1. A. The performance improvement program shall consist of:

   1. (1) A committee which:

      1. (a) Consists of representation of personnel and varied areas of job responsibility; and
      2. (b) Is responsible for analysis of data, reporting trends and corrective actions; and
      3. (c) Meets at least quarterly;
   2. (2) Quality assurance and performance improvement monitoring parameters;

   3. (3) Documentation requirements for:

      1. (a) Established monitoring parameters;
      2. (b) Trend analyses; and
      3. (c) Retention of committee meeting minutes for 3 years;

   4. (4) Documentation of tracking, trending, analyzing, resolving, and developing corrective action plans as appropriate for:

      1. (a) Medication errors;
      2. (b) Adverse drug reactions; and
      3. (c) Equipment malfunctions;
   5. (5) Reporting of adverse events to regulatory and standard-setting bodies as applicable to State and federal regulations;

   6. (6) Documentation and resolution of patient care issues involving:

      1. (a) Incorrect equipment, supplies, or medications;
      2. (b) Delays in delivery of care;
      3. (c) Missed doses;
      4. (d) Patient infections;
      5. (e) Failures in after-hours care; and
      6. (f) Patient, caregiver, or health care provider complaints;
   7. (7) Documentation of patient outcomes;
   8. (8) Recall management;
   9. (9) Patient compliance monitoring; and
   10. (10) Staff training and competency compliance.
2. B. The permit holder shall review the performance improvement program at a minimum of every 3 years.

Authority: Health-Occupations Article, §12-205, Annotated Code of Maryland

Effective date: March 1, 2012 (38:23 Md. R. 1421)