(a)  The medical staff shall have in effect a system to review medical services rendered, to assess quality, to provide a process for improving performance when indicated and to monitor the outcome.

(b)  The medical staff shall establish criteria for the evaluation of the quality of medical care.

(c)  The facility shall have a written plan approved by the medical staff, administration and governing body which generates reports to permit identification of patient care problems. The plan shall establish a system to use this data to document and identify interventions.

(d)  The medical staff shall establish and maintain a continuous review process of the care rendered to both inpatients and outpatients in every medical department of the facility. At least quarterly, the medical staff shall have a meeting to examine the review process and results. The review process shall include both practitioners and allied health professionals from the facility staff.

(e)  Minutes shall be taken at all meetings reviewing quality improvement, and these minutes shall be made available to the medical staff on a regular basis in accordance with established policy. These minutes shall be retained as determined by the facility.


History Note:        Authority G.S. 131E-79;

Eff. January 1, 1996;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.