§ 136.21. Quality management and improvement.
(a) A hospital performing open heart surgery shall maintain patient data on the following:
(1) Mortality/morbidity.
(2) Infections and complications.
(3) Patient risk factors.
(4) Volume of procedures performed.
(b) The hospital shall provide this information to the Department on a quarterly basis, on a form prescribed by the Department. This data shall be integrated into the hospital’s quality assurance program and used to ensure necessary corrections to improve outcomes.
(c) In lieu of the information listed under subsection (a), a hospital may submit information provided by its thoracic surgeons to the Risk Stratification Program of the Society of Thoracic Surgeons.
(d) The Department will review the information submitted by the hospital and other relevant information which is available to assess the qualitative performance of the hospital’s open heart surgery program.
(e) If the Department’s review of this information raises concerns with the quality of care in an open heart surgery program, the Department will undertake a review of that program to determine if these concerns are valid. The hospital shall cooperate with the Department in this review.
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