Sec.19a-495-6i. Quality assessment and performance improvement

(a) The licensee shall implement the quality assessment and performance improvement program established by the governing authority that includes all patient care disciplines and services provided, including those services provided by a contractor, throughout the hospice inpatient facility. The governing authority shall ensure that the program reflects the complexity of its organization and services, involves leadership working with input from facility staff, patients and families, involves all hospice inpatient facility services including those furnished under contract or arrangement, focuses on performance indicators to monitor a wide range of care processes and outcomes related to palliative care, and initiates actions to demonstrate improvement in hospice inpatient facility performance and promote sustained improvement.

(b) Such plan and program shall be ongoing and shall include:

(1) Oversight responsibility and program objectives;

(2) The use of quality indicator data to assess and monitor patient care and services;

(3) Evidenced based practices and policies for:

(A) Pain and symptom management;

(B) The prevention and treatment of pressure sores;

(C) The prevention of abuse, neglect and mistreatment;

(D) The prevention of accidents and injuries; and

(E) The prevention, surveillance and control of health care associated infections and communicable diseases.

(4) A method and mechanism for identifying, and as required, reporting:

(A) Infectious and communicable disease occurrences among patients and personnel;

(B) Health care associated infections and a plan for the implementation of actions that are expected to result in improvement and disease prevention;

(C) Adverse events; and

(D) Potential sources of injuries and medical errors and a plan for the implementation of actions that are expected to result in improvement and prevention of such occurrences.

(5) Review and investigation of all adverse events;

(6) Other criteria and data necessary to monitor the quality of patient care; and

(7) Evidence based practices to identify, evaluate, and correct problems.

(c) The hospice inpatient facility administrator shall designate a licensed employee to coordinate and manage the quality assessment and performance improvement program. The licensed employee shall ensure that:

(1) Program activities focus on high risk, high volume, or problem-prone areas;

(2) The program maintains records of appropriate corrective action to address problems identified through the quality assessment and performance improvement program; and

(3) The outcome of the corrective action is documented and submitted to the governing authority for its review.

(d) The members of the quality assessment and performance improvement committee members as described in section 19a-495-6c(e)(10) of the Regulations of Connecticut State Agencies shall be employees of the hospice inpatient facility and shall include at least one licensed independent practitioner, one registered nurse, and spiritual counselor.

(e) The functions of the quality assessment and performance improvement committee shall be to:

(1) Monitor the effectiveness and safety of services and quality of care;

(2) Identify opportunities for improvement;

(3) Recommend the frequency and detail of data collection to the governing authority;

(4) Develop, implement and evaluate performance improvement projects based on the hospice inpatient facility's population and needs that reflect the scope, complexity and past performance of the hospice inpatient facility's services and operations;

(5) Ensure there is a rationale as well as a goal and measurable objectives for each project that is implemented;

(6) Ensure progress is documented for each project;

(7) At least annually review and recommend to the governing authority revisions to the hospice inpatient facility's policies relating to:

(A) Quality assessment and improvement activities;

(B) Standards of care;

(C) Professional issues especially as they relate to the delivery of services and findings of the quality assessment and improvement program.

(f) The quality assessment and performance improvement committee shall meet at least twice per year and shall maintain records of all quality improvement activities.

(g) Written minutes shall document dates of meetings, attendance, agenda and recommendations. The minutes shall be presented, reviewed, and accepted at the next regular meeting of the governing authority of the hospice inpatient facility following the quality assessment and performance improvement committee meeting. These minutes shall be available upon request to the commissioner.

(Effective July 31, 2012)