Section 1250.1870  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 of death.

4)         National and State mortality rates.

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)         Criteria #3:  Are essential patient care support services available?

h)         Standard #1:

1)         All necessary support services are available.

2)         A dedicated cardiac catheterization laboratory must document the availability of the following support services:

A)        Nuclear medicine laboratory;

B)        Echocardiography service;

C)        Electrocardiography laboratory and services, including stress testing and continuous cardiogram monitoring;

D)        Pulmonary Function Unit;

E)         Blood bank;

F)         Hematology laboratory/coagulation laboratory;

G)        Microbiology laboratory;

H)        Blood Gas laboratory;

J)         Clinical pathology laboratory with facilities for blood chemistry.

3)         These support services need not be in operation on a 24 hour basis but must be available when needed.

i)          Data Factors:  Required support services availability.

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

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

l)          Data Factors:  Medical records policies.