Current through Register Vol. 42, No. 11, August 30, 2024
(1) The
hospital shall develop, implement, and maintain an effective, ongoing,
hospital-wide, data-driven quality assurance or quality assessment and
performance improvement (QAPI) program. The hospital's governing authority
shall ensure that the program reflects the complexity of the hospital's
organization and services; involves all hospital 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 hospital shall maintain and demonstrate
evidence of its QAPI program for review by the Department.
(2) Program scope.
(a) The program shall 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.
(b) The hospital shall
measure, analyze, and track quality indicators, including adverse patient
events, and other aspects of performance that assess processes of care,
hospital service and operations.
(3) Program data.
(a) The program shall incorporate quality
indicator data including patient care data, and other relevant data, for
example, information submitted to, or received from, the hospital's Quality
Improvement Organization (QIO).
(b)
The hospital shall use the data collected to:
1. Monitor the effectiveness and safety of
services and quality of care; and
2. Identify opportunities for improvement and
changes that will lead to improvement.
(c) The frequency and detail of data
collection shall be specified by the hospital's governing authority.
(4) Program activities.
(a) The hospital shall set priorities for its
performance improvement activities that:
1.
Focus on high-risk, high-volume, or problem-prone areas;
2. Consider the incidence, prevalence, and
severity of problems in those areas; and
3. Affect health outcomes, patient safety,
and quality of care.
(b)
Performance improvement and quality assurance activities shall track medical
errors and adverse patient events, analyze their causes, and implement
preventive actions and mechanisms that include feedback and learning throughout
the hospital.
(c) The hospital
shall take actions aimed at performance improvement and, after implementing
those actions, the hospital shall measure its success, and track performance to
ensure that improvements are sustained.
(5) Performance improvement projects. As part
of its QAPI program, the hospital shall conduct performance improvement
projects.
(a) The number and scope of
distinct improvement projects conducted annually shall be proportional to the
scope and complexity of the hospital's services and operations.
(b) A hospital may, as one of its projects,
develop and implement an information technology system explicitly designed to
improve patient safety and quality of care. This project, in its initial stage
of development, does not need to demonstrate measurable improvement in
indicators related to health outcomes.
(c) The hospital shall document what quality
improvement projects are being conducted, the reasons for conducting these
projects, and the measurable progress achieved on these projects.
(d) A hospital is not required to participate
in a QIO cooperative project, but its own projects are required to be of
comparable effort.
(6)
Executive responsibilities. The hospital's governing authority (or organized
group or individual who assumes full legal authority and responsibility for
operations of the hospital), medical staff, and administrative officials are
responsible and accountable for ensuring the following:
(a) That an ongoing program for quality
improvement and patient safety, including the reduction of medical errors, is
defined, implemented, and maintained.
(b) That the hospital-wide QAPI efforts
address priorities for improved quality of care and patient safety; and that
all improvement actions are evaluated.
(c) That clear expectations for safety are
established.
(d) That adequate
resources are allocated for measuring, assessing, improving, and sustaining the
hospital's performance and reducing risk to patients.
(e) That the determination of the number of
distinct improvement projects is conducted annually.
Rule .07 was renumbered to .10 as per certification filed
August 24, 2012; effective September 28, 2012.
Author: W.T. Geary, Jr., M.D., Carter
Sims
Statutory Authority:
Code of Ala.
1975, §§
22-21-20, et seq.
