Each facility shall develop and implement a facility-wide, data-driven quality assessment and performance improvement program that reflects the complexity of the facility and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The facility must maintain and demonstrate evidence of its quality assessment and performance improvement program for review by the department.

1. (1) Focus on high-risk, high-volume, or problem areas;
2. (2) Consider the incidence, prevalence, and severity of problems in those areas; and

3. (3) Affect health outcomes, patient safety, and quality of care.

   The governing body of the facility, its medical staff, and its administrative officials are responsible and accountable for ensuring adequate resources are allocated for measuring, assessing, improving, and sustaining the performance and reducing risks to patients.

The quality assessment and performance improvement program must measure, analyze, and track adverse patient events, medical errors, staffing, and other aspects of performance that assess processes of patient care and implement preventative actions and mechanisms, feedback, and learning throughout the hospital to address identified issues.

The program shall set priorities for quality assessment and performance improvement that:

Source: 42 SDR 51, effective October 13, 2015 ; 50 SDR 62, effective November 27, 2023 .

General Authority: SDCL 34-12-13 (5).

Law Implemented: SDCL 34-12-13 .

Prior versions effective: 2015-10-13.