La. Admin. Code tit. 48 § I-9401

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

Section I-9401 - Quality Assessment and Performance Improvement

A. There is a written plan for assessing and improving quality that describes the objectives, organization, scope and mechanisms for overseeing the effectiveness of monitoring, evaluation, and improvement activities. All organized services related to patient care, including services furnished by a contractor, shall be evaluated. Nosocomial infections and medication therapy shall be evaluated. All medical and surgical services and other invasive procedures performed in the hospital shall be evaluated as they relate to appropriateness of diagnosis and treatment. The services provided by each practitioner with hospital privileges shall be periodically evaluated to determine whether they are of an acceptable level of quality and appropriateness.

B. Each department or service of the hospital shall address:

1. patient care problems;

2. cause of problems;

3. documented corrective actions; and

4. monitoring or follow-up to determine effectiveness of corrective actions taken.

C. Each department or service of the hospital, through its governing body, shall take and document appropriate remedial action to address deficiencies found through the quality assessment and improvement program. The hospital shall document the outcome of all remedial actions.

La. Admin. Code tit. 48, § I-9401

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing LR 21:177 (February 1995), amended LR 29:2416 (November 2003), Amended by the Department of Health, Health Standards Section, LR 501487 (10/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S.36:254 and R.S. 40:2100-2115.