3701-84-80. Quality assessment and performance improvement - pediatric cardiac catheterization service

(A) Each provider of a pediatric cardiac catheterization service shall have a regular formal morbidity and mortality conference chaired by the medical director of the pediatric cardiac catheterization service or the medical director's designee. The morbidity and mortality conference shall:

(1) Be held at a minimum of once every ninety days or more frequently depending on the need; and

(2) Review all of the following:

(a) Deaths;

(b) Rescue extracorporeal membrane oxygenation;

(c) Emergency surgery; and

(d) Major complications, such as:

(i) Readmission to intensive care unit;

(ii) Emergent readmission to the hospital; or

(iii) Major non-surgical intervention.

(B) Each provider of a pediatric cardiac catheterization service shall establish and maintain a method for reviewing the quality of all cardiac catheterization procedures. This review shall assess the following:

(1) Appropriateness of cardiac catheterization studies and interventions;

(2) Technical quality of cardiac catheterization studies;

(3) Procedure result;

(4) Rate of therapeutic success; and

(5) Rate of procedural complications.

(C) Each provider of a pediatric cardiac catheterization service shall establish and maintain a database to support the review process detailed in paragraph (B) of this rule. The results of analyses and review shall be documented and used to guide periodic internal reviews of individual physicians with respect to maintaining their credentials to perform specific cardiac catheterization procedures.

Replaces: part of 3701-84-75

Effective: 8/1/2017
Five Year Review (FYR) Dates: 03/01/2022
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: 3/1/1997, 3/24/03, 6/1/07, 6/21/12