Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 1
Subtitle 07 - HOSPITALS
Chapter 10.07.08 - Freestanding Medical Facilities
Section 10.07.08.11 - Quality Assurance
Universal Citation: MD Code Reg 10.07.08.11
Current through Register Vol. 51, No. 19, September 20, 2024
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.
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