Ga. Comp. R. & Regs. 111-8-40-.13

Current through Rules and Regulations filed through December 24, 2024

Rule 111-8-40-.13 - Quality Management

The governing body shall establish and approve a plan for a hospital-wide quality management program, which includes the use of peer review committees. The purpose of the quality management program is to measure, evaluate, and improve the provision of patient care.

(a) The scope and organization of the quality management program shall be defined and shall include all patient services and clinical support services, contracted services, and patient care services provided by the medical staff.

(b) The hospital's quality management program shall be designed to systematically collect and assess performance data, prioritize data, and take appropriate action on important processes or outcomes related to patient care, including but not limited to:

1. Operative procedures and other invasive and non-invasive procedures that place patients at risk;

2. Nosocomial infection rates;

3. Patient mortality;

4. Medication use;

5. Patient injuries, such as, but not limited to, those related to falls and restraint use;

6. Errors in procedures or practices which could compromise patient safety ("near-miss" events);

7. Discrepancies or patterns of discrepancies between preoperative and postoperative diagnosis, including those identified during the pathologic review of specimens removed during surgical or invasive procedures;

8. Significant adverse drug reactions (as identified by the hospital);

9. Adverse events or patterns of adverse events during anesthesia;

10. Equipment malfunctions, for equipment used for patient care; and

11. Reportable patient incidents as required under Rule 111-8-40-.07.

(c) The quality management program shall utilize a defined methodology for implementation, including at least mechanisms and methodology for:

1. Performance measurement including consideration of scope of services;

2. Monitoring, evaluating, and assessing accountability;

3. Setting priorities;

4. Root cause analyses, as appropriate, of problems identified;

5. Process improvement;

6. Identification of expected outcomes;

7. Reporting mechanisms; and

8. Authority for problem resolution.

(d) Results or findings from quality management activities shall be disseminated to the governing body, the medical staff, and any services impacted by the results.

(e) The hospital shall take and document action to address opportunities for improvement identified through the quality management program.

(f) There shall be an on-going evaluation of the quality management program to determine its effectiveness, which shall be presented at least annually for review and appropriate action to the medical staff and governing body.

Ga. Comp. R. & Regs. R. 111-8-40-.13

O.C.G.A. §§ 31-7-2.1 and 31-7-15.

Original Rule entitled "Quality Management" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.