N.H. Admin. Code § He-P 812.21

Current through Register No. 45, November 7, 2024

Section He-P 812.21 - Quality Assessment and Performance Improvement

(a) The licensee shall develop and implement a quality improvement program that reviews policies and services and maximizes quality by preventing and correcting identified problems.

(b) As part of its quality improvement program, an interdisciplinary quality assurance and performance improvement committee shall be created and required to:

(1) Meet at least quarterly to evaluate quality assurance and performance improvement activities;

(2) Generate dated, written minutes for each meeting;

(3) Maintain all quality improvement activities, including minutes of meetings, for at least 2 years from the date the record was created; and

(4) Make recommendations to the governing body to improve the quality of care.

(c) Quality assurance and performance improvement activities shall include:

(1) Review of patterns and trends of activities which affect the quality of care;

(2) Ensuring that quality control logs for preventive maintenance and safety checks are maintained for all equipment according to manufacturer's recommendations or code requirements;

(3) Monitoring and evaluation of the quality of patient care and patient care services in the ASC which shall include:

a. Monitoring of medication use and review of pharmacy activity in the ASC;

b. Review of patient record quality;

c. Review of blood use in the ASC, as applicable; and

d. Review of other functions such as risk management, infection control, disaster planning, ASC safety, and utilization review; and

(4) Reviewing and making recommendations for improvement in areas such as:

a. Infection surveillance;

b. Morbidity;

c. Mortality;

d. Monitoring of personnel quality control practices in each service; and

e. Adverse events in accordance with He-P 812.15.

(d) For each quality assurance and performance improvement activity, the committee shall:

(1) Determine the information to be monitored;

(2) Determine the frequency with which information will be reviewed;

(3) Determine the indicators that will apply to the information being monitored;

(4) Evaluate the information that is gathered;

(5) Determine the action that is necessary to correct identified problems;

(6) Recommend corrective actions to the ASC; and

(7) Evaluate the effectiveness of the corrective actions and determine additional corrective actions as applicable.

N.H. Admin. Code § He-P 812.21

#9727-A, eff 6-18-10

Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12557, Effective 6/26/2018, Expires 12/24/2018.

Amended by Volume XXXIX Number 50, Filed December 12, 2019, Proposed by #12926, Effective 11/26/2019, Expires 11/26/2029.