N.M. Code R. § 7.7.2.23 - QUALITY IMPROVEMENT
A.
Responsibility of the Governing Body: The governing body shall ensure
that the hospital has a written quality improvement program for monitoring,
evaluating and improving the quality of patient care and the ancillary services
in the hospital on an on-going basis. The program shall promote the most
effective and efficient use of available health facilities and services
consistent with patient needs and professionally recognized standards of health
care.
B.
Responsibilities of
the Chief Executive Officer/Administrator and the Chief of the Medical
Staff. As part of the quality improvement program, the chief executive
officer/administrator and chief of the medical staff shall ensure that:
(1) the hospital's quality improvement
program is implemented and evaluated for effectiveness for all patient care and
all services;
(2) the findings of
the program are incorporated into a well defined method of assessing staff
performance in relation to patient care and the provision of services;
and
(3) program findings, actions
and results of the hospital's quality improvement program are reported to the
chief executive officer/administrator, chief of medical staff and governing
body not less than annually.
C.
Evaluation of Care to be
Problem-Focused.
(1) Monitoring and
evaluation of the quality of care given patients and services provided shall
focus on identifying patient care problems and opportunities for improving
patient care.
(2) Evaluation of
care and services shall be problem-focused whenever serious events occur which
have a major impact on patient care and services, or when the hospital receives
a quality-of-care concern or complaint.
D.
Evaluation of Care and Services to
Use Variety of Sources. The quality of care given patients shall be
evaluated using a variety of data sources, including, but not limited to,
medical records, hospital information systems, published research, literature
comparison, peer review organization data, patient satisfaction findings, and
when available, third party information.
E.
Activities. Hospitals shall
document how each of the monitoring and evaluation activities has produced data
used to institute changes to improve quality of care or services and promote
more efficient use of facilities and services. Quality improvement activities
shall:
(1) emphasize identification and
analysis of patterns of patient care and suggest possible changes for
maintaining consistently high quality care and effective and efficient use of
services;
(2) identify and analyze
factors related to the patient care rendered in the facility and, where
indicated, make recommendations to the governing body, chief executive
officer/administrator and chief of the medical staff for changes that are
beneficial to patients, staff, the facility and the community; and
(3) document the monitoring and evaluation
activities performed and indicate how the results of these activities have been
used to institute changes to improve the quality and a appropriateness of the
care provided.
F.
Evaluation of the Program. The chief executive officer/administrator and
chief of medical staff shall be involved in evaluation of the effectiveness of
the quality improvement program which is evaluated by clinical and
administrative staff at least once a year and that the results are communicated
to the governing body.
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