(b) The quality assurance committee shall:

1. (1) Determine the information to be monitored;
2. (2) Determine the frequency with which information will be reviewed;
3. (3) Determine the way in which the information being monitored will be evaluated and measured;
4. (4) Evaluate the information that is gathered;
5. (5) Determine the action that is necessary to correct identified problems;
6. (6) Recommend corrective actions and initiate changes to improve quality of care;
7. (7) Evaluate the effectiveness of the corrective actions;
8. (8) Ensure that quality control logs are maintained for any required laboratory controls and proficiency testing;
9. (9) Ensure that quality control logs for preventive maintenance and safety checks are maintained for all equipment according to manufacturers directions; and

10. (10) Review such areas as:

    1. a. Infection surveillance;
    2. b. Drug usage evaluation;
    3. c. Morbidity;
    4. d. Risk assessment;
    5. e. Mortality;
    6. f. Environmental safety;
    7. g. Monitoring of staff quality control practices in each service provided; and
    8. h. Physician and staff education, training and evaluation.

(c) The size and composition of the quality assurance committee shall be as follows:

1. (1) The quality assurance committee shall consist of at least one representative from each specialty area provided by the practice;
2. (2) One person may represent more than one specialty provided the person is trained and qualified to represent each specialty;
3. (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. (4) The quality assurance committee shall consist of at least 3 physicians;
5. (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. (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.

(e) The quality assurance committee shall generate dated written minutes after each meeting, including information on:

1. (1) Member attendance;
2. (2) Indicators reviewed at the present meeting;
3. (3) Conclusions of the committee;
4. (4) Recommendations for corrective action, if any; and
5. (5) Indicators to be reviewed at the next meeting.

(g) In accordance with RSA 329:29-a records related to the activities of the quality assurance program shall be confidential and privileged.

Source. #7694, eff 6-4-02; ss by #9719, eff 6-4-10

Appendix

Rule

Specific State Statute which the Rule Implements

He-P 401.01

RSA 329:29-a, I (b)

He-P 401.02

RSA 329:29-a, I (a)-(b)

He-P 401.03

RSA 329:29-a, I (b)

He-P 401.04

RSA 329:29-a, I-II