CHAPTER He-P 400 HEALTH CARE
PROVIDERS
Part He-P 401
QUALITY ASSURANCE IN PHYSICIAN PRACTICES
He-P
401.01 Purpose. The purpose of this rule is to promote
greater patient safety in the delivery of health care and to reduce medical
errors by encouraging physicians to improve quality of care through effective
and continuing quality assurance programs.
Source. #7694, eff 6-4-02; ss by #9719, eff 6-4-10
He-P
401.02 Scope. This part shall apply to physician practices
as defined by RSA 329:29-a.
Source. #7694, eff 6-4-02; ss by #9719, eff 6-4-10
He-P
401.03 Quality Assurance. Physician practices may develop and implement
a quality assurance program to monitor, evaluate and improve the quality and
appropriateness of the care provided to patients, so that important problems
and trends in the delivery of care are identified and steps are taken to
correct problems and to take advantage of opportunities to improve care.
Source. #7694, eff 6-4-02; ss by #9719, eff 6-4-10
He-P 401.04 Quality Assurance Committee.
(a) All physician practices choosing to implement
a quality assurance program shall establish a quality assurance committee.
(b) The quality assurance committee shall:
(1) Determine
the information to be monitored;
(2) Determine
the frequency with which information will be reviewed;
(3) Determine the
way in which the information being monitored will be evaluated and measured;
(4) Evaluate
the information that is gathered;
(5) Determine
the action that is necessary to correct identified problems;
(6) Recommend
corrective actions and initiate changes to improve quality of care;
(7) Evaluate
the effectiveness of the corrective actions;
(8) Ensure that
quality control logs are maintained for any required laboratory controls and
proficiency testing;
(9) Ensure that
quality control logs for preventive maintenance and safety checks are
maintained for all equipment according to manufacturers directions; and
(10) Review
such areas as:
a. Infection
surveillance;
b. Drug usage
evaluation;
c. Morbidity;
d. Risk
assessment;
e. Mortality;
f.
Environmental safety;
g. Monitoring
of staff quality control practices in each service provided; and
h. Physician
and staff education, training and evaluation.
(c) The size and composition of the quality
assurance committee shall be as follows:
(1) The quality
assurance committee shall consist of at least one representative from each
specialty area provided by the practice;
(2) One person
may represent more than one specialty provided the person is trained and
qualified to represent each specialty;
(3) When a
matter under consideration by the committee involves a particular specialty, a
member representing that specialty shall participate in the committee's
proceedings;
(4) The quality
assurance committee shall consist of at least 3 physicians;
(5) To comply
with (4) above, physician practices consisting of fewer than 3 physicians
shall, while maintaining patient confidentiality, associate with other
physician practices so that a total of at least 3 physicians are members of the
committee; and
(6) Physician
practices consisting of 3 or more physicians may associate with other physician
practices in a quality assurance program and committee provided patient
confidentiality is protected.
(d) The quality assurance committee shall meet at
least quarterly.
(e) The quality assurance committee shall
generate dated written minutes after each meeting, including information on:
(1) Member
attendance;
(2) Indicators
reviewed at the present meeting;
(3) Conclusions
of the committee;
(4)
Recommendations for corrective action, if any; and
(5) Indicators
to be reviewed at the next meeting.
(f) Documentation of all quality assurance
activities shall be maintained on-site by the physician practice for at least 2
years.
(g) In accordance with RSA 329:29-a records
related to the activities of the quality assurance program shall be
confidential and privileged.
Source. #7694, eff 6-4-02; ss by #9719, eff 6-4-10
Appendix
Rule |
|
He-P 401.01 |
RSA 329:29-a, I (b) |
He-P 401.02 |
RSA 329:29-a, I (a)-(b) |
He-P 401.03 |
RSA 329:29-a, I (b) |
He-P 401.04 |
RSA 329:29-a, I-II |