Current through Reg. 50, No. 187; September 24, 2024
(1) General Provisions. Each ambulatory
surgical center shall have an ongoing quality assessment and improvement system
designed to objectively and systematically monitor and evaluate the quality and
appropriateness of patient care, and opportunities to improve its performance
to enhance and improve the quality of 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 assessment and
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
members of the organized medical staff, whereby staff members do not initially
review their own cases for quality assessment and 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 the desired results are
achieved and sustained; and,
8.
Documentation of the activities and results of the
program.
(2)
Each center shall have in place a systematic process to collect data on process
outcomes, priority issues chosen for improvement, and the satisfaction of the
patient. Processes measured shall include:
(a)
Appropriate surgical procedures;
(b) Preparation of patient for the
procedure;
(c) Performance of the
procedure and monitoring of the patient;
(d) Provision of post-operative
care;
(e) Use of medications
including administration and monitoring of effects;
(f) Risk management activities;
(g) Quality assessment and improvement
activities including clinical laboratory services and radiology
services;
(h) Results of autopsies
if needed.
(3) Each
center 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
center shall have a process to incorporate quality assessment and improvement
activities in existing ambulatory surgical center processes and
procedures.
Rulemaking Authority 395.1055 FS. Law Implemented 395.1055
FS.
New 11-13-95, Amended
2-23-16.
