Current through Reg. 49, No. 38; September 20, 2024
(a) Scope and
content of program. A hospital shall develop, implement, and maintain an
effective, ongoing, hospital-wide, data-driven quality assessment and
performance improvement program. The program shall:
(1) reflect the complexity of the hospital's
organization and services;
(2)
involve all the hospital's services;
(3) specify the frequency and detail of data
collected; and
(4) focus on
high-risk, high-volume, and problem-prone areas in the hospital.
(b) Approval by governing body.
The hospital's governing body shall approve the hospital's quality assessment
and performance improvement program.
(c) Staff member participation. The director
of psychiatric nursing (DPN), the director of psychiatric services, and other
appropriate staff members shall participate in the development and
implementation of the quality assessment and performance improvement program.
(d) Quality assessment and
performance improvement program activities.
(1) As part of its quality assessment and
performance improvement activities, a hospital shall collect and aggregate data
to:
(A) monitor the effectiveness and safety
of services and the quality of care; and
(B) identify opportunities for improvement
and changes that will lead to improvement.
(2) The hospital shall collect and aggregate
all data, on an ongoing basis, for each of the following performance indicators
at a minimum:
(A) sentinel events;
(B) allegations of abuse and neglect, as
defined in §
510.46
of this title (relating to Abuse and Neglect Issues);
(C) findings of abuse and neglect made by
HHSC, in accordance with §
510.46
of this title (relating to Abuse and Neglect Issues);
(D) violations of patient rights described in
25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving
Mental Health Services);
(E)
nosocomial infections;
(F)
injuries of patients;
(G)
medication errors;
(H)
unauthorized departures of patients;
(I) deaths of patients;
(J) surveys of patients, patient's families,
and legally authorized representatives (LAR) regarding satisfaction with
hospital services; and
(K)
complaints and grievances made by patients, patient's families, and LARs.
(3) The hospital shall
analyze the aggregated data, at least quarterly, to assess the need for
performance improvement.
(4) When
a need for performance improvement is identified, the hospital shall develop
and implement an action plan to address the identified need.
(5) The hospital shall evaluate the success
of the action plan to determine if the positive outcomes are achieved and
sustained.
(6) If the hospital
determines that the positive outcomes have not been achieved or sustained, the
hospital shall modify the action plan and re-evaluate its implementation until
the outcomes are achieved and sustained.
(e) Evidence of program. The hospital shall
maintain and demonstrate evidence of the quality assessment and performance
improvement program for review by an external review entity, including HHSC,
the Centers for Medicare and Medicaid Services, or the accrediting
organization.
