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Title: Section 752-2.6 - Quality assurance and utilization review

Effective Date


752-2.6 Quality assurance and utilization review. In addition to meeting the requirements set forth in section 751.8 of this Title, the quality assurance program of the UD&TC shall be developed and implemented for all services in accordance with the on-going quality assurance program of the affiliated general hospital, at a minimum, and preferably, with a network quality assurance program should one exist.

(a) The UD&TC's quality assurance program shall be coordinated jointly with a general hospital participating in the network. This program should include provisions for risk management, quality improvement, and utilization review involving prospective, concurrent and retrospective analyses.

(b) If there is a network-wide quality assurance program, the center shall coordinate its quality assurance activities with such program to enhance the quality of patient care and to identify and prevent incidents of malpractice, and to implement the required medical malpractice prevention program.

(c) The UD&TC's quality assurance program shall utilize a performance- based approach, as well as:

(1) an established set of written criteria for care, using both process and outcome measures;

(2) a mechanism for tracking patients throughout the provider network and analyzing negative outcomes that result from the lack of access to and/or availability of needed care; such mechanism may include a network-wide patient registry or medical records system; and

(3) a dedicated, continuous on-line information system for linking the UD&TC with the facility or facilities providing network core services and other appropriate primary care and emergency services providers as identified by the governing body of the network.

(d) A UD&TC's utilization review program shall provide for prospective, concurrent and retrospective review processes, as follows:

(1) the prospective review process shall be locally developed by clinicians from the UD&TC and from the facility or facilities providing core hospital services to the network within which the center operates, and shall be based upon the service capabilities of those facilities;

(2) the concurrent review process shall provide for a review of patients treated at the UD&TC 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 initiation of treatment and exceed the service capabilities of the center;

(3) the retrospective review process shall focus on on-going improvement in care delivery at the network, facility and case levels. The review process shall include case level assessments for patients as set forth in paragraphs (i) through (v) of subdivision (c) of section 752-2.5 and, in cases involving the transfer or referral of a patient to another facility, shall involve a facility level assessment. Case level review of the emergency medical care services of the UD&TC shall include, at a minimum:

(i) the care provided by the medical/nursing and other professional staff and by other health care practitioners employed by or associated with the UD&TC;

(ii) mortalities;

(iii) morbidity in circumstances other than those related to the natural course of disease or illness;

(iv) infections, complications, errors in diagnosis, transfusions and results of treatments; and

(v) medical records, medical care evaluation studies, complaints, incidents and staff suggestions regarding patient care and safety, utilization review findings, patient profile analysis and other pertinent data sources.

(e) In addition to the activities of the quality assurance and utilization review provisions of this sub-part and section 751.8 of this Title, the UD&TC shall:

(1) review emergency service visits made at the UD&TC under exceptional circumstances involving life threatening situations, adverse weather, or non-availability of transport, equipment or staff that prohibits transfer to a more appropriate facility; and

(2) review cases involving transfer to a more service intensive facility.


VOLUME E (Title 10)