| (a) Each facility shall develop, implement, maintain,
and evaluate an effective, ongoing, facility-wide, data-driven, interdisciplinary
quality assessment and performance improvement (QAPI) program. The
program shall be individualized to the facility and meet the criteria
and standards described in this section.
(b) The program shall reflect the complexity of the
facility's organization and services involved. All facility services
(including services furnished under contract or arrangement) shall
focus on indicators related to improved health outcomes and prevention
and reduction of medical errors.
(c) The program shall include an ongoing program that
achieves measurable improvement in health outcomes and reduction of
medical errors by using indicators or performance measures associated
with improved health outcomes and with the identification and reduction
of medical errors.
(d) The facility shall demonstrate that facility staff,
including the medical, nursing, and pharmacy staff, evaluate the provision
of emergency care and patient services, set treatment goals, identify
opportunities for improvement, develop and implement improvement plans,
and evaluate the implementation until resolution is achieved.
(e) The facility shall measure, analyze, and track
quality indicators, or other aspects of performance that the facility
adopts or develops, that reflect processes of care and facility operations.
(f) The facility shall provide evidence supporting
that the facility continuously reviews aggregate patient data, including
identification and tracking of patient infections, for trends.
(g) Core staff members, including the medical, nursing,
and pharmacy staff, shall actively participate in the QAPI activities,
including QAPI meetings.
(1) QAPI meetings shall be held monthly, or more often
as necessary, to identify or correct problems.
(2) QAPI meetings shall be documented.
(h) The facility's QAPI program shall include:
(1) an ongoing review of key elements of care using
comparative and trend data to include aggregate patient data;
(2) identification of areas where performance measures
or outcomes indicate an opportunity for improvement;
(3) appointment of interdisciplinary improvement teams
to:
(A) identify, measure, analyze, and track indicators
for variation from desired outcomes;
(B) create and implement improvement plans;
(C) evaluate the implementation of the improvement
plans; and
(D) continue monitoring and improvement activities
until resolution of the improvement plan;
(4) establishing and monitoring quality indicators
related to improved health outcomes, which includes establishing and
monitoring a level of performance consistent with current professional
knowledge for each quality assessment indicator that must influence
or relate to the desired outcomes themselves;
(5) monthly measurement, analysis, and tracking of
at least the following indicators:
(A) infection control (staff and patient screening;
standard precautions);
(B) adverse events;
(C) mortality (review of each death and monitoring
modality specific mortality rates);
(D) complaints and suggestions (from patients, family,
or staff);
(E) staffing to include orientation, training, delegation,
licensing and certification, and non-adherence to policies and procedures
by facility staff;
(F) safety (fire and disaster preparedness, use of
the Texas Health and Human Services Commission (HHSC) emergency/disaster
notification form, and disposal of special waste); and
(G) clinical records review to include treatment errors
and medication errors; and
(6) the facility shall continuously monitor performance,
take actions that result in performance improvement, and track performance
to ensure that improvements are sustained over time. The facility
shall immediately correct any identified problems that threaten the
health and safety of patients.
(i) HHSC may review a facility's QAPI activities to
determine compliance with this section.
(1) An HHSC inspector shall verify that the facility
has a QAPI program, which addresses concerns relating to quality of
care provided to its patients and that the core staff members have
knowledge of and the ability to access the facility's QAPI program.
(2) HHSC may not require disclosure of QAPI program
records, except when disclosure is necessary for HHSC to determine
compliance with this section.
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