<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.s147215f6-d3f8-4d57-bdc7-e403697d4214P0 { margin-top: 0; line-height: 12.0pt; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; } span.s147215f6-d3f8-4d57-bdc7-e403697d4214C0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s147215f6-d3f8-4d57-bdc7-e403697d4214000002 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000003 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=44:75:04:14"><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000000">44:75:04:14</span></a><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000001">.  Quality assessment and performance improvement program.</span><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0"> Each facility shall develop and implement a facility-wide, data-driven quality assessment and performance improvement program that reflects the complexity of the facility and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The facility must maintain and demonstrate evidence of its quality assessment and performance improvement program for review by the department.</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214000002"> </span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">The quality assessment and performance improvement program must measure, analyze, and track adverse patient events, medical errors, staffing, and other aspects of performance that assess processes of patient care and implement preventative actions and mechanisms, feedback, and learning throughout the hospital to address identified issues</span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">.</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214000002"> </span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">The program shall set priorities for quality assessment and performance improvement that:</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214000002"> </span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    (1)  </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">Focus on high-risk, high-volume, or problem areas</span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">;</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    (2)  </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">Consider the incidence, prevalence, and severity of problems in those areas; and</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    (3)  </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">Affect health outcomes, patient safety, and quality of care</span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">.</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214000002"> </span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">The governing body of the facility, its medical staff, and its administrative officials are responsible and accountable for ensuring adequate resources are allocated for measuring, assessing, improving, and sustaining the performance and reducing risks to patients</span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">.</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214000002"> </span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000001">Source:</span><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0"> 42 SDR 51, effective October 13, 2015</span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">; 50 SDR 62, effective November 27, 2023</span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">.</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000001">General Authority:</span><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12-13"><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000003">34-12-13</span></a><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">(5).</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">    </span><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000001">Law Implemented:</span><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-12-13"><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0-000003">34-12-13</span></a><span class="s147215f6-d3f8-4d57-bdc7-e403697d4214C0">.</span></p><p dir="ltr" class="s147215f6-d3f8-4d57-bdc7-e403697d4214P0"><span xml:space="preserve" class="s147215f6-d3f8-4d57-bdc7-e403697d4214000002"> </span></p></div></body></html>