Quality improvement

(a) General. There shall be an ongoing quality improvement program, approved by the governing body, which shall identify problems in the facility, suggest solutions, and monitor resolutions. (b) Quality improvement plan. A written quality improvement plan shall be developed, approved, and implemented by the governing body with advice from the medical and professional staff. The plan shall include but not be limited to the following: (1) Methods of evaluating all patient services to ensure quality of care, including those provided under contract. (2) Methods of evaluating off-site health care services for appropriateness of use and the degree to which the services aid in the provision of quality patient care. (3) The evaluation of nosocomial infections and accompanying medication therapy shall be linked to the hospital-wide quality improvement program through regular reporting to the medical and professional staff committee of the whole. (4) Methods of evaluating physician and practitioner services to ensure these services are provided in conformance with facility policy and state law. (5) Methods of evaluating on-call services to ensure staff are available as required. (c) Quality improvement committee. The EH may establish a quality improvement committee or this function may be fulfilled by the medical and professional staff committee of the whole. Quality improvement activities shall be reported by facility staff to the committee at least every three (3) months or more frequently if findings require immediate action by the committee. (d) Quality improvement implementation. There shall be documentation that the EH has taken appropriate action to address problems identified. The EH shall document the monitoring of the effectiveness of the proposed solutions. (e) Communication. Quality improvement committee reports shall be communicated at least every three (3) months to the governing body. If the quality improvement committee meets separately from the medical and professional staff committee of the whole, these reports shall also be communicated at least every three (3) months to the medical and professional staff.