New Jersey Administrative Code
Title 8 - HEALTH
Chapter 41 - ADVANCED LIFE SUPPORT SERVICES; MOBILE INTENSIVE CARE PROGRAMS, SPECIALTY CARE TRANSPORT SERVICES AND AIR MEDICAL SERVICES
Subchapter 3 - GENERAL ADMINISTRATIVE, CREWMEMBER AND VEHICLE REQUIREMENTS
Section 8:41-3.15 - Quality assurance
Current through Register Vol. 56, No. 6, March 18, 2024
(a) A continuous quality improvement structural organization shall be made a part of a provider's organizational structure.
(b) A continuous quality improvement program shall contain the following policies and procedures:
(c) A continuous quality improvement program shall be coordinated by a designated staff member.
(d) A continuous quality improvement program shall evaluate the following patient services:
(e) Each provider shall develop and maintain a quality assurance plan that is consistent with the standards set forth at 8:43G-27.1 through 27.5.
(f) The provider's medical director (or his or her physician designee meeting the requirements for medical command physicians found at 8:41-9.5, 10.5 and 11.5) shall be responsible for the coordination of all aspects of the quality assurance program and shall be available to provide ongoing consultation to the provider, including assistance with the development of specific indicators utilized to evaluate service outcomes on the MICU, SCTU or AMU.
(g) There shall be an ongoing process of monitoring patient care. Evaluation of patient care on the MICU, SCTU or AMU shall be criteria-based, so that certain review actions are taken or triggered when specific quantified, predetermined levels of outcomes or potential problems are identified.
(h) The provider shall follow up on its findings to assure that effective corrective action is taken, including, at a minimum, policy revisions, procedural changes, educational activities and follow-up on recommendations, or shall establish that additional actions are no longer indicated or needed.
(i) The quality assurance program shall identify and establish indicators of quality care specific to the MICU, SCTU or AMU that are monitored and evaluated that encompass, as applicable:
(j) The director or specialty care coordinator, as applicable, shall ensure that all patient medical records meet the following standards:
(k) The medical director or his or her physician designee shall review at least 10 percent of all calls during which a patient was evaluated by the crewmembers (excluding the calls listed in (m) below). The method of determining which 10 percent of the calls will be reviewed shall be at the discretion of the medical director. The review shall determine:
(l) The quality assurance review shall be completed within 120 calendar days from date of service and shall encompass at least 10 percent of all calls, excluding cancelled calls.
(m) The quality assurance review for rapid sequence inductions, percutaneous needle cricothyrotomy, needle chest decompression, central venous access, intraosseous access and any patient who is triaged to BLS and subsequently admitted to a critical care unit shall be completed by the medical director within 120 calendar days from date of service and shall encompass 100 percent of the calls (not to be included into the 10 percent of calls required in (k) above).
(n) Each provider shall keep written records of medical director reviews and shall produce them upon demand to an authorized representative of the Department. Medical director reviews shall include the comments of the medical director or his or her physician designee in accordance with (i) and (j) above. The provider shall keep quality assurance reviews for a period of one year from the date of the review.