Oregon Oregon Health Authority, Public Health Division

Rule Rule 333-027-0160
Program Evaluation

An agency shall conduct an overall evaluation of its program at least annually. The Committee and the agency shall conduct the review. The evaluation shall consist of reviews of overall policies, administrative practices, and quality assurance activities. The evaluation shall assess the extent to which the agency’s program is appropriate, adequate, effective, and efficient. The Committee shall provide a written report of the evaluation to the governing body of the agency. Evaluation reports shall be maintained in its administrative records. The agency shall take corrective action, if appropriate, on negative findings identified as a result of the program evaluation.


Policy and Administrative Review: As part of the evaluation process, the agency shall review its policies and administrative practices to determine the extent to which they promote patient care that is appropriate, adequate, effective, and efficient.


Quality assurance: The agency shall implement an ongoing quality assurance program designed to objectively and systematically monitor the quality and appropriateness of patient care. The agency shall perform this review at least quarterly. The agency’s quality assurance program must include a review of clinical records.


The quality assurance program shall consist of problem identification, implementation of a corrective action plan, and re-monitoring of identified problems.


Quality assurance activities shall be performed by a multidisciplinary team consisting of health professionals from each of the services the agency provides.

Last accessed
Jun. 8, 2021