Compilation of Rules and Regulations of the State of Georgia
Department 111 - RULES OF DEPARTMENT OF COMMUNITY HEALTH
Chapter 111-8 - HEALTHCARE FACILITY REGULATION
Subject 111-8-22 - END STAGE RENAL DISEASE FACILITIES
Rule 111-8-22-.08 - Continuous Quality Improvement

(1) Through the facility administration, the medical director, and the medical and nursing staff, the facility shall develop and implement a facility-wide continuous quality improvement program, specific to the facility and designed to perform a systematic, ongoing, concurrent, and comprehensive review of the patient care provided, both in-facility and through the home dialysis program, if provided.

(2) All facility staff shall be involved in the continuous quality improvement program.

(3) Policies and procedures for the continuous quality improvement program shall include the use of a defined methodology for implementation. The methodology selected must include components for measuring the facility's performance, identifying opportunities for improvement through the use of such quality improvement tools as root cause analyses, setting priorities, and identifying expected outcomes. Reporting mechanisms shall be established, including at least a quarterly review of the continuous quality improvement activities.

(4) The continuous quality improvement program shall continuously monitor at a minimum:

(5) The results of continuous quality improvement activities and monitoring shall be disseminated to the governing body, the medical director, the medical staff, and any service staff impacted by the results.

(6) The facility shall take and document remedial action to address service deficiencies identified through the continuous quality improvement program.