Current through Register Vol. 35, No. 18, September 24, 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.
