.11 Quality Assurance.

A. The freestanding medical facility shall develop and implement a quality assurance program.

B. The quality assurance program shall have a quality management process that:

(1) Is multidisciplinary;

(2) Is integrated into the hospital's overall quality management program that is reported to the hospital's governing body;

(3) Has a structure to ensure that defined program outcomes and performance measures are developed and monitored regularly;

(4) Maintains sufficient documentation to:

(a) Verify problems;

(b) Identify opportunities for improvement; and

(c) Show corrective actions taken and resolution of problems;

(5) Includes review of morbidity and mortality; and

(6) Evaluates medical care, nursing care, utilization review, tissue review, and pre-hospital care.