Section 124.10. Quality assurance.

 

(1)   Responsibility of the governing body. The governing body shall ensure that the hospital has a written quality assurance program for monitoring and evaluating the quality of patient care and the ancillary services in the hospital on an ongoing basis. The program shall promote the most effective and efficient use of available health facilities and services consistent with patient needs and professionally recognized standards of health care.

(2)   Responsibilities of the chief executive officer and the chief of the medical staff. As part of the quality assurance program, the chief executive officer and chief of the medical staff shall ensure that:

(a) The hospital's quality assurance program is implemented and effective for all patient care related services;

(b) The findings of the program are incorporated into a well defined method of assessing staff performance in relation to patient care; and

(c) The findings, actions and results of the hospital's quality assurance program are reported to the governing body as necessary.

(3)   Evaluation of care to be problem-focused. Monitoring and evaluation of the quality of care given patients shall focus on identifying patient care problems and opportunities for improving patient care.

(4)   Evaluation of care to use variety of resources. The quality of care given patients shall be evaluated using a variety of data sources, including medical records, hospital information systems, peer review organization data and, when available, third party payer information.

(5)   Activities. For each of the monitoring and evaluation activities, a hospital shall document how it has used data to initiate changes that improve quality of care and promote more efficient use of facilities and services. Quality assurance activities shall:

(a) Emphasize identification and analysis of patterns of patient care and suggest possible changes for maintaining consistently high quality patient care and effective and efficient use of services;

(b) Identify and analyze factors related to the patient care rendered in the facility and, where indicated, make recommendations to the governing body, chief executive officer and chief of the medical staff for changes that are beneficial to patients, staff, the facility and the community; and

(c) Document the monitoring and evaluation activities performed and indicate how the results of these activities have been used to institute changes to improve the quality and appropriateness of the care provided.

(6)   Evaluation of the program. The chief executive officer shall ensure that the effectiveness of the quality assurance program is evaluated by clinical and administrative staffs at least once a year and that the results are communicated to the governing body.

Cr. Register, January, 1988, No. 385 , eff. 2-1-88. Note: See the table of Appellate Court Citations for Wisconsin appellate cases citing s. HSS 124.10.