Quality Assurance and Improvement Program - 28 Pa. Code § 557.3

Every Ambulatory Surgical Facility must have a written plan for a quality assurance and improvement program that describes the program’s objectives, organization, scope and mechanisms for overseeing the effectiveness of monitoring, evaluation and problem-solving activities; the plan must emphasize the ongoing nature of the program and the comprehensive of its scope, which shall include monitoring and evaluation of the following:

• Medical staff functions including:
  • Peer-based review of clinical performance of individuals with clinical privileges; and
  • Surgical case and tissue review.
• Anesthesia services;
• Nursing services;
• Pharmaceutical services;
• Pathology and radiology services;
• Infection control procedures;
• Procedures performed in the ASF and their necessity; and
• Reports of accidents, injuries and safety hazards.

The data monitored and collected will come from medical records, incident reports, infection control reports and patient complaints; the program must identify problems and measures taken to assure that the problem has been satisfactorily resolved, which may include:

• Changes in policies and procedures;
• Staffing and assignment changes;
• Appropriate education and training;
• Adjustments in clinical privileges; and
• Changes in equipment or physical plant.

The program must include a mechanism to assure that activities are documented and reports of the quality assurance activities are brought to the attention of the governing body; there shall be a periodic reappraisal of the program.