Oregon Oregon Health Authority, Public Health Division

Rule Rule 333-505-0060
Quality Assessment and Performance Improvement


The governing body of a hospital must ensure that there is an effective, written, facility-wide quality assessment and performance improvement program to evaluate and monitor the quality and appropriateness of patient care.


All organized services related to patient care, including services furnished by a contractor, must be evaluated.


Written documentation of quality assessment and performance improvement activities shall be recorded at least quarterly.


Healthcare associated infections, adverse drug reactions, errors in administration of drugs, and blood and blood product transfusions must be evaluated.


All medical and surgical services performed in the hospital must be evaluated as they relate to appropriateness of diagnosis and treatment.


The hospital must have an ongoing plan, consistent with available community and hospital resources, to provide and make available social work, psychological, and educational services to meet the medically-related needs of its patients.

Last accessed
Jun. 8, 2021