Quality management and improvement - 28 Pa. Code § 136.21

Hospitals performing open heart surgery must maintain patient data on the following:

•         Mortality/morbidity;
•         Infections and complications;
•         Patient risk factors;
•         Volume of procedures performed.

The hospital must quarterly provide this information to the department of health; this data will be integrated into the hospital’s quality assurance program and used to ensure necessary corrections to improve outcomes. The department will review the information submitted by the hospital to assess the qualitative performance of the hospital’s open heart surgery program.  If such review raises concerns with the quality of care in a program, the department will review that program to determine if these concerns all valid; the hospital must cooperate with the department in this review.