(a) A hospital performing open heart surgery shall maintain patient data on the following:
- (1) Mortality/morbidity.
- (2) Infections and complications.
- (3) Patient risk factors.
- (4) Volume of procedures performed.
- (b) The hospital shall provide this information to the Department on a quarterly basis, on a form prescribed by the Department. This data shall be integrated into the hospital’s quality assurance program and used to ensure necessary corrections to improve outcomes.
- (c) In lieu of the information listed under subsection (a), a hospital may submit information provided by its thoracic surgeons to the Risk Stratification Program of the Society of Thoracic Surgeons.
- (d) The Department will review the information submitted by the hospital and other relevant information which is available to assess the qualitative performance of the hospital’s open heart surgery program.
- (e) If the Department’s review of this information raises concerns with the quality of care in an open heart surgery program, the Department will undertake a review of that program to determine if these concerns are valid. The hospital shall cooperate with the Department in this review.