(a)  The medical staff shall have in effect a system to review care provided at the facility by members of the medical staff, to assess quality, to provide a process for quality improvement, and to monitor the outcome of quality improvement activities.

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

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

(d)  The medical staff shall establish a policy to maintain a review process of the care provided by members of the medical staff to all patients in every medical department of the facility. The medical staff shall have a policy to schedule meetings to examine the review process and results. The review process shall include both practitioners and allied health professionals from the medical staff.

(e)  Minutes shall be prepared for all meetings reviewing quality improvement and shall reflect all of the transactions, conclusions, and recommendations of the meeting.


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;

Amended Eff. July 1, 2020.