(a) Each facility shall develop, implement, maintain, and evaluate an effective, ongoing, facility-wide, data-driven, interdisciplinary quality assessment and performance improvement (QAPI) program. The program shall be individualized to the facility and meet the criteria and standards described in this section.     
      (b) The program shall reflect the complexity of the facility's organization and services involved. All facility services (including services furnished under contract or arrangement) shall focus on indicators related to improved health outcomes and prevention and reduction of medical errors.     
      (c) The program shall include an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors.     
      (d) The facility shall demonstrate that facility staff, including the medical, nursing, and pharmacy staff, evaluate the provision of emergency care and patient services, set treatment goals, identify opportunities for improvement, develop and implement improvement plans, and evaluate the implementation until resolution is achieved.     
      (e) The facility shall measure, analyze, and track quality indicators, or other aspects of performance that the facility adopts or develops, that reflect processes of care and facility operations.     
      (f) The facility shall provide evidence supporting that the facility continuously reviews aggregate patient data, including identification and tracking of patient infections, for trends.     
      (g) Core staff members, including the medical, nursing, and pharmacy staff, shall actively participate in the QAPI activities, including QAPI meetings.      
        (1) QAPI meetings shall be held monthly, or more often as necessary, to identify or correct problems.       
        (2) QAPI meetings shall be documented.       
      (h) The facility's QAPI program shall include:      
        (1) an ongoing review of key elements of care using comparative and trend data to include aggregate patient data;       
        (2) identification of areas where performance measures or outcomes indicate an opportunity for improvement;       
        (3) appointment of interdisciplinary improvement teams to:                  (A) identify, measure, analyze, and track indicators for variation from desired outcomes;                   (B) create and implement improvement plans;                   (C) evaluate the implementation of the improvement plans; and                   (D) continue monitoring and improvement activities until resolution of the improvement plan;         
        (4) establishing and monitoring quality indicators related to improved health outcomes, which includes establishing and monitoring a level of performance consistent with current professional knowledge for each quality assessment indicator that must influence or relate to the desired outcomes themselves;       
        (5) monthly measurement, analysis, and tracking of at least the following indicators:                  (A) infection control (staff and patient screening; standard precautions);                   (B) adverse events;                   (C) mortality (review of each death and monitoring modality specific mortality rates);                   (D) complaints and suggestions (from patients, family, or staff);                   (E) staffing to include orientation, training, delegation, licensing and certification, and non-adherence to policies and procedures by facility staff;                   (F) safety (fire and disaster preparedness, use of the Texas Health and Human Services Commission (HHSC) emergency/disaster notification form, and disposal of special waste); and                   (G) clinical records review to include treatment errors and medication errors; and         
        (6) the facility shall continuously monitor performance, take actions that result in performance improvement, and track performance to ensure that improvements are sustained over time. The facility shall immediately correct any identified problems that threaten the health and safety of patients.       
      (i) HHSC may review a facility's QAPI activities to determine compliance with this section.      
        (1) An HHSC inspector shall verify that the facility has a QAPI program, which addresses concerns relating to quality of care provided to its patients and that the core staff members have knowledge of and the ability to access the facility's QAPI program.       
        (2) HHSC may not require disclosure of QAPI program records, except when disclosure is necessary for HHSC to determine compliance with this section.       
     Source Note:        The provisions of this §509.63 adopted to be effective December 4, 2023, 48 TexReg 7064