Utah Admin. Code R432-100-10 - Quality Improvement Plan
(1) The
board members shall ensure that there is a well-defined quality improvement
plan designed to improve patient care.
(2) The plan shall:
(a) be consistent with the delivery of
patient care;
(b) be implemented
and include a system for the collection of indicator data;
(c) include an incident reporting system to
identify problems, concerns, and opportunities for improvement of patient
care;
(d) ensure that incident
reports are available for department review;
(e) include a system for assessing identified
problems, concerns, and opportunities for improvement; and
(f) implement actions that are designed to
eliminate identified problems and improve patient care.
(3) The licensee shall maintain a quality
improvement committee. The quality improvement committee shall maintain written
minutes documenting corrective actions and results and make these minutes
available for department review.
(4) The quality improvement committee shall
report findings and concerns, at least quarterly, to the board, the medical
staff, and the administrator.
(5)
The licensee shall ensure that infection reporting is integrated into the
quality improvement plan and is reported to the department in accordance with
Rule R386-702 Communicable Diseases.
Notes
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(1) The board members shall ensure that there is a well-defined quality improvement plan designed to improve patient care.
(2) The plan shall:
(a) be consistent with the delivery of patient care;
(b) be implemented and include a system for the collection of indicator data;
(c) include an incident reporting system to identify problems, concerns, and opportunities for improvement of patient care;
(d) ensure that incident reports are available for department review;
(e) include a system for assessing identified problems, concerns, and opportunities for improvement; and
(f) implement actions that are designed to eliminate identified problems and improve patient care.
(3) The licensee shall maintain a quality improvement committee. The quality improvement committee shall maintain written minutes documenting corrective actions and results and make these minutes available for department review.
(4) The quality improvement committee shall report findings and concerns, at least quarterly, to the board, the medical staff, and the administrator.
(5) The licensee shall ensure that infection reporting is integrated into the quality improvement plan and is reported to the department in accordance with Rule R386-702 Communicable Diseases.