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Title: Section 751.8 - Quality assurance program

751.8 Quality assurance program. (a) The operator shall ensure the development and implementation of a written quality assurance program that includes a planned and systematic process for monitoring and assessing the quality and appropriateness of patient care and clinical performance on an ongoing basis. The program shall resolve identified problems and pursue opportunities to improve patient care.

(b) The program shall be supervised by the medical director.

(c) There shall be a written plan for the quality assurance program which describes the program's objectives, organization, responsibilities of all participants, scope of the program and procedures for overseeing the effectiveness of monitoring, assessing and problem-solving activities.

(d) The quality assurance process shall define methods for the identification and selection of clinical and administrative problems to be reviewed. The process shall include but not be limited to:

(1) the establishment of review criteria developed in accordance with current standards of professional practice for monitoring and assessing patient care and clinical performance;

(2) regularly scheduled reviews of medical charts, patient complaints and suggestions, reported incidents and other documents pertinent to problem identification;

(3) documentation of all quality assurance activities, including but not limited to the findings, recommendations and actions taken to resolve identified problems; and

(4) the timely implementation of corrective actions and periodic assessments of the results of such actions.

(e) The scope of clinical and administrative problems selected to be reviewed for the purpose of quality assurance shall reflect the scope of services provided and the populations served at the center.

(f) The outcomes of quality assurance reviews shall be used for the revision or development of policies and in granting or renewing staff privileges, as appropriate.

(g) There shall be participation in the program by administrative staff and health-care professionals representing each professional service provided.

(h) The findings, conclusions, recommendations and actions taken as a part of the quality assurance program shall be reported to the operator by the medical director.


VOLUME E (Title 10)