Ch. 17, § 16. Quality Improvement

(a) The governing body, in accordance with W.S. 35-2-910, shall ensure there is an effective, on-going, facility-wide, written quality improvement program which ensures and evaluates the quality of patient care provided and includes an annual review of the following: (i) The utilization of facility services, including at least the number of patients served and volume of services; and (ii) The facility's health care policies. (b) The initiation and documentation of appropriate remedial action to address deficiencies found through the quality improvement program, as well as documentation of the outcome of remedial action.