|(a) Scope and content of program. A hospital shall
develop, implement, and maintain an effective, ongoing, hospital-wide,
data-driven quality assessment and performance improvement program.
The program shall:
(1) reflect the complexity of the hospital's organization
(2) involve all the hospital's services;
(3) specify the frequency and detail of data collected;
(4) focus on high-risk, high-volume, and problem-prone
areas in the hospital.
(b) Approval by governing body. The hospital's governing
body shall approve the hospital's quality assessment and performance
(c) Staff member participation. The director of psychiatric
nursing (DPN), the director of psychiatric services, and other appropriate
staff members shall participate in the development and implementation
of the quality assessment and performance improvement program.
(d) Quality assessment and performance improvement
(1) As part of its quality assessment and performance
improvement activities, a hospital shall collect and aggregate data
(A) monitor the effectiveness and safety of services
and the quality of care; and
(B) identify opportunities for improvement and changes
that will lead to improvement.
(2) The hospital shall collect and aggregate all data,
on an ongoing basis, for each of the following performance indicators
at a minimum:
(A) sentinel events;
(B) allegations of abuse and neglect, as defined in §510.46
of this title (relating to Abuse and Neglect Issues);
(C) findings of abuse and neglect made by HHSC, in
accordance with §510.46 of this title (relating to Abuse and
(D) violations of patient rights described in 25 TAC
Chapter 404, Subchapter E (relating to Rights of Persons Receiving
Mental Health Services);
(E) nosocomial infections;
(F) injuries of patients;
(G) medication errors;
(H) unauthorized departures of patients;
(I) deaths of patients;
(J) surveys of patients, patient's families, and legally
authorized representatives (LAR) regarding satisfaction with hospital
(K) complaints and grievances made by patients, patient's
families, and LARs.
(3) The hospital shall analyze the aggregated data,
at least quarterly, to assess the need for performance improvement.
(4) When a need for performance improvement is identified,
the hospital shall develop and implement an action plan to address
the identified need.
(5) The hospital shall evaluate the success of the
action plan to determine if the positive outcomes are achieved and
(6) If the hospital determines that the positive outcomes
have not been achieved or sustained, the hospital shall modify the
action plan and re-evaluate its implementation until the outcomes
are achieved and sustained.
(e) Evidence of program. The hospital shall maintain
and demonstrate evidence of the quality assessment and performance
improvement program for review by an external review entity, including
HHSC, the Centers for Medicare and Medicaid Services, or the accrediting