Quality Improvement-N.M. Code R. § 7.7.2.23

All hospitals must have a written quality improvement program that monitors and improves patients’ care. It is the responsibility of the Chief Executive Officer of the hospital to implement the quality improvement program. When evaluating care and services, the quality improvement program must analyze medical records, hospital information systems, published research, literature comparison, and peer review organization data, among other sources. Such quality improvement recommendations must emphasize identification and analysis of patterns of care and suggest changes as needed, identify and analyze factors related to patient care, and document all monitoring and evaluation activities.