Section R9-10-204. Quality Management

A.      A governing authority shall ensure that an ongoing quality management program is established that:

1.        Complies with the requirements in A.R.S. § 36-445; and

2.        Evaluates the quality of hospital services and environ- mental services related to patient care.

B.       An administrator shall ensure that:

1.        A plan is established, documented, and implemented for an ongoing quality management program that, at a mini- mum, includes:

a.         A method to identify, document, and evaluate inci- dents;

b.        A method to collect data to evaluate hospital ser- vices and environmental services related to patient care;

c.         A method to evaluate the data collected to identify a concern about the delivery of hospital services or environmental services related to patient care;

d.        A method to make changes or take action as a result of the identification of a concern about the delivery of hospital services or environmental  services related to patient care;

e.         A method to identify and document each occurrence of exceeding licensed capacity, as described in R9- 10-203(C)(5), and to evaluate the occurrences of exceeding licensed capacity, including the actions taken for resolving occurrences of exceeding licensed capacity; and

f.         The frequency of submitting a documented report required in subsection (B)(2) to the governing authority;

2.        A documented report is submitted to the governing authority that includes:

a.         An identification of each concern about the delivery of hospital services or environmental  services related to patient care, and

b.        Any changes made or actions taken as a result of the identification of a concern about the delivery of hos- pital services or environmental services related to patient care;

3.        The acuity plan required in R9-10-214(C)(2) is reviewed and evaluated at least once every 12 months and the results are documented and reported to the governing authority;

4.        The reports required in subsections (B)(2) and (3) and the supporting documentation for the reports are maintained for at least 12 months after the date the report is submit- ted to the governing authority; and

5.        Except for information or documentation that is confiden- tial under federal or state law, a report or documentation required in this Section is provided to the Department for review within two hours after the Department’s request.

Historical Note

New Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Amended by final

rulemaking at 11 A.A.R. 536, effective March 5, 2005 (Supp. 05-1). Amended by exempt rulemaking at 19

A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Amended by exempt rulemaking at 20 A.A.R. 1409, pur- suant to Laws 2013, Ch. 10, § 13; effective July 1, 2014

(Supp. 14-2).