Regulation .08 Performance Improvement Program.
Regulation .08 Performance Improvement Program.LinkCopy Citation
A.
The performance improvement program shall consist of:
(1)
A committee which:
(a)
Consists of representation of personnel and varied areas of job responsibility; and
(b)
Is responsible for analysis of data, reporting trends and corrective actions; and
(c)
Meets at least quarterly;
(2)
Quality assurance and performance improvement monitoring parameters;
(3)
Documentation requirements for:
(a)
Established monitoring parameters;
(b)
Trend analyses; and
(c)
Retention of committee meeting minutes for 3 years;
(4)
Documentation of tracking, trending, analyzing, resolving, and developing corrective action plans as appropriate for:
(a)
Medication errors;
(b)
Adverse drug reactions; and
(c)
Equipment malfunctions;
(5)
Reporting of adverse events to regulatory and standard-setting bodies as applicable to State and federal regulations;
(6)
Documentation and resolution of patient care issues involving:
(a)
Incorrect equipment, supplies, or medications;
(b)
Delays in delivery of care;
(c)
Missed doses;
(d)
Patient infections;
(e)
Failures in after-hours care; and
(f)
Patient, caregiver, or health care provider complaints;
(7)
Documentation of patient outcomes;
(8)
Recall management;
(9)
Patient compliance monitoring; and
(10)
Staff training and competency compliance.
B.
The permit holder shall review the performance improvement program at a minimum of every 3 years.