The freestanding medical facility shall develop and implement a quality assurance program. The quality assurance program shall have a quality management process that: Is multidisciplinary; Is integrated into the hospital's overall quality management program that is reported to the hospital's governing body; Has a structure to ensure that defined program outcomes and performance measures are developed and monitored regularly; Maintains sufficient documentation to: Verify problems; Identify opportunities for improvement; and Show corrective actions taken and resolution of problems; Includes review of morbidity and mortality; and Evaluates medical care, nursing care, utilization review, tissue review, and pre-hospital care.