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.
Notes
Stat. Auth.: ORS 441.015 & 441.025
Stats. Implemented: ORS 441.025
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