3/24/03, 6/1/07, 6/21/12