Title: Section 721.9 - Regional Quality Improvement Activities

Effective Date

09/14/2005

Section 721.9 Regional quality improvement activities.

(a) Quality of care reviews of affiliates. Each hospital with a Level I, Level II or Level III perinatal care service shall enter into and comply with a perinatal affiliation agreement as defined in this Part with an RPC in its geographic area or network of perinatal affiliates. RPC representatives shall participate in the affiliate hospital's quality assurance committee and other reviews of the quality of perinatal care provided by the affiliate and in the provision of recommendations for quality improvement of perinatal services. Each RPC and each affiliate hospital shall take actions necessary, including but not limited to entering into a perinatal affiliation agreement, to authorize such participation by the RPC's representatives in the affiliate hospital's quality assurance committee and for purposes of such participation, the RPC representative or representatives shall be deemed members of the affiliate's quality assurance committee. RPC representatives may only access confidential patient information for quality improvement purposes through their roles on the affiliate hospitals’ quality assurance committees as set forth in the affiliation agreements and these regulations. Members of hospitals’ quality assurance committees must maintain the confidentiality of patient information and are subject to the confidentiality restrictions of Public Health Law Section 2805-m.

(1) The RPC representative(s) shall participate in the review of information and data for quality improvement purposes as described in the affiliation agreement which may include:

(i) statistical data from the statewide perinatal data system or equivalent data available from other sources;

(ii) the affiliate hospital's quality improvement program, policies, and procedures;

(iii) care provided by medical, nursing, and other health care practitioners associated with the perinatal service;

(iv) appropriateness and timeliness of maternal and newborn referrals and transfers and of patients retained at the affiliate hospital who met criteria for transfer to a higher level of care; and

(v) maternal and newborn serious adverse events or occurrences that may include the following:

(a) maternal and newborn fatalities;

(b) maternal and newborn morbidity in circumstances other than those related to the natural course of disease or illness;

(c) maternal and newborn nosocomial infections;

(d) maternal and newborn high-risk procedures; or

(vi) pathology related to all deaths and significant surgical specimens.

(2) The hospital shall implement quality improvement recommendations by its RPC. In the event of a disagreement related to a recommendation, the hospital and the RPC shall follow the dispute resolution process outlined in their perinatal affiliation agreement and section 721.2 of this Title.

(b) Each RPC shall cooperate with the department in regular quality improvement reviews by the department of the RPC's perinatal care, the RPC's internal quality improvement activities, and the services it provides to its perinatal affiliates:

(1) The department's quality of care review of the RPC shall include the elements set forth in section 721.9(a)(1) of this Title.

(2) The department's quality improvement review of an RPC shall include review of the quality of the services it has provided to its perinatal affiliates.

(3) The RPC shall cooperate with the department by providing medical records and other relevant documents and information on a timely basis when requested.

(c) Quality improvement outreach program. Each RPC shall provide professional education and training for physicians, nurses, and other staff at all hospitals in the region or affiliative network for which it provides quality of care review. Education and training shall be designed to update and enhance staff knowledge and familiarity with relevant procedures and technological advances.

Volume

VOLUME E (Title 10)

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