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 provider of an open heart surgery service shall:

(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 society for thoracic surgeons congenital heart surgery database; 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 open heart surgery service or the medical director's designee. The morbidity and mortality conferences shall:

(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, and perioperative myocardial infarction and any patterns that might indicate a problem shall be investigated and remedied if necessary.

Replaces: 3701-84-85

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, 6/21/12