LAC 48:I.9401. Quality Assessment and Performance Improvement

A. There is a written plan for assessing and improving quality that describes the objectives, organization, scope and mechanisms for overseeing the effectiveness of monitoring, evaluation, and improvement activities. All organized services related to patient care, including services furnished by a contractor, shall be evaluated. Nosocomial infections and medication therapy shall be evaluated. All medical and surgical services and other invasive procedures performed in the hospital shall be evaluated as they relate to appropriateness of diagnosis and treatment. The services provided by each practitioner with hospital privileges shall be periodically evaluated to determine whether they are of an acceptable level of quality and appropriateness. B. Each department or service of the hospital shall address: 1. patient care problems; 2. cause of problems; 3. documented corrective actions; and 4. monitoring or follow-up to determine effectiveness of corrective actions taken. C. Each department or service of the hospital, through its governing body, shall take and document appropriate remedial action to address deficiencies found through the quality assessment and improvement program. The hospital shall document the outcome of all remedial actions.