410 IAC 15-1.4-2 Quality assessment and improvement

Sec. 2. (a) The hospital shall have an effective, organized, hospital-wide, comprehensive quality assessment and improvement program in which all areas of the hospital participate. The program shall be ongoing and have a written plan of implementation that evaluates, but is not limited to, the following: (1) All services, including services furnished by a contractor. (2) All functions, including, but not limited to, the following: (A) Discharge planning. (B) Infection control. (C) Medication therapy. (D) Response to emergencies as defined in 410 IAC 15-1.5-5(b)(3)(L)(i). (3) All medical and surgical services performed in the hospital with regard to appropriateness of diagnosis and treatments related to a standard of care and anticipated or expected outcomes. (b) The hospital shall take appropriate action to address the opportunities for improvement found through the quality assessment and improvement program as follows: (1) The action shall be documented. (2) The outcome of the action shall be documented as to its effectiveness, continued follow-up, and impact on patient care.