N.J. Admin. Code § 8:41-3.15

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:41-3.15 - Quality assurance

(a) A continuous quality improvement structural organization shall be made a part of a provider's organizational structure.

1. The governing authority of the hospital (such as the board of trustees) or provider shall have ultimate responsibility for the continuous quality improvement program.

2. The provider shall have a continuous quality improvement program based on a written continuous quality improvement plan that is implemented and that monitors the quality of patient care.

3. Each provider shall have continuous quality improvement activities that are part of the overall quality assurance plan.

(b) A continuous quality improvement program shall contain the following policies and procedures:

1. The continuous quality improvement plan shall be reviewed at least annually and revised as necessary. Responsibility for reviewing and revising the plan shall be designated in the plan itself.

2. The continuous quality improvement plan shall delineate lines of communication between the continuous quality improvement program and the medical staff, chief executive officer or administrator, and governing authority.

3. The provider's continuous quality improvement plan shall specify procedures for the development, implementation, and coordination of quality reviews. The plan shall also establish a mechanism for the evaluation of the continuous quality improvement program.

4. The provider shall disseminate its findings and results of continuous quality improvement activities internally, as defined in the continuous quality improvement plan.

(c) A continuous quality improvement program shall be coordinated by a designated staff member.

1. There shall be an individual responsible for coordinating all aspects of the continuous quality improvement program.

(d) A continuous quality improvement program shall evaluate the following patient services:

1. There shall be an ongoing process of monitoring patient care. Evaluation of patient care is criteria-based, so that certain review actions are taken or triggered when specific quantified, predetermined levels of outcomes or potential problems are identified.

2. The continuous quality improvement coordinator shall be available to provide ongoing consultation to employees including assistance with the development of specific indicators used to evaluate service outcome.

3. The program shall follow up on its findings to assure that effective corrective actions have been taken, including at least policy revisions, procedural changes, educational activities, and follow-up on recommendations, or that additional actions are no longer indicated or needed.

4. The continuous quality improvement program shall provide information that is utilized in the evaluation of the clinical competence of all clinical practitioners.

(e) Each provider shall develop and maintain a quality assurance plan that is consistent with the standards set forth at 8:43G-27.1 through 27.5.

(f) The provider's medical director (or his or her physician designee meeting the requirements for medical command physicians found at 8:41-9.5, 10.5 and 11.5) shall be responsible for the coordination of all aspects of the quality assurance program and shall be available to provide ongoing consultation to the provider, including assistance with the development of specific indicators utilized to evaluate service outcomes on the MICU, SCTU or AMU.

(g) There shall be an ongoing process of monitoring patient care. Evaluation of patient care on the MICU, SCTU or AMU shall be criteria-based, so that certain review actions are taken or triggered when specific quantified, predetermined levels of outcomes or potential problems are identified.

(h) The provider shall follow up on its findings to assure that effective corrective action is taken, including, at a minimum, policy revisions, procedural changes, educational activities and follow-up on recommendations, or shall establish that additional actions are no longer indicated or needed.

(i) The quality assurance program shall identify and establish indicators of quality care specific to the MICU, SCTU or AMU that are monitored and evaluated that encompass, as applicable:

1. Medical calls;

2. Trauma calls;

3. Pediatric calls;

4. Cardiac/respiratory arrest incidents;

5. Patients triaged to BLS;

6. Utilization of communications failure protocols;

7. Utilization of, and adherence to, standing orders;

8. On-scene times;

9. Utilization of special procedures;

10. Triage to specialty care facilities; and

11. Other areas the medical director finds necessary to track in this manner.

(j) The director or specialty care coordinator, as applicable, shall ensure that all patient medical records meet the following standards:

1. Completeness of the patient care report;

2. Adherence to policies regarding treatment and triage of patients including the guidelines for pediatric and adult patients in Chapter Appendices E and F, incorporated herein by reference, as applicable;

3. Compliance with the requirements of this chapter;

4. Documentation of excessive time spent at the scene or receiving health care facility, as applicable, based on the nature of the call, deviations from established protocols, unsuccessful procedures, communications failure, and other unusual incidents; and

5. The conditions set forth in (i) above.

(k) The medical director or his or her physician designee shall review at least 10 percent of all calls during which a patient was evaluated by the crewmembers (excluding the calls listed in (m) below). The method of determining which 10 percent of the calls will be reviewed shall be at the discretion of the medical director. The review shall determine:

1. Consistency with accepted treatment and triage protocols, as applicable;

2. Consistency of the written record with any voice recording of the call;

3. Appropriateness of orders issued by the medical command physician;

4. Appropriateness of the carrying out of orders received by the ALS crewmembers; and

5. Completeness of the patient care report.

(l) The quality assurance review shall be completed within 120 calendar days from date of service and shall encompass at least 10 percent of all calls, excluding cancelled calls.

(m) The quality assurance review for rapid sequence inductions, percutaneous needle cricothyrotomy, needle chest decompression, central venous access, intraosseous access and any patient who is triaged to BLS and subsequently admitted to a critical care unit shall be completed by the medical director within 120 calendar days from date of service and shall encompass 100 percent of the calls (not to be included into the 10 percent of calls required in (k) above).

1. Quality assurance reviews for rapid sequence inductions shall be maintained for the first 24 months that the procedure is utilized by a provider's ALS crewmembers. The patient care report shall be sent to the Department for review within 14 days after the procedure is conducted.

(n) Each provider shall keep written records of medical director reviews and shall produce them upon demand to an authorized representative of the Department. Medical director reviews shall include the comments of the medical director or his or her physician designee in accordance with (i) and (j) above. The provider shall keep quality assurance reviews for a period of one year from the date of the review.

N.J. Admin. Code § 8:41-3.15