26 Tex. Admin. Code § 511.64 - Quality Assessment and Performance Improvement Program
(a) A limited
services rural hospital (LSRH) shall develop, implement, and maintain an
effective, ongoing, LSRH-wide, data-driven quality assessment and performance
improvement (QAPI) program.
(b) An
LSRH's governing body shall ensure the QAPI program is individualized to ensure
the LSRH complies with the requirements of this section, reflects the
complexity of the LSRH's organization and services, involves all LSRH
departments and services (including those services furnished under contract or
arrangement), and focuses on indicators related to improved health outcomes and
the prevention and reduction of medical errors. The LSRH must maintain and
demonstrate evidence of its QAPI program.
(c) The LSRH shall measure, analyze, and
track quality indicators, including adverse patient events, staffing, and other
aspects of performance to evaluate processes of care, including LSRH service
and operations.
(d) The QAPI
program shall:
(1) include an ongoing program
that shows measurable improvement in indicators for which there is evidence
that it will improve health outcomes and identify and reduce medical
errors;
(2) incorporate quality
indicator data, including patient care data, and other relevant data, to
achieve the goals of the QAPI program;
(3) evaluate all LSRH departments and
services, including services furnished under contract or arrangement;
(4) evaluate health care associated
infections;
(5) evaluate medication
therapy;
(6) evaluate all medical
and surgical services performed in the LSRH as they relate to appropriateness
of diagnosis and treatment;
(7)
measure, analyze, and track quality indicators, including adverse patients'
events, and other aspects of performance that assess processes of care, LSRH
services, and operations; and
(8)
use the data collected to monitor the effectiveness and safety of service and
quality of care, and to identify opportunities for changes that will lead to
improvement.
(e) For
each quality assessment indicator, the LSRH shall establish and monitor a level
of performance consistent with current professional knowledge. These
performance components shall influence or relate to the desired outcomes. The
LSRH shall measure, analyze, and track at least the following indicators on a
monthly basis:
(1) infection control,
including staff and patient screening and standard precautions;
(2) adverse events;
(3) mortality, including review of each death
and monitoring modality specific mortality rate;
(4) complaints and suggestions from patients,
family, or staff;
(5) staffing,
including orientation, training, delegation, licensing and certification, and
non-adherence to policies and procedures by facility staff;
(6) safety, including fire and disaster
preparedness, use of a Texas Health and Human Services Commission-required
reporting system, and disposal of special waste; and
(7) clinical records review, including
treatment errors and medication errors.
(f) The LSRH shall establish priorities for
performance improvement activities that focus on high-risk, high-volume, or
problem-prone areas; consider the incidence, prevalence, and severity of
problems in those areas; and affect health outcomes, patient safety, and
quality of care. Performance improvement activities shall:
(1) track medical errors and adverse patient
events;
(2) analyze their causes;
and
(3) implement preventive
actions and mechanisms that include feedback and learning throughout the
LSRH.
(g) The LSRH shall
measure the success of actions implemented resulting from performance
improvement activities and track ongoing performance to ensure sustained
improvements.
(h) The LSRH shall
ensure staff, including the medical, nursing, and pharmacy staff, complete the
following activities:
(1) evaluate the
provision of emergency care and patient services;
(2) set treatment goals;
(3) identify opportunities for
improvement;
(4) develop and
implement improvement plans; and
(5) evaluate the implementation until
resolution is achieved.
(i) The LSRH shall measure, analyze, and
track quality indicators or other aspects of performance the LSRH adopts or
develops that reflect processes of care and LSRH operations. The LSRH shall
document evidence demonstrating the LSRH continuously reviews aggregate patient
data, including identifying and tracking patient infections trends.
(j) The LSRH shall hold QAPI meetings as
necessary, but not less than quarterly. Core staff members, including the
medical, nursing, and pharmacy staff, shall actively participate in QAPI
activities and meetings to identify or correct problems. The LSRH shall
document QAPI meetings.
(k) The
LSRH's governing body, medical staff, and administrative officials are
responsible and accountable for ensuring:
(1)
the LSRH defines, implements, and maintains an ongoing quality improvement and
patient safety program, including the reduction of medical errors;
(2) the LSRH-wide QAPI efforts address
priorities for improved quality of care and patient safety, and evaluates all
improvement actions;
(3) the LSRH
establishes clear expectations for safety; and
(4) the LSRH allocates adequate resources for
measuring, assessing, improving, and sustaining the LSRH's performance and
reducing risk to patients.
(l) The LSRH shall have an ongoing plan,
consistent with available community and LSRH resources, to provide or make
available social work, psychological, and educational services to meet the
medically related needs of its patients.
(m) When an LSRH is part of a system
consisting of multiple separately certified hospitals, critical access
hospitals (CAHs), or LSRHs using a system governing body that is legally
responsible for the conduct of two or more hospitals, CAHs, or LSRHs, the
system governing body can elect to have a unified and integrated QAPI program
for all of its member facilities after determining that such a decision is in
accordance with all applicable state and local laws. The system governing body
is responsible and accountable for ensuring that each of its separately
certified LSRHs meets all of the requirements of this section. Each separately
certified LSRH subject to the system governing body must demonstrate:
(1) the unified and integrated QAPI program
is established in a manner that takes into account each member LSRH's unique
circumstances and any significant differences in patient populations and
services offered in each LSRH; and
(2) the unified and integrated QAPI program
establishes and implements policies and procedures to ensure that the needs and
concerns of each of its separately certified LSRHs, regardless of practice or
location, are given due consideration, and the unified and integrated QAPI
program has mechanisms in place to ensure that issues localized to particular
LSRHs are duly considered and addressed.
Notes
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