La. Admin. Code tit. 48, § I-4427 - Quality Assurance and Performance Improvement Program (QAPI)

A. The outpatient abortion facility shall develop, implement, enforce, maintain, and annually review a written QAPI program subject to approval by the governing body, which puts systems in place to effectively identify issues for which quality monitoring and performance improvement activities are necessary. The QAPI program shall include plans of action to correct identified issues including, but not limited to, monitoring the effect of implemented changes and making necessary revisions to the plan of action.

1. Plans of Action. The outpatient abortion facility shall develop and implement a QAPI plan of action designed to effectively identify issues for which quality monitoring and performance improvement activities are necessary.

2. The QAPI plan of action shall include on a quarterly basis the following:

a. processes for receiving input regarding the quality of medical and clinical services received;

b. processes for review of patient medical records to ensure that such are complete and current;

c. processes for identifying on a quarterly basis the risk factors that affect or may affect the health and safety of the patients of the outpatient abortion facility receiving medical and clinical services. Examples may include, but are not limited to:

i. review and resolution of patient grievances; and

ii. review and resolution of patient/employee incidents involving medication errors and equipment failure;

d. a process to review and develop action plans to resolve all system wide issues identified as a result of the processes above.

3. The QAPI outcomes shall be documented and reported to the administrator in writing for action, as necessary, for any identified systemic problems.

Notes

La. Admin. Code tit. 48, § I-4427

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 41700 (4/1/2015).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2175.1 et seq.