R432-100-9. Quality Improvement Plan

(1) The board members shall ensure that there is a well-defined quality improvement plan designed to improve patient care. (2) The plan shall: (a) be consistent with the delivery of patient care; (b) be implemented and include a system for the collection of indicator data; (c) ensure that incident reports are available for department review; (d) implement actions designed to eliminate identified problems and improve patient care; (e) include a system for assessing identified problems, concerns, and opportunities for improvement of patient care; and (f) include an incident reporting system to identify problems, concerns, and opportunities for improvement of patient care. (3)(a) The licensee shall maintain a quality improvement committee. (b) The quality improvement committee shall maintain written minutes documenting any corrective action and result and make these minutes available for department review. (4) The quality improvement committee shall report findings and concerns, at least quarterly, to the board, the medical staff, and the administrator. (5) The licensee shall ensure that infection reporting is integrated into the quality improvement plan and is reported to the department in accordance with Rule R386-702.