Regulation .11 Quality Assurance.

The freestanding medical facility shall develop and implement a quality assurance program.

The quality assurance program shall have a quality management process that:

(1)

Is multidisciplinary;

(2)

Is integrated into the hospital's overall quality management program that is reported to the hospital's governing body;

(3)

Has a structure to ensure that defined program outcomes and performance measures are developed and monitored regularly;

(4)

Maintains sufficient documentation to:

(a)

Verify problems;

(b)

Identify opportunities for improvement; and

(c)

Show corrective actions taken and resolution of problems;

(5)

Includes review of morbidity and mortality; and

(6)

Evaluates medical care, nursing care, utilization review, tissue review, and pre-hospital care.