Section He-P 827.22 - Quality Improvement(a) The FMRTF shall develop and implement a quality improvement program that reviews policies and services and maximizes quality by preventing or correcting identified problems.(b) The FMRTF shall determine the size and composition of the quality improvement committee based on the size of the facility and the care and services provided.(c) The quality improvement committee shall: (1) Determine the information to be monitored;(2) Determine the frequency with which information will be reviewed;(3) Determine the indicators that will apply to the information being monitored;(4) Evaluate the information that is gathered;(5) Determine the action that is necessary to correct identified problems;(6) Recommend corrective actions to the FMRTF;(7) Evaluate the effectiveness of the corrective actions and determine additional corrective action as applicable;(8) Meet at least quarterly;(9) Generate dated, written minutes after each meeting; and(10) Documentation of all quality improvement activities, including minutes of meetings, shall be maintained on-site for at least 2 years from the date the record was created.(d) Mandatory monitoring of radiological safety practice standards according to He-P 4000 shall be part of the quality improvement program.N.H. Admin. Code § He-P 827.22
Adopted by Volume XXXIX Number 16, Filed April 18, 2019, Proposed by #12751, Effective 3/26/2019, Expires 3/26/2029.