Section 1250.1760  Quality

 

a)         Criteria #1:  Does the delivery of the service prove beneficial to both patients and the community?

 

b)         Standard #1:  The mortality rate of patients treated should not significantly (95% confidence level) exceed national and state mortality rates based upon the types of patients treated.

 

c)         Data Factors:

 

1)         Patients treated - volume.

 

2)         Mortality rate.

 

3)         Deaths by cause.

 

4)         National and state mortality rates.

 

5)         Characteristics of patients.

 

d)         Criteria #2:  Is there an adequate patient care and utilization review process?

 

e)         Standard #1:  Existence of acceptable peer review programs.

 

f)          Data Factors:  Peer review programs.

 

g)         Standard #2:

 

1)         All necessary support services are available.

 

A)        Surgical and cardiological team appropriate for age group served.

 

B)        Cardiac surgical intensive care unit.

 

C)        Emergency room with full-time director, staffed 24 hours for cardiac emergencies with acute coronary suspect surveillance area and voice communication linkage to the ambulance service and the coronary care unit.

 

D)        Cardiac catheterization-angiographics laboratory services in house.

 

E)         Nuclear medicine laboratory.

 

F)         Cardiographics laboratory, electrocardiography including exercise stress testing, continuous ECG monitoring and phonocardiography.

 

G)        Echocardiography service.  This may or may not be a part of the cardiographics laboratory.

 

H)        Hematology laboratory.

 

I)          Microbiology laboratory.

 

J)         Blood gas and electrolyte laboratory with microtechniques for pediatric patients.

 

K)        Electrocardiographic laboratory.

 

L)         Blood bank and coagulation laboratory.

 

M)       Pulmonary function unit.

 

N)        Installations of pacemakers.

 

O)        Organized cardiopulmonary resuscitation team or capability.

 

P)         Preventive maintenance program for all biomedical, electrical devices.

 

Q)        Renal Dialysis.

 

2)         It is not essential that all of these services, units and laboratories be available on an inpatient basis in the facility.  What must be documented is how such services can be immediately mobilized for emergencies at all times.

 

h)         Data Factors:  Required support service availability.

 

i)          Criteria #3:  Do appropriate referral agreements exist for the transfer and acceptance of catheterization studies from free standing laboratories?

 

j)          Standard #1:  Agreements with free standing laboratories should be in existence including an administrative policy relative to acceptance of catheterization studies by referral facilities.

 

k)         Data Factors:

 

1)         Agreements.

 

2)         Policy on acceptance.

 

l)          Criteria #4:  Are patient records available and accessible?

 

m)        Standard #1:  Policies should be in place relative to the use and release of medical records.

 

n)         Data Factors:  Medical records policies.

 

o)         Criteria #5:  Does a heart disease data system exist in all facilities providing the service?

 

p)         Standard #1:

 

1)         A heart disease data system should exist in all facilities providing the service.

 

2)         All facilities offering open heart surgery should have a data system reflective of patient morbidity and mortality, type of cases performed (congenital, valvular, acquired, etc.) and the average time for such procedures.  The data system should also include the number and composition of cardiac surgery teams and procedure volume performed by each team annually.

 

q)         Data Factors:  Data system description.