W. Va. Code R. § 64-12-15

Current through Register Vol. XLI, No. 36, September 6, 2024

Section 64-12-15 - Quality Assessments and Performance Improvement

15.1. The governing body, medical staff, and hospital administration are responsible for and shall review at least annually the development, implementation, and maintenance and effective evaluation of quality assessments for performance improvement. This process systematically collects, measures, analyzes, and tracks objective indicators of the care and hospital operations. This evaluation plan should reflect the complexity of the hospital's organization and services.

15.2. The focus of performance evaluation shall be in areas over which the hospital exercises authority and responsibility, including services furnished by contract.

15.3. Priorities for performance improvement projects shall be based upon the prevalence and severity of problems which most affect clinical outcomes identified through the data collected.

15.4. Performance measures may be designed and implemented under contract by the hospital staff through research or consensus groups within the facility or through the use of credible consultants.

15.5. Performance measures shall be commensurate with the size and resources available to each hospital.

15.6. Performance measures should use not only hospital-specific data, but peer review organizations and any other available relevant data for comparative purposes as an integral part of the assessment plan.

15.7. The hospital shall make available to the Department the results of peer review and quality assessments and performance improvement information, upon the Department's request.

15.8. Quality improvement activities should be demonstrably linked to findings of performance evaluations and cover the full range of the hospital's services to patients.

15.9. The hospital shall conduct an assessment of the impact of quality improvement activities and corrections or reevaluation of the performance indicators, no longer than six months after any change is instituted, unless another time period for assessment can be justified based upon analytic factors, such as adequate sample size, or circumstances outside the control of the hospital.

15.10. Areas of measurement.

At a minimum the measure shall include, but not be limited to:

15.10.1. Nosocomial infections and other infection control issues;

15.10.2. Staff, administrative, and practitioner performance;

15.10.3. Complaints, grievances, or risk management findings;

15.10.4. Evaluation of diagnostic and therapeutic services provided;

15.10.5. Medication errors and other incidents or occurrences;

15.10.6. Drug therapy and adverse drugs reactions; and

15.10.7. Evaluation of all services provided to patients by staff accountable to the hospital through employment or contract.

W. Va. Code R. § 64-12-15