W. Va. Code R. § 69-8-13

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 69-8-13 - Quality Assurance and Performance Improvement

13.1. The designated physician owner, medical staff, and clinic administration are responsible for and shall review at least annually the development, implementation, maintenance, and effective evaluation of quality assessments for performance improvement. This process systematically collects, measures, analyzes, and tracks objective indicators of patient care and clinic operations. This evaluation plan should reflect the complexity of the pain management clinic's organization and services.

13.2. The pain management clinic shall maintain current quality assessment and performance improvement policies that objectively and systematically monitor and evaluate the quality and appropriateness of patient care, evaluate the methods to improve patient care, identify and correct deficiencies within the clinic, and provide for opportunities to improve the clinic's performance and quality of care.

13.3. The clinic shall make available to the secretary the results of peer review and quality assessment and performance improvement information upon request.

13.4. Quality assessment and performance improvement policies and areas of measurement shall include, but not be limited to:

13.4.1. Staff, administrative, and practitioner performance;

13.4.2. Grievance findings;

13.4.3. Evaluation of diagnostic and therapeutic services provided;

13.4.4. Medication errors, drug diversion, and other incidents or occurrences;

13.4.5. Drug therapy and adverse drug reactions;

13.4.6. Evaluation of all services provided to patients by staff accountable to the clinic through employment or contract;

13.4.7. Review and verification of staff credentials, training, periodic education, and licensure;

13.4.8. Review of clinic policies and procedures;

13.4.9. Review of patient satisfaction of services;

13.4.10. Infection control issues in regard to universal infection control guidelines as set forth by the Centers for Disease Control; and

13.4.11. Review of patient outcomes and treatment outcomes.

W. Va. Code R. § 69-8-13