Section 410 IAC 15-1.4-2 - Quality assessment and improvementAuthority: IC 16-21-1-7
Affected: IC 16-21-1
Sec. 2.
(a) The hospital shall have an effective, organized, hospital-wide, comprehensive quality assessment and improvement program in which all areas of the hospital participate. The program shall be ongoing and have a written plan of implementation that evaluates, but is not limited to, the following: (1) All services, including services furnished by a contractor.(2) All functions, including, but not limited to, the following: (D) Response to emergencies as defined in 410 IAC 15-1.5-5(b)(3)(L)(i).(3) All medical and surgical services performed in the hospital with regard to appropriateness of diagnosis and treatments related to a standard of care and anticipated or expected outcomes.(b) The hospital shall take appropriate action to address the opportunities for improvement found through the quality assessment and improvement program as follows: (1) The action shall be documented.(2) The outcome of the action shall be documented as to its effectiveness, continued follow-up, and impact on patient care.Indiana State Department of Health; 410 IAC 15-1.4-2; filed Dec 21, 1994, 9:40 a.m.: 18 IR 1267; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Jul 14, 2011, 11:42 a.m.: 20110810-IR-410110253RFAReadopted filed 9/13/2017, 4:08 p.m.: 20171011-IR-410170339RFAReadopted filed 11/28/2023, 12:13 p.m.: 20231227-IR-410230639RFA