N.H. Admin. Code § He-P 401.04

Current through Register No. 50, December 12, 2024

Section He-P 401.04 - Quality Assurance Committee

(a) All physician practices choosing to implement a quality assurance program shall establish a quality assurance committee.

(b) The quality assurance committee shall:

(1) Determine the information to be monitored;

(2) Determine the frequency with which information will be reviewed;

(3) Determine the way in which the information being monitored will be evaluated and measured;

(4) Evaluate the information that is gathered;

(5) Determine the action that is necessary to correct identified problems;

(6) Recommend corrective actions and initiate changes to improve quality of care;

(7) Evaluate the effectiveness of the corrective actions;

(8) Ensure that quality control logs are maintained for any required laboratory controls and proficiency testing;

(9) Ensure that quality control logs for preventive maintenance and safety checks are maintained for all equipment according to manufacturers directions; and

(10) Review such areas as:

a. Infection surveillance;

b. Drug usage evaluation;

c. Morbidity;

d. Risk assessment;

e. Mortality;

f. Environmental safety;

g. Monitoring of staff quality control practices in each service provided; and

h. Physician and staff education, training and evaluation.

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

(1) The quality assurance committee shall consist of at least one representative from each specialty area provided by the practice;

(2) One person may represent more than one specialty provided the person is trained and qualified to represent each specialty;

(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) The quality assurance committee shall consist of at least 3 physicians;

(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) 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.

(d) The quality assurance committee shall meet at least quarterly.

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

(1) Member attendance;

(2) Indicators reviewed at the present meeting;

(3) Conclusions of the committee;

(4) Recommendations for corrective action, if any; and

(5) Indicators to be reviewed at the next meeting.

(f) Documentation of all quality assurance activities shall be maintained on-site by the physician practice for at least 2 years.

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

N.H. Admin. Code § He-P 401.04

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