3701-84-39 Quality assessment and performance improvement.

(A) The provider of an open heart surgery service shall have a regular formal morbidity and mortality conference chaired by the medical director of the open heart surgery service or his or her designee. Morbidity and mortality conferences shall be held at a minimum once a month or more frequently depending on the need. All deaths and complications such as reoperation for bleeding, deep sternal wound infection, stroke, and perioperative myocardial infarction shall be reviewed and any patterns that might indicate a problem shall be investigated and remedied if necessary.

(B) The provider of an open heart surgery service shall maintain a clinical pathway for coronary bypass graft surgery and valve replacements.

Effective: 06/21/2012
R.C. 119.032 review dates: 04/05/2012 and 05/01/2017
Promulgated Under: 119.03
Statutory Authority: 3702.11 , 3702.13
Rule Amplifies: 3702.11 , 3702.12 , 3702.13 , 3702.14 , 3702.141 , 3702.15 , 3702.16 , 3702.18 , 3702.19 , 3702.20
Prior Effective Dates: 3/20/1997, 3/24/03, 5/15/08