General quality assessment and performance improvement – Ohio Admin. Code 3701-83-12

Each health care facility (HCF) must establish a quality assessment and performance improvement program and develop a written plan that describes the program’s objectives, organization, scope and mechanism for overseeing the effectiveness of monitoring, evaluation, improvement, and problem-solving activities.  The program must do all of the following:

• Monitor and evaluate all aspects of care including effectiveness, appropriateness, accessibility, continuity, efficiency, patient outcome, and patient satisfaction;
• Establish expectations, develop plans, and implement procedures to assess and improve the quality of care and resolve identified problems;
• Establish expectations, develop plans, and implement procedures to assess and improve the HCF’s governance, management, clinical and support processes;
• Establish information systems and appropriate data management processes to facilitate the collection, management, and analysis of data needed for quality assessment and performance improvement, and to comply with applicable data collection requirements;
• Annually document and report the status of the quality assessment and performance improvement program to the HCF’s governing body;
• Document and review all unexpected complications and adverse events that arise during an operation or procedure; and
• Hold regular meetings, chaired by the medical director of the HCF or his designee, within sixty days after a serious injury or death, to review all deaths and serious injuries and report findings. Any pattern that might indicate a problem must be investigated and remedied, if necessary.