1. (a) develops, implements, and maintains an ongoing, effective, hospice-wide data-driven program for quality assessment and performance improvement, which shall be evaluated annually. The program must:

   1. (1) reflect the complexity of the hospice organization and services;
   2. (2) involve all hospice services, including those services furnished under contract or arrangement, and all locations;
   3. (3) include the use of quality indicator data in the design of the program, which focuses on improved palliative and end of life outcomes;
   4. (4) take actions to demonstrate improvement in hospice performance;
   5. (5) address priorities for improved quality of care and patient safety; and
   6. (6) be capable of showing measurable improvement in indicators related to improved palliative outcomes and hospice services.
2. (b) maintains documentary evidence of the program, and be capable of demonstrating its operation;
3. (c) designates one or more individual(s) responsible for operating the program;

4. (d) designates a committee which includes licensed professionals, representative of the services provided by the hospice, and administrative personnel to participate in and make recommendations to the governing authority regarding the quality program and perform other quality management activities including:

   1. (1) review of quality assessment and performance improvement efforts, at least annually, and in collaboration with the hospice interdisciplinary group recommend revisions to the governing authority, as necessary, of policies and procedures;
   2. (2) review of patient care records for appropriateness of admission, adequacy of assessment of patient/family needs and quality and quantity of services provided;
   3. (3) review of complaints and other investigations; and
   4. (4) review of the effectiveness of the hospice’s infection control program, including appropriate identification of infection and communicable disease transmission and control problems and plans for appropriate corrective action, improvement and subsequent prevention.

5. (e) measures, analyzes, and tracks quality indicators, including adverse patient events and/or potentially avoidable events and other aspects of performance, in the frequency and detail approved by the governing authority. The data shall include patient care data and other relevant data reflective of the hospice operation, the quality of all services provided and all activities that may impact patient care and must enable the hospice to:

   1. (1) assess processes of care, hospice services, and operations;
   2. (2) monitor the effectiveness and safety of services and quality of care; and
   3. (3) identify opportunities and priorities for improvement.

6. (f) develops, implements and evaluates performance improvement projects conducted annually, sufficient in number and scope to reflect the hospice’s population, internal organizational needs, and scope, complexity and past performance of services and operation, using quality indicator data collected. These projects must:

   1. (1) focus on high risk, high volume, or problem-prone areas;
   2. (2) consider incidence, prevalence, and severity of problems in those areas;
   3. (3) take actions aimed at performance improvement in palliative outcomes, patient safety, and quality of care;
   4. (4) measure the success of such actions and track performance to ensure that improvements are sustained;
   5. (5) track and analyze the cause of any adverse patient event;
   6. (6) implement preventive actions and mechanisms that include feedback and learning throughout the hospice; and
   7. (7) be documented by the hospice including the reasons for conducting the project and the measurable progress achieved.

The governing authority must ensure that the hospice: