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.