(a)  The governing authority shall establish a quality assurance program for the purpose of providing standards of care for the facility. The program shall include the establishment of a committee which shall evaluate:

(1)           appropriateness and necessity of surgical procedures performed, and

(2)           compliance with facility procedure and policies.

The committee shall determine corrective action if indicated.

(b)  The committee shall consist of at least one physician or dentist (who is not an owner), the chief executive officer (or his designee), and other health professionals as indicated. There shall be at least one meeting of the committee quarterly.

(c)  The functions of the committee shall include development of policies for selection of patients, review of credentials for staff privileges, peer review, tissue review, establishment of infection control procedures, and approval of additional surgical procedures to be performed in the facility.

(d)  Records shall be kept of the activities of the committee. These records shall include as a minimum:

(1)           reports made to the governing authority;

(2)           minutes of committee meetings including date, time, persons attending, description and results of cases reviewed, and recommendations made by the committee; and

(3)           information on any corrective action taken.

(e)  Appropriate orientation, training or education programs shall be conducted as necessary to correct deficiencies which are uncovered as a result of the quality assurance program.


History Note:        Authority G.S. 131E‑149;

Eff. October 14, 1978;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. December 23, 2017.