Ohio Admin. Code 3701-84-39 - Quality assessment and performance improvement - open heart surgery service

(A) In addition to the general quality assessment and performance improvement requirements set forth in rule 3701-84-12 of the Administrative Code, each provider of an open heart surgery service shall will:

(1) As part of the service's overall quality assessment and performance improvement process:

(a) Utilize the quality performance measures outcomes data obtained from the service's participation in the society for thoracic surgeons national a database data registry to monitor operator and institutional volumes and outcomes; and

(b) Include a periodic review and evaluation of the multidisciplinary meetings required by paragraph (J) of rule 3701-84-36 of the Administrative Code.

(2) Have a regular formal morbidity and mortality conference chaired by the medical director of the open heart surgery service or the medical director's designee. The morbidity and mortality conferences shall will:

(a) Be held at least a minimum once a month every sixty days or more frequently depending on the need; and

(b) Review all deaths and complications such as reoperation for bleeding, deep sternal wound infection, stroke, and perioperative myocardial infarction and any patterns that might indicate a problem shall will be investigated and remedied if necessary.

(B) Each provider of an open heart surgery service shall will maintain a clinical pathway for coronary bypass graft surgery and valve replacements.

Notes

Ohio Admin. Code 3701-84-39

Effective: 5/15/2023
Five Year Review (FYR) Dates: 2/27/2023 and 05/05/2028
Promulgated Under: 119.03
Statutory Authority: 3702.11, 3702.13
Rule Amplifies: 3702.11, 3702.12, 3702.13, 3702.14, 3702.141, 3702.15, 3702.16, 3702.18, 3702.19, 3702.20
Prior Effective Dates: 03/01/1997, 03/24/2003, 05/15/2008, 06/21/2012, 08/01/2017