Section 557.3. Quality Assurance and Improvement Program

(a) The quality assurance program shall include monitoring and evaluation of data collected, based on defined criteria that reflect current knowledge and clinical experience and relate to the care provided by the service. Sources of data include the medical records, incident reports, infection control records and patient complaints. The medical record shall contain sufficient data to support the diagnosis and determine that the procedures are appropriate to the diagnosis. Facilities that treat pediatric patients shall segregate data regarding these patients.

(b) The quality assurance program shall provide for the identification of problems and actions taken—through the monitoring and evaluation process—which improve the quality of patient care.

(c) The frequency, severity and source of suspected problems or concerns are evaluated by practitioners and nurses.

(d) Measures shall be implemented to resolve important problems or concerns identified. The results of these corrective measures shall be monitored to assure that the problem has been satisfactorily resolved. Measures which may be taken include:

(1) Changes in policies and procedures.

(2) Staffing and assignment changes.

(3) Appropriate education and training.

(4) Adjustments in clinical privileges.

(5) Changes in equipment or physical plant.

(e) The program shall include a mechanism to assure that activities are documented and reports of the quality assurance activities are brought to the attention of the governing body. There shall be a periodic reappraisal of the program.

(f) The quality assurance program shall include the establishment of a quality assurance committee.

The provisions of this § 557.3 amended October 22, 1999, effective November 22, 1999, 29 Pa.B. 5583. Immediately preceding text appears at serial page (256570).