PURPOSE: This rule specifies the requirements for quality improvement programs in a hospital.

1. (1) The governing body shall ensure the development and implementation of an effective, ongoing, systematic hospital-wide, patient-oriented performance improvement plan.
2. (2) This plan shall be designed to measure, assess and improve the quality of patient care as evidenced by patient health outcomes or improvement in processes, or both.

3. (3) The performance improvement plan shall be written and shall include:

   1. (A) Description of the plan purpose, objectives, organizations, scope, authority, responsibility, and mechanisms of a planned systematic, organization-wide approach to designing, measuring, assessing and improving performance;
   2. (B) Assurance of collaborative participation from appropriate departments and services, both clinical and nonclinical, including those services provided directly and under contract;
   3. (C) Provision for assessment and coordination of quality improvement activities through an established oversight team that meets on an established periodic basis;
   4. (D) Assurance of ongoing communication, reporting and documentation of patient-care issues and quality improvement activities and their effectiveness to the governing body and medical staff at least quarterly; and
   5. (E) Development of an annual assessment of the effectiveness of the plan.

4. (4) At a minimum, the plan shall include:

   1. (A) Organization-wide design, measurement, assessment and improvement of patient care and organizational functions;
   2. (B) Review of care that includes outcomes of care provided by the medical and nursing staff and by other health care practitioners employed or contracted by the hospital;
   3. (C) Measurements of quality of care which are outcomeor process-based, specific to the hospital, and to identified needs and expectations of the patients and staff;
   4. (D) Review on a continuing basis of the processes that affect a large percentage of patients, that place patients at risk or that have caused or are likely to cause quality problems; and
   5. (E) Review of all hospital specific data and state normative data provided by the Department of Health (DOH). The CEO or his/her designee shall respond to the DOH with a corrective plan when the hospital is directed to do so by the Bureau of Hospital Licensing and Certification.
   6. (F) The performance improvement plan shall be designed to review activity, actions initiated and reassessments. Documentation shall be maintained on these activities. 19 CSR 30-20

AUTHORITY: sections 192.006 and 197.080, RSMo 2000 and 197.154, RSMo Supp. 2007.* This rule previously filed as 19 CSR 30-20.021(3)(M). Original rule filed June 27, 2007, effective Feb. 29, 2008. *Original authority: 192.006, RSMo 1993, amended 1995; 197.080, RSMo 1953, amended 1993, 1995; and 197.154, RSMo 2004.