La. Admin. Code tit. 48 § I-6775

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

Section I-6775 - 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 client care. This program shall include all services, provided directly or through contract.

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 and for participation in the state perinatal quality collaborative, which is under the authority of the Louisiana Commission on Perinatal Care and Prevention on Infant Mortality, defined as reporting perinatal measures determined by the Louisiana Commission on Perinatal Care and Prevention on Infant Mortality.

C. The FSBC shall ensure there is a written quality assurance plan for assessing and improving quality of care that is focused on problem-prone areas, and which specifies the intervals that the FSBC shall actively collect data related to the quality indicators and show participation in the state perinatal quality collaborative as required. Performance improvement activities shall consider incidence, prevalence, and severity of problems and those that can affect health outcomes, client 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 client care, including services furnished by a contractor shall be evaluated.

D. Nosocomial infections, client care outcomes, and perinatal and newborn care services performed in the FSBC shall be evaluated as they relate to appropriateness of care and services rendered.

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

F. The QAPI program shall monitor, identify, and develop a plan for elimination of medication errors and adverse client (mother and infant) events.

G. 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 FSBC. Staff education and training related to the correction of problems shall be documented.

La. Admin. Code tit. 48, § I-6775

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 482124 (8/1/2022).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and R.S. 40:2180.21-2180.28.