Or. Admin. R. 333-700-0080 - Quality Assessment and Performance Improvement

(1) The facility shall establish a program to monitor the quality of care given to patients. This program shall document that the facility staff evaluate the provision of care, determine treatment goals, identify opportunities for improvement, develop and implement improvement plans, and evaluate implementation until resolution of a problem is achieved.
(2) The medical director of the facility is responsible for quality monitoring and improvement activities. The Quality Assessment and Performance Improvement (QAPI) team shall consist of a multi-disciplinary team to include representatives of medical staff, administration, nursing, technical, social work and dietary. Meetings of the QAPI team shall be held at least quarterly or more often if needed to resolve a particular issue.
(3) QAPI mechanisms shall include:
(a) An ongoing review of key elements of care using comparative and trend data to include aggregate patient data and to promote the reduction of risks;
(b) Identification of areas where performance measures or outcome data indicate a need for improvement;
(c) Establishment of QAPI committees to identify any variations from desired outcomes; create and implement improvement plans; evaluate the effectiveness of the improvement plan; and
(d) Establishment and monitoring of key quality indicators. For each indicator, the facility shall establish a performance level consistent with current professional knowledge. At a minimum, the following indicators shall be monitored on an ongoing basis:
(A) Water Quality including chemical and bacteriological indicators;
(B) Equipment maintenance and repair;
(C) Reprocessing of dialyzers including performance measures, labeling, disinfection, and pyrogenic reactions;
(D) Infection control including monitoring of staff and patient infections;
(E) Clinical outcomes including laboratory values, dialysis adequacy, hospitalizations, vascular access complications;
(F) Incidents and rate of adverse occurrences (clinical variances) including accidents, medication errors, treatment errors, infiltrations, needle sticks, adverse drug reactions, and other occurrences affecting patients, visitors, or staff;
(G) Mortality including review of each patient death and monitoring of mortality rates and trends;
(H) Complaints and suggestions including those from patients, family and staff; and
(I) Other indicators as required by federal regulations and Network requirements.


Or. Admin. R. 333-700-0080
PH 7-2003, f. & cert. ef. 6-6-03; PH 4-2012, f. 3-30-12, cert. ef. 4-1-12

Stat. Auth.: ORS 441.015 & 441.025

Stats. Implemented: ORS 441.025

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