16 Del. Admin. Code § 3340-9.0

Current through Register Vol. 28, No. 3, September 1, 2024

Section 3340-9.0 - Quality Assessment Performance Improvement

9.1 The FSED shall develop, implement, maintain, and evaluate an effective, ongoing facility-wide, data driven, interdisciplinary QAPI program.

9.2 The QAPI program shall reflect the complexity of the facility's organization and services. All facility services (including those services furnished under contract or arrangement) shall focus on indicators related to improved health outcomes and the prevention and reduction of medical errors.

9.3 The FSED shall measure, analyze and track quality indicators or other aspects of performance that the facility adopts or develops that reflects processes of care and facility operations.

9.4 The facility's ongoing QAPI program shall include:

9.4.1 An ongoing review of key elements of care using comparative and trend data to include aggregate patient data;

9.4.2 Identification of areas where performance measures or outcomes indicate an opportunity for improvement;

9.4.3 Appointment of an interdisciplinary team to:

9.4.3.1 Identify, measure, analyze and track indicators for variation from desired outcomes;

9.4.3.2 Create and implement improvement plan or plans;

9.4.3.3 Evaluate the implementation of the improvement plan or plans; and

9.4.3.4 Continue monitoring and improvement activities until resolution of the improvement plan.

9.4.4 Establishment and monitoring of quality indicators related to improved health outcomes. For each quality assessment indicator, the facility shall establish and monitor a level of performance consistent with current professional knowledge. These performance components shall influence or relate to the desired outcomes themselves. At a minimum, the following indicators shall be measured, analyzed, and tracked on a monthly basis:

9.4.4.1 Infection control (staff and patient screening, standard precautions);

9.4.4.2 Adverse incidents;

9.4.4.3 Mortality (review of each death and monitoring modality specific mortality rates);

9.4.4.4 Complaints and suggestions;

9.4.4.5 Staffing;

9.4.4.6 Safety; and

9.4.4.7 Clinical record reviews to include treatment and medication errors.

9.5 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.

16 Del. Admin. Code § 3340-9.0

24 DE Reg. 692( 1/1/2021) (final)