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Quality Assurance and Improvement Program - 28 Pa. Code § 557.3

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Every Ambulatory Surgical Facility must have a written plan for a quality assurance and improvement program that describes the program’s objectives, organization, scope and mechanisms for overseeing the effectiveness of monitoring, evaluation and problem-solving activities; the plan must emphasize the ongoing nature of the program and the comprehensive of its scope, which shall include monitoring and evaluation of the following:

  • Medical staff functions including:
    • Peer-based review of clinical performance of individuals with clinical privileges; and
    • Surgical case and tissue review.
  • Anesthesia services;
  • Nursing services;
  • Pharmaceutical services;
  • Pathology and radiology services;
  • Infection control procedures;
  • Procedures performed in the ASF and their necessity; and
  • Reports of accidents, injuries and safety hazards.

The data monitored and collected will come from medical records, incident reports, infection control reports and patient complaints; the program must identify problems and measures taken to assure that the problem has been satisfactorily resolved, which may include:

  • Changes in policies and procedures;
  • Staffing and assignment changes;
  • Appropriate education and training;
  • Adjustments in clinical privileges; and
  • Changes in equipment or physical plant.

The program must include a mechanism to assure that activities are documented and reports of the quality assurance activities are brought to the attention of the governing body; there shall be a periodic reappraisal of the program.

Current as of June 2015