Rule 3701-84-85 | Quality assessment and performance improvement - pediatric cardiovascular surgery service.
In addition to the general quality assessment and performance improvement requirements set forth in rule 3701-84-12 of the Administrative Code, each pediatric cardiovascular surgery service will:
(A) As part of the service's overall quality assessment and performance improvement process:
(1) Utilize the quality performance measures outcomes data obtained from the service's participation in the service's chosen data registry; and
(2) Include a periodic review and evaluation of the multidisciplinary meetings required by paragraph (D) of rule 3701-84-81 of the Administrative Code.
(B) Have a regular formal morbidity and mortality conference chaired by the medical director of the pediatric cardiovascular surgery service or the medical director's designee. The morbidity and mortality conferences will:
(1) Be held at a minimum, once a month or more frequently depending on the need; and
(2) Review all deaths and complications such as reoperation for bleeding, deep sternal wound infection, stroke, perioperative myocardial infarction, and any patterns that might indicate a problem will be investigated and remedied if necessary.
Last updated May 15, 2023 at 12:45 AM
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