Quality improvement programs.

(1) Each service provider must maintain a quality improvement program to objectively and systematically monitor and evaluate the appropriateness and quality of care, to ensure that services are rendered consistent with prevailing professional standards, and to identify and resolve problems.

(2) For each service provider, a written plan must be developed with a copy made available upon request to the department which addresses the minimum guidelines for the provider’s quality improvement program, including, but not limited to:

(a) Individual care and services standards.

(b) Individual records maintenance procedures.

(c) Staff development policies and procedures.

(d) Service-environment safety and maintenance standards.

(e) Peer review and utilization management review procedures.

(f) Incident reporting policies and procedures that include verification of corrective action, provision for reporting to the department within a time period prescribed by rule, documentation that incident reporting is the affirmative duty of all staff, and a provision that specifies that a person who files an incident report may not be subjected to any civil action by virtue of that incident report.

(3) The quality improvement program is the responsibility of the director and is subject to review and approval by the governing board of the service provider.

(4) Each director shall designate a person who is an employee of or under contract with the service provider as the provider’s quality improvement manager.

(5) The department may access all service provider records necessary to determine compliance with this section. Records relating solely to actions taken in carrying out this section and records obtained by the department to determine a provider’s compliance with this section are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. Such records are not admissible in any civil or administrative action except in disciplinary proceedings by the Department of Health or the appropriate regulatory board, and are not part of the record of investigation and prosecution in disciplinary proceedings made available to the public by the Department of Health or the appropriate regulatory board. Meetings or portions of meetings of quality improvement program committees that relate solely to actions taken pursuant to this section are exempt from s. 286.011.

(6) The quality improvement program must also:

(a) Provide a framework for evaluating outcomes, including:

1. Output measures, such as capacities, technologies, and infrastructure, that make up the system of care.

2. Process measures, such as administrative and clinical components of treatment.

3. Outcome measures pertaining to the outcomes of services;

(b) Provide for a system of analyzing those factors which have an effect on performance at the local level;

(c) Provide for a system of reporting the results of quality improvement reviews; and

(d) Incorporate best practice models for use in improving performance in those areas which are deficient.

(7) Contingent upon specific appropriation, a quality improvement coordinator position shall be established within each substate entity to oversee the implementation and operation of the quality improvement program.