Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 117 - END STAGE RENAL DISEASE FACILITIES › Subchapter D - MINIMUM STANDARDS FOR PATIENT CARE AND TREATMENT › Section 117.43 - Quality Assessment and Performance Improvement

Current through Reg. 49, No. 28; July 12, 2024
(a) A 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 those services furnished under contract or arrangement); shall focus
				  on indicators related to improved health outcomes and the prevention and
				  reduction of medical errors.
(c)
				  The program shall include, but not be limited to, 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 evaluate the provision of dialysis care and
				  patient services, set treatment goals, identify opportunities for improvement,
				  develop and implement improvement plans, and evaluate the implementation until
				  resolution is achieved. The dialysis 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. Evidence shall
				  support that aggregate patient data, including identification and tracking of
				  patient infections, is continuously reviewed for trends.
(e) Core staff members shall actively
				  participate in the QAPI activities and monthly meetings.
(f) Core staff members shall actively
				  participate in QAPI meetings more often as necessary to identify or correct
				  problems. The QAPI meetings shall be conducted separately from a patient plan
				  of care conference and the meetings shall be documented.
(g) 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 team(s) to:
(A)
				  identify, measure, analyze, and track indicators for variation from desired
				  outcomes;
(B) create and implement
				  improvement plan(s);
(C) evaluate
				  the implementation of the improvement plan(s); and
(D) continue monitoring and improvement
				  activities until resolution of the improvement plan.
(4) establishment and monitoring of quality
				  indicators related to improved health outcomes. For each quality assessment
				  indicator, the facility shall establish and monitor a level of performance
				  consistent with current professional knowledge. These performance components
				  shall influence or relate to the desired outcomes themselves. At a minimum, the
				  following indicators shall be measured, analyzed, and tracked on a monthly
				  basis:
(A) water quality (chemical,
				  bacteriological analysis, and other indicators specific to the facility's water
				  treatment system);
(B) equipment
				  preventive maintenance and repair;
(C) reprocessing of hemodialyzers (dialyzer
				  performance measures, labeling, and disinfection);
(D) infection control (staff and patient
				  screening; standard precautions; bacteriological monitoring of dialyzer(s),
				  water, machine(s), and dialysate; pyrogen reactions; sepsis episodes; patient
				  infections; and peritonitis rate);
(E) adverse event;
(F) vascular access;
(G) reportable incidents as required to be
				  reported under §
												117.48 of this
				  title (relating to Incident Reports);
(H) mortality (review of each death and
				  monitoring modality specific mortality rate(s));
(I) complaints and suggestions (from
				  patients, family, or staff);
(J)
				  staffing to include, but not limited to orientation, training, delegation,
				  licensing and certification, and non-adherence to policies and procedures by
				  facility staff;
(K) safety (fire
				  and disaster preparedness, use of a department approved reporting system, and
				  disposal of special waste);
(L)
				  clinical records review to include dialysis treatment errors, and medication
				  errors;
(M) clinical outcomes
				  (laboratory indicators, hospitalizations, vascular access complications,
				  intradialytic complications, patient no-shows, patient non-adherence to the
				  dialysis prescription, and transplantation);
(N) patient's health-related quality of life
				  surveys; and
(O) involuntary
				  transfer or discharge of a patient.
(5) The dialysis facility shall continuously
				  monitor the 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.