SECTION 310:667-39-7. Quality improvement

(a)   General. There shall be an ongoing quality improvement program, approved by the governing body, which shall identify problems in the facility, suggest solutions, and monitor results.

(b)   Quality improvement plan. A written quality improvement plan shall be developed, approved, and implemented by the governing body with advice from the medical and professional staff. The plan shall include but not be limited to the following:

(1)   Methods of evaluating all patient services to ensure quality of care, including those provided under contract.

(2)   Methods of evaluating off-site health care services for appropriateness of use and the degree to which the services aid in the provision of quality patient care.

(3)   The evaluation of nosocomial infections and accompanying medication therapy shall be linked to the hospital-wide quality improvement program through regular reporting by appropriate hospital committees and functions such as pharmacy and therapeutics, infection control, pharmaceutical services, etc.

(4)   Evaluation of all surgical procedures if surgery is performed at the facility.

(5)   Methods of evaluating licensed independent practitioner services to ensure these services are provided in conformance with facility policy and state law.

(6)   Methods of evaluating on-call services to ensure staff are available as required.

(c)   Quality improvement committee. The CAH may establish a quality improvement committee or this function may be fulfilled by the medical and professional staff committee of the whole. Quality improvement activities shall be reported by facility staff to the committee at least every three (3) months or more frequently if findings require immediate action by the committee.

(d)   Quality improvement implementation. There shall be documentation that the CAH has taken appropriate action to address problems identified. The CAH shall document the monitoring of the effectiveness of the proposed solutions.

(e)   Communication. Quality improvement committee reports shall be communicated at least every three (3) months to the governing body. If the quality improvement committee meets separately from the medical and professional staff committee of the whole, these reports shall also be communicated at least every three (3) months to the medical and professional staff.

[Source: Added at 12 Ok Reg 1555, eff 4-12-95 (emergency); Added at 12 Ok Reg 2429, eff 6-26-95; Amended at 17 Ok Reg 692, eff 12-16-99 (emergency); Amended at 17 Ok Reg 2992, eff 7-13-00; Amended at 20 Ok Reg 1664, eff 6-12-03]