- (1) The governing body of a hospital must ensure that there is an effective, written, facility-wide quality assessment and performance improvement program to evaluate and monitor the quality and appropriateness of patient care.
- (2) All organized services related to patient care, including services furnished by a contractor, must be evaluated.
- (3) Written documentation of quality assessment and performance improvement activities shall be recorded at least quarterly.
- (4) Healthcare associated infections, adverse drug reactions, errors in administration of drugs, and blood and blood product transfusions must be evaluated.
- (5) All medical and surgical services performed in the hospital must be evaluated as they relate to appropriateness of diagnosis and treatment.
- (6) The hospital must have an ongoing plan, consistent with available community and hospital resources, to provide and make available social work, psychological, and educational services to meet the medically-related needs of its patients.
Statutory/Other Authority
ORS 441.055
Statutes/Other Implemented
ORS 441.025
History
PH 17-2012, f. 12-20-12, cert. ef. 1-1-13
PH 11-2009, f. & cert. ef. 10-1-09
HD 2-2000, f. & cert. ef. 2-15-00
HD 21-1993, f. & cert. ef. 10-28-93
HD 29-1988, f. 12-29-88, cert. ef. 1-1-89