(a)

1. (1) The organization shall develop, implement, and maintain an ongoing program to assess and improve the quality of care and services provided.
2. (2) A quality improvement (QI) plan shall be developed and maintained to describe the manner in which QI activities shall be conducted.
3. (3) The QI plan shall be reviewed and approved by the medical staff and governing body annually.
4. (4) All hospice programs, services, departments, and functions, including contracted services related to patient care, shall participate in ongoing quality improvement activities.
5. (5) The hospice shall collect and assess data on the functional activities identified as priorities in the QI plan.
6. (6) Improvement strategies shall be developed for programs, services, departments, and functions identified with opportunities for improvement.
7. (7) The effectiveness of improvement strategies and actions taken shall be monitored and evaluated, with documentation of conclusions regarding effectiveness.

(b) The QI program shall include but not be limited to ongoing assessment and improvement activities regarding the following:

1. (1) Access to care, processes of care, outcomes of care, and hospice-specific clinical data; and
2. (2) Customer satisfaction (patients and families, physicians, and employees).