Texas Administrative Code › Title 25 - HEALTH SERVICES › Part 1 - DEPARTMENT OF STATE HEALTH SERVICES › Chapter 135 - AMBULATORY SURGICAL CENTERS › Subchapter A - OPERATING REQUIREMENTS FOR AMBULATORY SURGICAL CENTERS › Section 135.8 - Quality Assurance

Current through Reg. 49, No. 28; July 12, 2024
(a) Quality
				  assurance includes the selection of professional personnel prior to engagement
				  for service, ongoing review of clinical responsibilities and authority, and
				  peer review and supervision of all professional and technical activities of
				  personnel.
(b) The professional and
				  administrative staff shall understand, support, and participate in the quality
				  assurance program.
(c) The quality
				  assurance program shall address clinical, administrative, and cost effective
				  issues. Exclusive concentration on administrative cost effective issues does
				  not fulfill this requirement.
(d)
				  Quality assurance activities shall be conducted by the quality assurance
				  committee, which is composed of specific clinical disciplines within the
				  ambulatory surgical center (ASC) (individual medical specialties, nursing,
				  etc.), and shall be consistent with the characteristics of the overall quality
				  assurance program and the services provided by the ASC.
(e) Problem identification and resolution
				  activities shall be conducted as part of an ongoing, organized quality
				  assurance program in which all practitioners in all clinical disciplines have
				  an opportunity to participate. A variety of self-assessment methodologies may
				  be used to implement the quality assurance program. Assessment techniques shall
				  examine the structure, process, or outcome of care, and shall be assessed
				  prospectively, concurrently, or retrospectively.
(f) Quality assurance activities shall
				  address the following.
(1) Important problems
				  or concerns in the care of patients shall be identified. Although the medical
				  record is an important data source for identifying previously unrecognized
				  problems, any sources may be used. Problems concerning accessibility,
				  medical-legal issues, and wasteful practices shall be considered, as well as
				  concerns previously recognized by patients and staff but inadequately
				  addressed.
(2) The frequency,
				  severity, and source of suspected problems or concerns shall be assessed.
(A) Health care practitioners shall
				  participate in the development and application of the criteria used to evaluate
				  the care they provide.
(B) Health
				  care practitioners shall participate in the evaluation of the problems or
				  concerns identified.
(C) A record
				  shall be maintained of all fires, patient deaths, and all transfers from the
				  ASC to the hospital.
(3)
				  Measures shall be implemented to resolve important problems or concerns that
				  have been identified. Health care practitioners as well as administrative staff
				  shall participate in the resolution of the problems or concerns that are
				  identified.
(4) The problems or
				  concerns shall be reassessed to determine objectively whether or not the
				  measures have achieved and sustained the desired result, and if not, why
				  not.
(5) Through the ASC's
				  designated mechanisms, quality assurance activities shall be reported, as
				  appropriate, to the proper personnel and the governing body.