Current through Register Vol. 35, No. 6, March 26, 2024
Each facility shall establish and maintain policies and
procedures for quality assurance and quality improvement systems, as well as an
internal quality committee and an external quality committee.
A.
Policies and procedures: The
administrator shall establish written policies and procedures which govern the
facility's complete operation. The facility shall ensure that these policies
are adopted, administered and enforced to provide quality health services in a
safe environment. At a minimum, the facility's written policies and procedures
shall include how the facility intends to comply with all requirements of these
regulations and address:
(1) the facility
organization including the legal entity or organization which owns the
facility, any management companies or managers which manage the facility, the
identity and credentials of the administrator responsible for establishing
lines of responsibility and accountability for both licensed and non-licensed
staff, and the administrator's responsibility to direct employees or
contractually retain qualified individuals providing fiscal management and all
operations in the facility, as well as maintaining records of disclosure of
conflicts of interest and all ownership interests and controlling
parties;
(2) the facility
administration including designation of an administrator with authority,
responsibility, and accountability for overall administration and operation,
including plans for the administrator's absence;
(3) the maintenance of the facility,
equipment and supplies including sterilization and disinfection of supplies,
equipment and instruments; cleaning of birthing room after each use; inspection
and maintenance of emergency equipment; maintenance of emergency supplies;
maintenance, upkeep and cleaning of the building(s) and equipment; fire and
emergency evacuation procedures; and proper disposal of waste liquids used for
cleaning contaminated areas;
(4)
quality of care and services including appropriate and inappropriate admission
criteria; client rights; client risk assessment; administration and preparation
of drugs; quality assurance and performance improvement programs; referral of
clients for additional services including, but not limited to,, laboratory and
sonography; transfer of clients to a hospital; ambulance transfer services;
emergency procedures and resuscitative techniques; aseptic techniques;
infectious waste and biohazard disposal in accordance with all applicable
statutes and regulations; and safe handling of the placenta for families
requesting to keep the placenta;
(5) staffing and personnel including written
job descriptions for all staff with necessary qualifications consistent with
these rules; minimum staffing and staff qualifications; and staff development
and evaluation;
(6) maintenance of
the client health record including protection of client confidentiality and
privacy as required by law; secure release of medical information and records;
and safe handling and storage of client records including appropriate document
destruction procedures; and
(7)
research procedures for any research being conducted at the facility in
compliance with these regulations.
B.
Internal quality committee:
The internal quality committee is comprised at a minimum of the
administrator and clinical director. If the administrator and the clinical
director are the same person, another staff person with clinical experience
shall be made a member of this committee. This committee shall establish and
implement quality assurance and quality improvement systems monitoring and
promoting quality care to clients through reviews that include chart review,
data collection, client satisfaction surveys, and other program monitoring
processes; data analyses; identification of areas for improvement; intervention
plans, including action steps, responsible parties, and response time; and,
evaluation of the effectiveness of interventions. The internal quality
committee shall at a minimum, implement a thorough chart review process, as
defined in these regulations, which considers and reviews outcome data
analysis, targeted concern and improvement areas, client satisfaction surveys,
and evidence based research to identify necessary quality improvement areas and
processes. When areas of concern or potential problems are identified by the
committee, the facility shall act as soon as possible to avoid and prevent
risks to clients. The internal quality committee shall take and maintain
meeting minutes. The internal quality committee shall, at a minimum, meet or
convene:
(1) within 72 hours of every
emergent or sentinel event to conduct an initial review and follow-up; if the
internal quality committee consists of less than three people, the external
quality committee shall convene to review emergent and sentinel
events;
(2) monthly to document any
significant events and any necessary quality care improvement steps to be
applied to future events;
(3)
quarterly for a detailed chart review, as provided in these regulations, of a
minimum of five charts consisting of a minimum of one chart for each midwife
and physician practicing at the facility; charts of all labor, postpartum, and
newborn transfers; Apgar scores less than seven at five minutes; hemorrhage
greater than 1000 ml; and any other significant problems encountered within the
quarter;
(4) annually for review of
policies and procedures, including, but not limited to,,:
(a) environment of care:
(b) testing and maintenance of equipment
according to manufacturer's recommendations:
(c) housekeeping procedures:
(d) infection control procedures:
(e) privacy and security processes:
(f) compliance with policies and
procedures for all emergency drills, including, but not limited to,,, fire,
maternal/newborn emergencies, power failures, and natural disasters:
(g) evaluation of maintenance policies and
procedures for heat, ventilation, emergency lighting, waste disposal, water
supply, laundry, and nourishment station:
(h) annual employee performance evaluations:
(i) clinical practice guidelines;
and
(5) submission of an
annual quality report to the external quality committee.
C.
External quality committee:
The facility shall establish an external quality committee which
includes the members of the internal quality committee, an external peer
reviewer or a clinical consultant and other healthcare partners, if available.
The external quality committee shall meet at least quarterly and perform an
in-depth peer review case study on a minimum of five charts which include at a
minimum one case for each midwife and physician practicing at the facility. The
external quality committee shall also review the care of individual clients,
targeted types of clients, and appropriateness of the clinical practitioner's
judgment and management of the case under the facility's standards of care and
policies, and make recommendations for care improvements. The external quality
committee shall also discuss relevant evidence based research and make
recommendations relating to clinical practice guidelines to improve quality of
care.
