Ohio Administrative Code|Rule 3701-83-12 | General quality assessment and performance improvement.

                                                
(A) Each HCF shall establish a quality
		  assessment and performance improvement program designed to systematically
		  monitor and evaluate the quality of patient care, pursue opportunities to
		  improve patient care, and resolve identified problems.
(B) Each HCF shall develop a written plan
		  that describes the quality assessment and performance improvement
		  program's objectives, organization, scope, and mechanism for overseeing
		  the effectiveness of monitoring, evaluation, improvement and problem-solving
		  activities.
(C) The quality assessment and
		  performance improvement program shall do all of the following:
(1) Monitor and evaluate
			 all aspects of care including effectiveness, appropriateness, accessibility,
			 continuity, efficiency, patient outcome, and patient satisfaction;
(2) Establish
			 expectations, develop plans, and implement procedures to assess and improve
			 quality of care and resolve identified problems;
(3) Establish
			 expectations, develop plans, and implement procedures to assess and improve the
			 health care facility's governance, management, clinical, and support
			 processes;
(4) Establish information
			 systems and appropriate data management processes to facilitate the collection,
			 management, and analysis of data needed for quality assessment and performance
			 improvement and to comply with the applicable data collection requirements of
			 Chapter 3701-83 of the Administrative Code;
(5) Document and report
			 the status of the quality assessment and performance improvement program to the
			 governing body every twelve months;
(6) Document and review
			 all unexpected complications and adverse events, whether serious injury or
			 death, that arise during an operation or procedure; and
(7) Hold regular
			 meetings, chaired by the medical director of the HCF or designee, as necessary,
			 but at least within sixty days after a serious injury or death, to review all
			 deaths and serious injuries, and report findings. Any pattern that might
			 indicate a problem shall be investigated and remedied, if
			 necessary.
(D) Each HCF shall implement a program
		  for proactive assessment of high-risk activities related to patient safety and
		  to undertake appropriate improvements.
(E) Each HCF shall report to the
		  director, in a manner and interval prescribed by the director, the data
		  specified in the applicable rules of Chapter 3701-83 of the Administrative
		  Code.