(a) To be eligible for a license, each hospital shall have in operation an internal risk management program that shall
- (1) investigate the frequency and causes of incidents in hospitals that cause injury to patients;
- (2) develop and implement measures to minimize the risk of injury to patients; in developing these measures each hospital shall take into account recommendations of its medical staff, private underwriters, industry standards, experience of other hospitals, and recommendations of licensing boards of other health care providers; and
- (3) analyze patient grievances that relate to patient care.