Quality, Safety, and Performance Improvement Program. The Quality, Safety, and Performance Improvement Department shall ensure that, within 90 days after the completion of the Survey, Parkland establishes and implements a program for performing internal quality audits and reviews (hereinafter “Quality, Safety, and Performance Improvement Program”). The Quality, Safety, and Performance Improvement Program shall make findings as to:
i. whether the patients at Parkland are receiving the quality of care consistent with professionally recognized standards of care and any other applicable Federal and State statutes, regulations, and directives;
ii. whether Parkland is effectively reviewing quality of care related incidents and completing root cause analyses; and
iii. whether Parkland’s action plans in response to identified quality of care problems are appropriate, timely, implemented, and enforced.
