OAR 333-700-0080
Quality Assessment and Performance Improvement

(1)

The facility shall establish a program to monitor the quality of care given to patients. This program shall document that the facility staff evaluate the provision of care, determine treatment goals, identify opportunities for improvement, develop and implement improvement plans, and evaluate implementation until resolution of a problem is achieved.

(2)

The medical director of the facility is responsible for quality monitoring and improvement activities. The Quality Assessment and Performance Improvement (QAPI) team shall consist of a multi-disciplinary team to include representatives of medical staff, administration, nursing, technical, social work and dietary. Meetings of the QAPI team shall be held at least quarterly or more often if needed to resolve a particular issue.

(3)

QAPI mechanisms shall include:

(a)

An ongoing review of key elements of care using comparative and trend data to include aggregate patient data and to promote the reduction of risks;

(b)

Identification of areas where performance measures or outcome data indicate a need for improvement;

(c)

Establishment of QAPI committees to identify any variations from desired outcomes; create and implement improvement plans; evaluate the effectiveness of the improvement plan; and

(d)

Establishment and monitoring of key quality indicators. For each indicator, the facility shall establish a performance level consistent with current professional knowledge. At a minimum, the following indicators shall be monitored on an ongoing basis:

(A)

Water Quality including chemical and bacteriological indicators;

(B)

Equipment maintenance and repair;

(C)

Reprocessing of dialyzers including performance measures, labeling, disinfection, and pyrogenic reactions;

(D)

Infection control including monitoring of staff and patient infections;

(E)

Clinical outcomes including laboratory values, dialysis adequacy, hospitalizations, vascular access complications;

(F)

Incidents and rate of adverse occurrences (clinical variances) including accidents, medication errors, treatment errors, infiltrations, needle sticks, adverse drug reactions, and other occurrences affecting patients, visitors, or staff;

(G)

Mortality including review of each patient death and monitoring of mortality rates and trends;

(H)

Complaints and suggestions including those from patients, family and staff; and

(I)

Other indicators as required by federal regulations and Network requirements.

Source: Rule 333-700-0080 — Quality Assessment and Performance Improvement, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=333-700-0080.

333‑700‑0000
Statement of Purpose 333‑700‑0004
Referenced Codes and Standards 333‑700‑0005
Definitions 333‑700‑0010
Application for Licensure 333‑700‑0015
Annual License Fee 333‑700‑0017
Application Review 333‑700‑0018
Approval of License Application 333‑700‑0019
Denial of License Application 333‑700‑0020
Expiration and Renewal of License 333‑700‑0025
Denial or Revocation of a License 333‑700‑0030
Discontinuance and Recommencement of Operation of Outpatient Renal Dialysis Facilities 333‑700‑0035
Return of Facility License 333‑700‑0040
Classification 333‑700‑0045
Hearings 333‑700‑0050
Adoption by Reference 333‑700‑0053
Complaints 333‑700‑0057
Investigations 333‑700‑0060
Surveys 333‑700‑0061
Violations 333‑700‑0062
Informal Enforcement 333‑700‑0063
Formal Enforcement 333‑700‑0064
Civil Penalties 333‑700‑0072
Waivers 333‑700‑0073
Outpatient Mobile Dialysis 333‑700‑0075
Administrative Authority and Management 333‑700‑0080
Quality Assessment and Performance Improvement 333‑700‑0085
Patient Care Plan 333‑700‑0090
Medical Records 333‑700‑0095
Medical Director of an Outpatient Renal Dialysis Facility 333‑700‑0100
Patient Care Staff 333‑700‑0105
Minimal Service Requirements for an Outpatient Renal Dialysis Facility 333‑700‑0110
Infection Control 333‑700‑0115
Patients’ Rights, Responsibilities and Family Education 333‑700‑0120
Facility Safety and Emergency Preparedness 333‑700‑0125
Reuse of Hemodialyzers and other Dialysis Supplies 333‑700‑0131
Physical Environment Requirements
Last Updated

Jun. 8, 2021

Rule 333-700-0080’s source at or​.us