NAC449.3152. Quality improvement program.

     1. The governing body of a hospital shall ensure that the hospital has an effective, comprehensive quality improvement program to evaluate the provision of care to its patients.

     2. The quality improvement program must:

     (a) Be ongoing;

     (b) Include a written plan for carrying out the program; and

     (c) Provide for the creation of a committee to oversee the program.

     3. All services related to patient care, including services furnished by a contractor, must be evaluated by the committee.

     4. Nosocomial infections, medication therapy and deaths occurring in the hospital must be evaluated by the committee.

     5. All medical and surgical services performed in the hospital must be evaluated by the committee as those services relate to the appropriateness of the diagnosis and treatment.

     6. The committee shall initiate an assessment of a service or the provision of care when any statistical analysis detects an undesirable variation in performance.

     7. The committee shall take and document appropriate remedial action to address deficiencies found through the quality improvement program. The committee shall document the outcome of any remedial action taken.

     8. When the findings of an assessment relate to the performance of an individual licensed practitioner, the medical staff shall determine how such a finding will be used in any peer review, ongoing monitoring and periodic evaluations of the competence of the practitioner. If the findings of the assessment relate to the performance of a person who is not a licensed practitioner, the director of the department, unit or service in which that person works shall determine how the finding will be used in evaluating the competence of the person.

     (Added to NAC by Bd. of Health by R050-99, eff. 9-27-99)