Current through Vol. 42, No. 1, September 16, 2024
(a) The hospice must develop, implement, and
maintain an effective, ongoing, hospice-wide data-driven quality assessment and
performance improvement program. The hospice's governing body must ensure that
the program: Reflects the complexity of its organization and services; involves
all hospice services (including those services furnished under contract or
arrangement); focuses on indicators related to improved palliative outcomes;
and takes actions to demonstrate improvement in hospice performance. The
hospice must maintain documentary evidence of its quality assessment and
performance improvement program and be able to demonstrate its operation to the
Department of Health.
(b)
Program scope.
(1) The program
must at least be capable of showing measurable improvement in indicators
related to improved palliative outcomes and hospice services.
(2) The hospice must measure, analyze, and
track quality indicators, including adverse patient events, and other aspects
of performance that enable the hospice to assess processes of care, hospice
services, and operations.
(c)
Program data.
(1) The program must use quality indicator
data, including patient care, and other relevant data, in the design of its
program.
(2) The hospice must use
the data collected to do the following:
(A)
Monitor the effectiveness and safety of services and quality of care;
and
(B) Identify opportunities and
priorities for improvement.
(3) The frequency and detail of the data
collection must be approved by the hospice's governing
body.
(d)
Program
activities.
(1) The hospice's
performance improvement activities must:
(A)
Focus on high risk, high volume, or problem-prone areas;
(B) Consider incidence, prevalence, and
severity of problems in those areas; and
(C) Affect palliative outcomes, patient
safety, and quality of care.
(2) Performance improvement activities must
track adverse patient events, analyze their causes, and implement preventive
actions and mechanisms that include feedback and learning throughout the
hospice.
(3) The hospice must take
actions aimed at performance improvement and, after implementing those actions,
the hospice shall measure its success and track performance to ensure that
improvements are sustained.
(e)
Performance improvement
projects. Hospices must develop, implement, and evaluate performance
improvement projects.
(1) The number and
scope of distinct performance improvement projects conducted annually, based on
the needs of the hospice's population and internal organizational needs, must
reflect the scope, complexity, and past performance of the hospice's services
and operations.
(2) The hospice
must document what performance improvement projects are being conducted, the
reasons for conducting these projects, and the measurable progress achieved on
these projects.
(f)
Executive responsibilities. The hospice's governing body is
responsible for ensuring the following:
(1)
An ongoing program for quality improvement and patient safety is defined,
implemented, and maintained, and is evaluated annually;
(2) The hospice-wide quality assessment and
performance improvement efforts address priorities for improved quality of care
and patient safety, and that all improvement actions are evaluated for
effectiveness; and
(3) One or more
individual(s) who are responsible for operating the quality assessment and
performance improvement program are designated.
Added at 26 Ok Reg 2042,
eff 6-25-09
