Current through Register No. 40, October 3, 2024
(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.
#7694, eff 6-4-02; ss by #9719, eff
6-4-10
