Ariz. Admin. Code § R9-10-204 - Quality Management
A. A
governing authority shall ensure that an ongoing quality management program is
established that:
1. Complies with the
requirements in A.R.S. §
36-445; and
2. Evaluates the quality of hospital services
and environmental services related to patient care.
B. An administrator shall ensure that:
1. A plan is established, documented, and
implemented for an ongoing quality management program that, at a minimum,
includes:
a. A method to identify, document,
and evaluate incidents;
b. A method
to collect data to evaluate hospital services and environmental services
related to patient care;
c. A
method to evaluate the data collected to identify a concern about the delivery
of hospital services or environmental services related to patient
care;
d. A method to make changes
or take action as a result of the identification of a concern about the
delivery of hospital services or environmental services related to patient
care;
e. A method to identify and
document each occurrence of exceeding licensed capacity, as described in
R9-10-203(C)(5),
and to evaluate the occurrences of exceeding licensed capacity, including the
actions taken for resolving occurrences of exceeding licensed capacity;
and
f. The frequency of submitting
a documented report required in subsection (B)(2) to the governing
authority;
2. A
documented report is submitted to the governing authority that includes:
a. An identification of each concern about
the delivery of hospital services or environmental services related to patient
care, and
b. Any changes made or
actions taken as a result of the identification of a concern about the delivery
of hospital services or environmental services related to patient
care;
3. The acuity plan
required in
R9-10-214(C)(2) is
reviewed and evaluated at least once every 12 months and the results are
documented and reported to the governing authority;
4. The reports required in subsections (B)(2)
and (3) and the supporting documentation for the reports are maintained for at
least 12 months after the date the report is submitted to the governing
authority; and
5. Except for
information or documentation that is confidential under federal or state law, a
report or documentation required in this Section is provided to the Department
for review within two hours after the Department's request.
Notes
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