# COMAR Title 10 — Maryland Department of Health

## Subtitle 07 — Hospitals

### Chapter 08 — Freestanding Medical Facilities

#### Regulation .11 Quality Assurance.

*COMAR 10.07.08.11*

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

B. 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.