Section 205.240  Policies and Procedures Manual

a)         In cooperation with the medical and professional staff, the management/owner of the ambulatory surgical treatment center shall formulate a written policies and procedures manual, which shall be submitted to the qualified consulting committee and the governing body for review and approval.

b)         The procedures shall provide for the acceptance, care, treatment, anesthesia services, discharge, referral, and follow-up of all patients and all incidental operations of the facility.

c)         The policies and procedures manual shall include an ongoing data-driven quality assessment and improvement program that addresses measurable improvements in patient health outcomes and improves patient safety by addressing quality of care indicators or performance measures, adverse events, the reduction of medical errors, and infection control.  Components of the quality assessment and improvement program shall include:

1)         The use of quality indicators or performance measures and data to document improvements in outcomes and to effect improvements in patient care, patient health outcomes, and patient safety;

2)         Measurement, identification and analysis of incidence, prevalence, severity and causes of the problems and tracking and implementing improvements that are sustained over time to reduce medical errors and to improve health outcomes;

3)         The facility-wide infection control program (Section 205.550); and

4)         A focus on performance improvement activities and preventive strategies that address high risk, high volume, and problem-prone areas that affect health outcomes, patient safety, and quality of care, and that address adverse patient events and ensure that improvements are sustained over time.

d)         Data, activities and outcomes of quality assessment and improvement efforts and projects are to be reviewed at least annually and submitted annually in writing to the governing body.

e)         The policies and procedures manual shall include a methodology for conducting an ongoing comprehensive assessment of the quality of care provided in the facility, including the medical necessity of procedures performed, the appropriateness of care, and methods to revise and implement changes in existing policies and procedures.

f)         The policies and procedures manual shall include an ongoing infection control program designed to prevent, investigate, manage, control and minimize infections and communicable diseases.

g)         The policies and procedures manual shall include a written disaster preparedness plan that provides for the emergency care of patients, staff and others in the facility in the event of a fire, natural disaster, functional failure of equipment, or other unexpected events or circumstances that are likely to threaten the health and safety of patients and staff in the facility.  The plan's effectiveness shall be tested and evaluated each year by conducting and evaluating drills, and by promptly implementing any needed corrections.  The plan shall be coordinated with State and local authorities, as appropriate.

h)         The policies and procedures manual shall include a written patient rights plan that includes the designation of a grievance officer, a system to protect and promote patient rights, and a system to investigate violations or incidents and grievances.

i)          The policies and procedures manual shall be available to all staff in the facility and shall be followed by the staff at all times in the performance of their duties.

(Source:  Amended at 38 Ill. Reg. 19208, effective September 9, 2014)