77 Ill. Adm. Code 270.2300
Quality Assessment and Improvement
Section 270
Section 270.2300Â Quality
Assessment and Improvement
a)Â Â Â Â Â Â Â Â The licensee shall develop and implement a quality assessment
and improvement program designed to meet at least the following goals:
1)Â Â Â Â Â Â Â Â Ongoing monitoring and evaluation of the quality and
accessibility of care and services provided at the facility or under contract,
including but not limited to:
A)Â Â Â Â Â Â Â Admission of patients appropriate to the capabilities of the
facility;
B)Â Â Â Â Â Â Â Patient assessment;
C)Â Â Â Â Â Â Â Development and implementation of appropriate comprehensive
care plans;
D)Â Â Â Â Â Â Â Patient satisfaction;
E)Â Â Â Â Â Â Â Costs for delivery of services; and
F)Â Â Â Â Â Â Â Â Infection control.
2)Â Â Â Â Â Â Â Â Identification and analysis of problems.
3)Â Â Â Â Â Â Â Â Identification and implementation of corrective action or
changes in response to problems.
b)Â Â Â Â Â Â Â Â The program shall operate pursuant to a written plan, which
shall include, but not be limited to:
1)Â Â Â Â Â Â Â Â A detailed statement of its goals;
2)Â Â Â Â Â Â Â Â The methodology and criteria that will be used to meet each
stated goal;
3)Â Â Â Â Â Â Â Â The action plans for addressing problems;
4)Â Â Â Â Â Â Â Â Procedures for evaluating the effectiveness of action plans
and revising action plans to prevent reoccurrence of problems;
5)Â Â Â Â Â Â Â Â Procedures for documenting the activities of the program; and
6)Â Â Â Â Â Â Â Â Identifying the persons responsible for administering the
program.
c)Â Â Â Â Â Â Â Â The licensee shall afford the Department and the Board access
to any materials or documents generated pursuant to the facility's quality assessment
and improvement program or that otherwise relate to patient demand, utilization
and satisfaction; healthcare costs; healthcare cost effectiveness; financial
viability of the facility; and access to healthcare services. Such information
shall be used by the Department and the Board to evaluate and assess the
facility in relation to the Demonstration Program, and shall be afforded the
same confidential status as is provided information concerning medical studies
in Article VIII, Part 21 of the Code of Civil Procedure (Ill. Rev. Stat. 1991,
ch. 110, pars 1-101 et seq.) [735 ILCS 5/1-101 - 1-109].