Rule 3701-84-39 | Quality assessment and performance improvement - open heart surgery service.
(A) In addition to the general quality assessment and performance improvement requirements set forth in rule 3701-84-12 of the Administrative Code, each open heart surgery service will:
(1) As part of the service's overall quality assessment and performance improvement process:
(a) Utilize the quality performance measures outcomes data obtained from the service's participation in a data registry to monitor operator and institutional volumes and outcomes; and
(b) Include a periodic review and evaluation of the multidisciplinary meetings required by paragraph (J) of rule 3701-84-36 of the Administrative Code.
(2) Have a regular formal morbidity and mortality conference chaired by the medical director of the open heart surgery service or the medical director's designee. The morbidity and mortality conferences will:
(a) Be held at least once every sixty days or more frequently depending on the need; and
(b) Review all deaths and complications such as reoperation for bleeding, deep sternal wound infection, stroke, and perioperative myocardial infarction and any patterns that might indicate a problem will be investigated and remedied if necessary.
(B) Each open heart surgery service will maintain a clinical pathway for coronary bypass graft surgery and valve replacements.
Last updated May 15, 2023 at 12:45 AM
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