South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-91 - Standards for Licensing Ambulatory Surgical Facilities
Sec2 61-91.1600 - QUALITY IMPROVEMENT PROGRAM
Section 61-91.1600.1601 - General (II)

Universal Citation: SC Code Regs 61-91.1600.1601

Current through Register Vol. 48, No. 9, September 27, 2024

A. There shall be a written, implemented quality improvement program that provides effective self-assessment and implementation of changes designed to improve the care, treatment, procedures, surgery, and/or services provided by the facility.

B. The quality improvement program, at a minimum, shall:

1. Establish desired outcomes and the criteria by which policy and procedure effectiveness is systematically, objectively, and regularly accomplished at a frequency as determined by the facility to ensure that policies and procedures and this regulation are met, but not less than every three months;

2. Identify, evaluate, and determine the causes of any deviation from the desired outcomes;

3. Identify the action taken to correct deviations and prevent future deviation, and the person(s) responsible for implementation of these actions;

4. Establish ways to measure the quality of patient care and staff performance as well as the degree to which the policies and procedures are followed;

5. Analyze the necessity of care, treatment, procedures, surgery, and/or services rendered;

6. Analyze the effectiveness of the fire plan;

7. Analyze all serious incidents and accidents, to include all patient deaths and significant medication errors;

8. Analyze any other unusual occurrences that threaten the health, safety, or well-being of the patients;

9. At least every three months, review an established percentage of patient records to verify the accuracy and integrity of the system, and take corrective action as needed;

10. Establish a systematic method of obtaining feedback from patients and other interested persons, e.g., family members and peer organizations, as expressed by the level of satisfaction with care, treatment, procedures, surgery, and/or services received.

C. The governing body must ensure the quality improvement program:

1. Is defined, implemented, and maintained by the Facility;

2. Addresses the Facility's priorities and that all improvements are evaluated for effectiveness;

3. Specifies data collection methods, frequency, and details;

4. Clearly establishes its expectations for safety; and

5. Adequately allocates sufficient staff, time, information systems, and training to implement the quality improvement program.

Disclaimer: These regulations may not be the most recent version. South Carolina may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.