1. A. The freestanding medical facility shall develop and implement a quality assurance program.

2. B. The quality assurance program shall have a quality management process that:

   1. (1) Is multidisciplinary;
   2. (2) Is integrated into the hospital's overall quality management program that is reported to the hospital's governing body;
   3. (3) Has a structure to ensure that defined program outcomes and performance measures are developed and monitored regularly;

   4. (4) Maintains sufficient documentation to:

      1. (a) Verify problems;
      2. (b) Identify opportunities for improvement; and
      3. (c) Show corrective actions taken and resolution of problems;
   5. (5) Includes review of morbidity and mortality; and
   6. (6) Evaluates medical care, nursing care, utilization review, tissue review, and pre-hospital care.

Authority: Health-General Article, §2-104 and Title 19, Subtitle 3A, Annotated Code of Maryland

Effective date: February 12, 2007 (34:3 Md. R. 297)

Regulation .04B amended effective March 13, 2017 (44:5 Md. R. 292)

Regulation .05A amended effective March 13, 2017 (44:5 Md. R. 292)

Regulation .05C amended effective August 29, 2016 (43:17 Md. R. 953)