N.M. Admin. Code § 8.370.12.23

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.370.12.23 - QUALITY IMPROVEMENT

A.Responsibility of the governing body: The governing body shall ensure that the hospital has a written quality improvement program for monitoring, evaluating and improving the quality of patient care and the ancillary services in the hospital on an on-going basis. The program shall promote the most effective and efficient use of available health facilities and services consistent with patient needs and professionally recognized standards of health care.

B.Responsibilities of the chief executive officer/ administrator and the chief of the medical Staff. As part of the quality improvement program, the chief executive officer/administrator and chief of the medical staff shall ensure that:

(1) the hospital's quality improvement program is implemented and evaluated for effectiveness for all patient care and all services;

(2) the findings of the program are incorporated into a well defined method of assessing staff performance in relation to patient care and the provision of services; and

(3) program findings, actions and results of the hospital's quality improvement program are reported to the chief executive officer/administrator, chief of medical staff and governing body not less than annually.

C.Evaluation of Care to be Problem-Focused.

(1) Monitoring and evaluation of the quality of care given patients and services provided shall focus on identifying patient care problems and opportunities for improving patient care.

(2) Evaluation of care and services shall be problem-focused whenever serious events occur which have a major impact on patient care and services, or when the hospital receives a quality-of-care concern or complaint.

D.Evaluation of care and services to use variety of sources. The quality of care given patients shall be evaluated using a variety of data sources, including, but not limited to, medical records, hospital information systems, published research, literature comparison, peer review organization data, patient satisfaction findings, and when available, third party information.

E.Activities. Hospitals shall document how each of the monitoring and evaluation activities has produced data used to institute changes to improve quality of care or services and promote more efficient use of facilities and services. Quality improvement activities shall:

(1) emphasize identification and analysis of patterns of patient care and suggest possible changes for maintaining consistently high quality care and effective and efficient use of services;

(2) identify and analyze factors related to the patient care rendered in the facility and, where indicated, make recommendations to the governing body, chief executive officer/ administrator and chief of the medical staff for changes that are beneficial to patients, staff, the facility and the community; and

(3) document the monitoring and evaluation activities performed and indicate how the results of these activities have been used to institute changes to improve the quality and a appropriateness of the care provided.

F.Evaluation of the program. The chief executive officer/administrator and chief of medical staff shall be involved in evaluation of the effectiveness of the quality improvement program which is evaluated by clinical and administrative staff at least once a year and that the results are communicated to the governing body.

N.M. Admin. Code § 8.370.12.23

Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024