General quality assessment and improvement – Ohio Admin. Code 3701-84-12

Each provider of a health care service (HCS) must establish a quality assessment and improvement program and develop a written plan for each service that describes the quality assessment and improvement program’s objectives, organization, scope, and mechanism for overseeing the effectiveness of monitoring, evaluation, improvement and problem-solving activities.   The program must do all the following:

• Monitor and evaluate all aspects of care including effectiveness, appropriateness, accessibility, continuity, efficiency, patient outcome, and patient satisfaction;
• Establish expectations, develop plans, and implement procedures to assess and improve the quality of care and resolve identified problems;
• Establish expectations, develop plans, and implement procedures to assess and improve the HCS’s governance, management, clinical and support processes;
• Establish information systems and appropriate data management processes to facilitate the collection, management, and analysis of data needed for quality improvement;
• Internally document and report findings, conclusions, actions taken, and the results of any actions taken to the HCS’s management and medical director;
• Document and review all unexpected complications and adverse events, which arise during the provision of the service or during the hospital stay; and
• Hold regular meetings, chaired by the medical director of the HCS, or his designee within sixty days after a death or complication, to review all deaths and complications and to report findings. Any pattern that might indicate a problem must be investigated and remedied, if necessary.