Section 511.64 - Quality Assessment and Performance Improvement Program(a) A limited services rural hospital (LSRH) shall develop, implement, and maintain an effective, ongoing, LSRH-wide, data-driven quality assessment and performance improvement (QAPI) program.(b) An LSRH's governing body shall ensure the QAPI program is individualized to ensure the LSRH complies with the requirements of this section, reflects the complexity of the LSRH's organization and services, involves all LSRH departments and services (including those services furnished under contract or arrangement), and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The LSRH must maintain and demonstrate evidence of its QAPI program.(c) The LSRH shall measure, analyze, and track quality indicators, including adverse patient events, staffing, and other aspects of performance to evaluate processes of care, including LSRH service and operations.(d) The QAPI program shall: (1) include an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors;(2) incorporate quality indicator data, including patient care data, and other relevant data, to achieve the goals of the QAPI program;(3) evaluate all LSRH departments and services, including services furnished under contract or arrangement;(4) evaluate health care associated infections;(5) evaluate medication therapy;(6) evaluate all medical and surgical services performed in the LSRH as they relate to appropriateness of diagnosis and treatment;(7) measure, analyze, and track quality indicators, including adverse patients' events, and other aspects of performance that assess processes of care, LSRH services, and operations; and(8) use the data collected to monitor the effectiveness and safety of service and quality of care, and to identify opportunities for changes that will lead to improvement.(e) For each quality assessment indicator, the LSRH shall establish and monitor a level of performance consistent with current professional knowledge. These performance components shall influence or relate to the desired outcomes. The LSRH shall measure, analyze, and track at least the following indicators on a monthly basis: (1) infection control, including staff and patient screening and standard precautions;(3) mortality, including review of each death and monitoring modality specific mortality rate;(4) complaints and suggestions from patients, family, or staff;(5) staffing, including orientation, training, delegation, licensing and certification, and non-adherence to policies and procedures by facility staff;(6) safety, including fire and disaster preparedness, use of a Texas Health and Human Services Commission-required reporting system, and disposal of special waste; and(7) clinical records review, including treatment errors and medication errors.(f) The LSRH shall establish priorities for performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, patient safety, and quality of care. Performance improvement activities shall: (1) track medical errors and adverse patient events;(2) analyze their causes; and(3) implement preventive actions and mechanisms that include feedback and learning throughout the LSRH.(g) The LSRH shall measure the success of actions implemented resulting from performance improvement activities and track ongoing performance to ensure sustained improvements.(h) The LSRH shall ensure staff, including the medical, nursing, and pharmacy staff, complete the following activities:(1) evaluate the provision of emergency care and patient services;(3) identify opportunities for improvement;(4) develop and implement improvement plans; and(5) evaluate the implementation until resolution is achieved.(i) The LSRH shall measure, analyze, and track quality indicators or other aspects of performance the LSRH adopts or develops that reflect processes of care and LSRH operations. The LSRH shall document evidence demonstrating the LSRH continuously reviews aggregate patient data, including identifying and tracking patient infections trends.(j) The LSRH shall hold QAPI meetings as necessary, but not less than quarterly. Core staff members, including the medical, nursing, and pharmacy staff, shall actively participate in QAPI activities and meetings to identify or correct problems. The LSRH shall document QAPI meetings.(k) The LSRH's governing body, medical staff, and administrative officials are responsible and accountable for ensuring:(1) the LSRH defines, implements, and maintains an ongoing quality improvement and patient safety program, including the reduction of medical errors;(2) the LSRH-wide QAPI efforts address priorities for improved quality of care and patient safety, and evaluates all improvement actions;(3) the LSRH establishes clear expectations for safety; and(4) the LSRH allocates adequate resources for measuring, assessing, improving, and sustaining the LSRH's performance and reducing risk to patients.(l) The LSRH shall have an ongoing plan, consistent with available community and LSRH resources, to provide or make available social work, psychological, and educational services to meet the medically related needs of its patients.(m) When an LSRH is part of a system consisting of multiple separately certified hospitals, critical access hospitals (CAHs), or LSRHs using a system governing body that is legally responsible for the conduct of two or more hospitals, CAHs, or LSRHs, the system governing body can elect to have a unified and integrated QAPI program for all of its member facilities after determining that such a decision is in accordance with all applicable state and local laws. The system governing body is responsible and accountable for ensuring that each of its separately certified LSRHs meets all of the requirements of this section. Each separately certified LSRH subject to the system governing body must demonstrate: (1) the unified and integrated QAPI program is established in a manner that takes into account each member LSRH's unique circumstances and any significant differences in patient populations and services offered in each LSRH; and(2) the unified and integrated QAPI program establishes and implements policies and procedures to ensure that the needs and concerns of each of its separately certified LSRHs, regardless of practice or location, are given due consideration, and the unified and integrated QAPI program has mechanisms in place to ensure that issues localized to particular LSRHs are duly considered and addressed.26 Tex. Admin. Code § 511.64
Adopted by Texas Register, Volume 48, Number 39, September 29, 2023, TexReg 5682, eff. 10/5/2023