Current through Reg. 50, No. 187; September 24, 2024
(1)
General Provisions. Each hospital shall have a planned, systematic, hospital
wide approach to the assessment, and improvement of its performance to enhance
and improve the quality of health care provided to the public.
(a) Such a system shall be based on the
mission and plans of the organization, the needs and expectations of the
patients and staff, up-to-date sources of information, and the performance of
the processes and their outcomes.
(b) Each system for quality improvement,
which shall include utilization review, must be defined in writing, approved by
the governing board, and enforced, and shall include:
1. A written delineation of responsibilities
for key staff;
2. A policy for all
privileged staff, whereby staff members do not initially review their own cases
for quality improvement program purposes;
3. A confidentiality policy;
4. Written, measurable criteria and
norms;
5. A description of the
methods used for identifying problems;
6. A description of the methods used for
assessing problems, determining priorities for investigation, and resolving
problems;
7. A description of the
methods for monitoring activities to assure that desired results are achieved
and sustained; and,
8.
Documentation of the activities and results of the
program.
(2)
Each hospital shall have in place a systematic process to collect data on
process outcomes, priority issues chosen for improvement, and the satisfaction
of the patients. Processes measured shall include:
(a) Appropriate surgical and other invasive
procedures;
(b) Preparation of the
patient for the procedure;
(c)
Performance of the procedure and monitoring of the patient;
(d) Provision of post-procedure
care;
(e) Use of medications
including prescription, preparation and dispensing, administration, and
monitoring of effects;
(f) Results
of autopsies;
(g) Risk management
activities;
(h) Quality improvement
activities including at least clinical laboratory services, diagnostic imaging
services, dietetic services, nuclear medicine services, and radiation oncology
services.
(3) Each
hospital shall have a process to assess data collected to determine:
(a) The level and performance of existing
activities and procedures,
(b)
Priorities for improvement, and,
(c) Actions to improve
performance.
(4) Each
hospital shall have a process to incorporate quality improvement activities in
existing hospital processes and procedures.
Rulemaking Authority 395.1055 FS. Law Implemented 395.1055
FS.
New 9-4-95, Formerly
59A-3.216.
