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Title: Section 407.6 - Quality assurance and utilization review

Effective Date


407.6 Quality assurance and utilization review.

(a) The governing body shall require the establishment and maintenance of a written coordinated quality assurance program which integrates the review activities of all PCH/CAH services to enhance the quality of patient care. This program shall be designed to identify and prevent potential malpractice issues, shall incorporate the minimum standards for a quality assurance program delineated in Section 405.6 of this Title and shall require at least quarterly quality assurance reports to be submitted to the governing body. For purposes of this Part, the quality assurance program may be developed and implemented for all services in accordance with the ongoing quality assurance program of the affiliated full service hospital.

(b) Where a PCH/CAH is a member of a rural health network and there is a network-wide quality assurance program and/or health information system, the PCH/CAH shall coordinate its assessment and improvement activities with such program or system.

(c) The PCH's/CAH's quality assurance program shall support a care delivery continuum and may utilize a performance measurement system for the analysis of care provided which includes, but need not be limited to:

(1) a permanent patient record; and

(2) an indicator measurement system for analysis of undesired outcomes related to:

(i) access to and availability of care;

(ii) variations from generally accepted standards of professional practice; and

(iii) if the PCH/CAH is a member of a rural health network, any departures within the network from established medical/professional standards delineated in paragraph (1) of subdivision (a) of section 405.4 of this Title, and generally accepted practice guidelines.

(d) In addition to implementing the activities required by the quality assurance provisions of this Part and subdivision (b) of section 405.6 of this Title, the PCH/CAH shall:

(1) review admissions made under exceptional circumstances;

(2) review cases involving an unanticipated transfer to a more service intensive facility;

(3) review cases involving a readmission within two days of discharge; and

(4) review cases that exceed a length of stay determined by the governing body to be in excess of what is appropriate for the PCH/CAH.

(e) A PCH's/CAH's utilization review program shall provide for prospective, concurrent and retrospective review processes.

(1) The prospective review process shall be locally developed by clinicians from the PCH/CAH and from the facility or facilities providing hospital support services to the network within which the PCH/CAH operates, and shall be based upon the service capabilities of those facilities.

(2) The concurrent review process shall provide for a review of patients admitted to the PCH/CAH under exceptional circumstances (i.e., emergency or other life threatening situations, weather, availability of transport, equipment or staff prohibits transfer to a more appropriate facility) and patients whose service needs have changed after admission and may exceed the service capacity or capabilities of the PCH/CAH.

(3) The retrospective review process shall include case level assessments for patients as set forth in subdivision (b) of section 405.6 of this Title and subdivision (d) of this section and, in cases involving the transfer or referral of a patient to another facility, shall involve a facility level assessment.


VOLUME C (Title 10)