481—51.3 (135B) Quality improvement program.
	   51.3(1) There shall be an ongoing hospitalwide quality improvement program. This program is to be designed to improve, as needed, the quality of patient care by:
	      a.    	 Assessing clinical patient care;
	      b.    	 Assessing nonclinical and patient-related services within the hospital;
	      c.    	 Developing remedial action as needed; and
	      d.    	 Ongoing monitoring and evaluating of the progress of remedial action taken.
	   51.3(2) The governing body shall ensure there is an effective hospitalwide patient-oriented quality improvement program.
	   51.3(3) The quality improvement program shall involve active participation of physician members of the hospital’s medical staff and other health care professionals, as appropriate. Evidence of this participation will include ongoing case review and assessment of other patient care problems which have been identified through the quality improvement process.
	   51.3(4) The quality improvement plan may include external, state, local, federal, and regional benchmarking activities designed to improve the quality of patient care. The quality improvement plan shall be written and may address the following:
	      a.    	 The program’s objectives, organization, scope, and mechanisms for overseeing the effectiveness of monitoring, evaluation, and problem-solving activities;
	      b.    	 The participation from all departments, services (including services provided both directly and under contract), and disciplines;
	      c.    	 An assessment of participation through a quality improvement committee meeting on an established periodic basis;
	      d.    	 The coordination of quality improvement activities;
	      e.    	 The communication, reporting and documentation of all quality improvement activities on a regular basis to the governing board, the medical staff, and the hospital administrator;
	      f.    	 An annual evaluation by the governing board of the effectiveness of the quality improvement program; and
	      g.    	 The accessibility and confidentiality of materials relating to, generated by or part of the quality improvement process.
This rule is intended to implement Iowa Code chapter 135B.
[ARC 2472C, IAB 3/30/16, effective 5/4/16]