Indiana Administrative Code
Title 410 - INDIANA DEPARTMENT OF HEALTH
Article 15 - HOSPITAL LICENSURE RULES
Rule 2.4 - Governing Body
Section 2.4-2 - Quality assessment and improvement
Universal Citation: 410 IN Admin Code 2.4-2
Current through March 20, 2024
Authority: IC 16-21-1-7
Affected: IC 16-21-1
Sec. 2.
(a) The center must develop, implement, and maintain an effective, organized, center-wide, comprehensive quality assessment and improvement program in which all areas of the center participate. The program shall be ongoing and have a written plan of implementation that evaluates, but is not limited to, the following:
(1) All services, including
services furnished by a contractor.
(2) All functions, including, but not limited
to, the following:
(A) Discharge and
transfer.
(B) Infection
control.
(C) Medication
errors.
(D) Response to patient
emergencies.
(3) All
services performed in the center with regard to appropriateness of diagnoses
and treatments related to a standard of care and anticipated or expected
outcomes.
(b) The center shall take appropriate action to address the opportunities for improvement found through the quality assessment and improvement program as follows:
(1) The action must be documented.
(2) The outcome of the action must be
documented as to its effectiveness, continued follow-up, and impact on patient
care.
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