§ 138.20. Quality management and improvement.
(a) A hospital providing cardiac catheterization services shall maintain patient data on the following:
(1) Mortality/morbidity.
(2) Infections and complications.
(3) Patient risk factors.
(4) Volume of procedures performed (including separate volumes for diagnostic visualizations, PTCA and electrophysiology procedures).
(b) The hospital shall provide this information to the Department through the Pennsylvania Cardiac Catheterization Report. This data shall be integrated into the hospital’s quality assurance program and used to ensure necessary corrections to improve outcomes.
(c) 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 cardiac catheterization program.
(d) If the Department’s review of this information raises concerns with the quality of care in a cardiac catheterization 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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