| (a) A limited services rural hospital (LSRH) shall
develop, implement, and maintain an effective, ongoing, LSRH-wide,
data-driven quality assessment and performance improvement (QAPI)
program.
(b) An LSRH's governing body shall ensure the QAPI
program is individualized to ensure the LSRH complies with the requirements
of this section, reflects the complexity of the LSRH's organization
and services, involves all LSRH departments and services (including
those services furnished under contract or arrangement), and focuses
on indicators related to improved health outcomes and the prevention
and reduction of medical errors. The LSRH must maintain and demonstrate
evidence of its QAPI program.
(c) The LSRH shall measure, analyze, and track quality
indicators, including adverse patient events, staffing, and other
aspects of performance to evaluate processes of care, including LSRH
service and operations.
(d) The QAPI program shall:
(1) include an ongoing program that shows measurable
improvement in indicators for which there is evidence that it will
improve health outcomes and identify and reduce medical errors;
(2) incorporate quality indicator data, including patient
care data, and other relevant data, to achieve the goals of the QAPI
program;
(3) evaluate all LSRH departments and services, including
services furnished under contract or arrangement;
(4) evaluate health care associated infections;
(5) evaluate medication therapy;
(6) evaluate all medical and surgical services performed
in the LSRH as they relate to appropriateness of diagnosis and treatment;
(7) measure, analyze, and track quality indicators,
including adverse patients' events, and other aspects of performance
that assess processes of care, LSRH services, and operations; and
(8) use the data collected to monitor the effectiveness
and safety of service and quality of care, and to identify opportunities
for changes that will lead to improvement.
(e) For each quality assessment indicator, the LSRH
shall establish and monitor a level of performance consistent with
current professional knowledge. These performance components shall
influence or relate to the desired outcomes. The LSRH shall measure,
analyze, and track at least the following indicators on a monthly
basis:
(1) infection control, including staff and patient
screening and standard precautions;
(2) adverse events;
(3) mortality, including review of each death and monitoring
modality specific mortality rate;
(4) complaints and suggestions from patients, family,
or staff;
(5) staffing, including orientation, training, delegation,
licensing and certification, and non-adherence to policies and procedures
by facility staff;
(6) safety, including fire and disaster preparedness,
use of a Texas Health and Human Services Commission-required reporting
system, and disposal of special waste; and
(7) clinical records review, including treatment errors
and medication errors.
(f) The LSRH shall establish priorities for performance
improvement activities that focus on high-risk, high-volume, or problem-prone
areas; consider the incidence, prevalence, and severity of problems
in those areas; and affect health outcomes, patient safety, and quality
of care. Performance improvement activities shall:
(1) track medical errors and adverse patient events;
(2) analyze their causes; and
(3) implement preventive actions and mechanisms that
include feedback and learning throughout the LSRH.
(g) The LSRH shall measure the success of actions implemented
resulting from performance improvement activities and track ongoing
performance to ensure sustained improvements.
(h) The LSRH shall ensure staff, including the medical,
nursing, and pharmacy staff, complete the following activities:
(1) evaluate the provision of emergency care and patient
services;
(2) set treatment goals;
(3) identify opportunities for improvement;
(4) develop and implement improvement plans; and
(5) evaluate the implementation until resolution is
achieved.
(i) The LSRH shall measure, analyze, and track quality
indicators or other aspects of performance the LSRH adopts or develops
that reflect processes of care and LSRH operations. The LSRH shall
document evidence demonstrating the LSRH continuously reviews aggregate
patient data, including identifying and tracking patient infections
trends.
(j) The LSRH shall hold QAPI meetings as necessary,
but not less than quarterly. Core staff members, including the medical,
nursing, and pharmacy staff, shall actively participate in QAPI activities
and meetings to identify or correct problems. The LSRH shall document
QAPI meetings.
(k) The LSRH's governing body, medical staff, and administrative
officials are responsible and accountable for ensuring:
(1) the LSRH defines, implements, and maintains an
ongoing quality improvement and patient safety program, including
the reduction of medical errors;
(2) the LSRH-wide QAPI efforts address priorities for
improved quality of care and patient safety, and evaluates all improvement
actions;
(3) the LSRH establishes clear expectations for safety;
and
(4) the LSRH allocates adequate resources for measuring,
assessing, improving, and sustaining the LSRH's performance and reducing
risk to patients.
(l) The LSRH shall have an ongoing plan, consistent
with available community and LSRH resources, to provide or make available
social work, psychological, and educational services to meet the medically
related needs of its patients.
(m) When an LSRH is part of a system consisting of
multiple separately certified hospitals, critical access hospitals
(CAHs), or LSRHs using a system governing body that is legally responsible
for the conduct of two or more hospitals, CAHs, or LSRHs, the system
governing body can elect to have a unified and integrated QAPI program
for all of its member facilities after determining that such a decision
is in accordance with all applicable state and local laws. The system
governing body is responsible and accountable for ensuring that each
of its separately certified LSRHs meets all of the requirements of
this section. Each separately certified LSRH subject to the system
governing body must demonstrate:
(1) the unified and integrated QAPI program is established
in a manner that takes into account each member LSRH's unique circumstances
and any significant differences in patient populations and services
offered in each LSRH; and
(2) the unified and integrated QAPI program establishes
and implements policies and procedures to ensure that the needs and
concerns of each of its separately certified LSRHs, regardless of
practice or location, are given due consideration, and the unified
and integrated QAPI program has mechanisms in place to ensure that
issues localized to particular LSRHs are duly considered and addressed.
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