Each hospital shall: (a) Formulate and specify its goals and objectives and describe its programs (including volunteer services, if any) in a written plan for professional services. The plan shall be written in such a manner that the hospital's performance can be measured;

1. (b) have a written statement of goals and objectives for each program and each patient population served;
2. (c) conduct a utilization review program;
3. (d) exhibit evidence of a well-defined, organized program designed to enhance patient care through ongoing, objective assessment of important aspects of patient care and correction of identified problems; and
4. (e) if conducting research with human subjects, have written policies which assure that a rigorous review is conducted with regard to the merits of each research project and the potential effects of the research procedures on the participants.

(Authorized by and implementing K.S.A. 75-3307b; effective May 1, 1985.)