La. Admin. Code tit. 48 § I-4573

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4573 - Quality Assurance and Performance Improvement

A. The governing body shall ensure that there is an implemented, maintained, effective, written, data-driven and ongoing program designed to assess and improve the quality of patient care. This program shall include all services, provided directly or through contract, and those services provided under a use agreement, where applicable.

B. The governing body shall ensure that it allocates sufficient staff, time, information systems and training to implement the Quality Assurance and Performance Improvement (QAPI) Program.

C. The ASC shall ensure there is a written quality assurance plan for assessing and improving quality of care that is focused on high risk, high volume and problem-prone areas, and which specifies the intervals that the ASC shall actively collect data related to the quality indicators. Performance improvement activities shall consider incidence, prevalence and severity of problems and those that can affect health outcomes, patient safety and quality of care. The plan shall describe the system for overseeing and analyzing the effectiveness of monitoring, evaluation and sustained improvement activities. All services related to patient care, including services furnished by a contractor or under a use agreement, shall be evaluated.

D. Nosocomial infections, patient care outcomes, surgical services and other invasive procedures performed in the ASC shall be evaluated as they relate to appropriateness of diagnosis and treatment.

E. The services provided by each licensed practitioner with ASC privileges shall be periodically evaluated to determine whether they are of an acceptable level of quality and appropriateness and in accordance with medical staff bylaws/rules and regulations.

F. Quality assurance and performance improvement shall include monitoring of in-line gases.

G. The QAPI program shall monitor, identify and develop a plan for elimination of medication errors and adverse patient events.

H. Corrective actions to problems identified through the QAPI program with on-going monitoring for sustained corrective action shall be documented. All QAPI data shall be documented and remain within the ASC. Staff education and training related to the correction of problems shall be documented.

I. The number and scope of distinct QAPI improvement projects conducted annually shall reflect the scope and complexity of the ASCs services and operations.

J. The ASC shall document the projects that are being conducted. The documentation, at a minimum, shall include:

1. the reason(s) for implementing the project; and

2. a description of the projects results.

La. Admin. Code tit. 48, § I-4573

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 431751 (9/1/2017).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2131-2141.