Wis. Admin. Code DHS §124-10 - Quality Assurance

This law governs quality assurance at hospitals.  The law makes the governing body responsible for ensuring that the hospital has a quality assurance program constantly monitoring and evaluating the quality of patient care and other services.  The program must aim to promote the most effective and efficient use of resources while fulfilling patient needs.  The law makes the hospital’s CEO responsible for ensuring that this program is implemented effectively, that findings of the program are incorporated into staff performance assessments, and that the findings of the program are reported back to the governing body when necessary.
 
The law gives examples of the kind of data sources that are to be used in evaluating the quality of services – medical records, hospital information systems, peer review data, and third party payer information.  Hospitals are further required to document how the information from the quality assurance program has been used to improve quality of care and initiate changes for the better of the patients.  The CEO is tasked with the responsibility of ensuring that the effectiveness of the quality assurance program is evaluated by the clinical and administrative staff at least once a year, and of forwarding these results to the governing body.