N.J. Admin. Code § 8:43G-27.1

Current through Register Vol. 56, No. 21, November 4, 2024

Section 8:43G-27.1 - Continuous quality improvement structural organization

(a) The governing authority of the hospital (such as the board of trustees) shall have ultimate responsibility for the continuous quality improvement program.

(b) The hospital shall have a hospital-wide continuous quality improvement program based on a written continuous quality improvement plan that is implemented and that monitors the quality of patient care.

(c) Each clinical department shall have continuous quality improvement activities that are part of the overall hospital-wide plan, a multi-department plan, or an internally generated plan.

(d) There shall be a multidisciplinary committee responsible for the direction of the continuous quality improvement program. The committee shall include at least representation from the medical staff, nursing, and administration. The committee shall establish a mechanism to include participation of all disciplines in identifying areas of review that affect patient care throughout the hospital.

(e) The hospital shall perform risk management functions. Reports generated by risk management activities shall be routinely provided to the multidisciplinary committee responsible for coordinating the quality improvement program.

N.J. Admin. Code § 8:43G-27.1

Amended by R.1999 d.436, effective 12/20/1999.
See: 31 New Jersey Register 367(a), 31 New Jersey Register 614(a), 31 New Jersey Register 4293(c).
Substituted references to continuous quality improvement for references to quality assurance throughout; in (c), substituted a reference to continuous quality improvement for a reference to continuous quality assurance; and in (e), substituted a reference to quality improvement for a reference to quality assurance.