(a) Scope and content of program. A hospital shall develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The program shall:
  (1) reflect the complexity of the hospital's organization and services;
  (2) involve all the hospital's services;
  (3) specify the frequency and detail of data collected; and
  (4) focus on high-risk, high-volume, and problem-prone areas in the hospital.
(b) Approval by governing body. The hospital's governing body shall approve the hospital's quality assessment and performance improvement program.
(c) Staff member participation. The director of psychiatric nursing (DPN), the director of psychiatric services, and other appropriate staff members shall participate in the development and implementation of the quality assessment and performance improvement program.
(d) Quality assessment and performance improvement program activities.
  (1) As part of its quality assessment and performance improvement activities, a hospital shall collect and aggregate data to:
    (A) monitor the effectiveness and safety of services and the quality of care; and
    (B) identify opportunities for improvement and changes that will lead to improvement.
  (2) The hospital shall collect and aggregate all data, on an ongoing basis, for each of the following performance indicators at a minimum:
    (A) sentinel events;
    (B) allegations of abuse and neglect, as defined in §510.46 of this title (relating to Abuse and Neglect Issues);
    (C) findings of abuse and neglect made by HHSC, in accordance with §510.46 of this title (relating to Abuse and Neglect Issues);
    (D) violations of patient rights described in 25 TAC Chapter 404, Subchapter E (relating to Rights of Persons Receiving Mental Health Services);
    (E) nosocomial infections;
    (F) injuries of patients;
    (G) medication errors;
    (H) unauthorized departures of patients;
    (I) deaths of patients;
    (J) surveys of patients, patient's families, and legally authorized representatives (LAR) regarding satisfaction with hospital services; and
    (K) complaints and grievances made by patients, patient's families, and LARs.
  (3) The hospital shall analyze the aggregated data, at least quarterly, to assess the need for performance improvement.
  (4) When a need for performance improvement is identified, the hospital shall develop and implement an action plan to address the identified need.
  (5) The hospital shall evaluate the success of the action plan to determine if the positive outcomes are achieved and sustained.
  (6) If the hospital determines that the positive outcomes have not been achieved or sustained, the hospital shall modify the action plan and re-evaluate its implementation until the outcomes are achieved and sustained.
(e) Evidence of program. The hospital shall maintain and demonstrate evidence of the quality assessment and performance improvement program for review by an external review entity, including HHSC, the Centers for Medicare and Medicaid Services, or the accrediting organization.

Source Note: The provisions of this §568.141 adopted to be effective May 27, 2021, 46 TexReg 3276