NAC449.9812. Program for quality assurance.

     1. The administrator of an ambulatory surgical center shall establish a program for quality assurance for the center.

     2. The program for quality assurance must include, without limitation:

     (a) Periodic reviews of the clinical responsibilities and authority of the members of the staff.

     (b) Periodic evaluations of members of the staff that are conducted by their peers.

     (c) Procedures for the supervision of the professional and technical activities of the members of the staff.

     (d) Procedures for identifying and correcting any problems or concerns that provide an opportunity for all members of the staff who are health care practitioners to participate in the program for quality assurance.

     (e) Techniques for self-assessment that are required to be used by the members of the staff and provide for an examination of the manner in which care has been, is and will be provided and the quality of the care provided.

     (f) Procedures for identifying and addressing any problems or concerns related to the care provided to patients using the medical records of the center and any other sources of data that may be useful to identify previously unrecognized concerns, and for assessing the frequency, severity and sources of suspected problems and concerns. The procedures must include, without limitation, procedures for assessing:

          (1) The clinical performances of members of the staff who are health care practitioners;

          (2) The standards used for the maintenance of medical records;

          (3) The procedures used to control the quality of radiological, pathological, laboratory and pharmaceutical services provided by the center;

          (4) The procedures used to control the quality of other professional and technical services provided by the center;

          (5) The care and services provided by the extended recovery unit, if such a unit is operated by the center;

          (6) The procedures used to control infection; and

          (7) The satisfaction of patients who have been treated at the center.

     (g) The maintenance of a record of all fires and deaths that have occurred at the center and the transfer of all patients from the center to a hospital.

     (h) Procedures for assessing any actions taken to correct identified problems or concerns and for determining whether the actions taken have achieved or sustained the desired result and, if not, why not.

     3. The members of the professional and administrative staffs of the center shall:

     (a) Understand, support and participate in the program for quality assurance; and

     (b) Participate in the resolution of any problems and concerns identified pursuant to the procedures required by subsection 2.

     4. The members of the staff who are health care practitioners shall participate in the development and application of the criteria used to evaluate the care provided at the center and the evaluation of any problems and concerns identified pursuant to the procedures required by subsection 2.

     5. Activities conducted pursuant to the program for quality assurance must be reported to the appropriate members of the staff and to the governing body. The administrator of the center shall establish procedures for carrying out any recommendations of the governing body.

     6. As used in this section, “health care practitioner” means a person who is licensed or certified to provide health care services in this State, including, without limitation, a physician, dentist, podiatrist, and registered or licensed practical nurse.

     (Added to NAC by Bd. of Health by R049-99, eff. 9-27-99; A by R181-09, 10-4-2013)