N.J. Admin. Code § 8:33E-1.6

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

Section 8:33E-1.6 - Quality improvement

(a) All facilities applying to provide or providing any invasive cardiac diagnostic services pursuant to this subchapter shall provide for and shall maintain an appropriate mechanism for peer review which shall include, but not necessarily be limited to, the delineation of criteria for the evaluation of:

1. Overall case selection for study (for example, rate of normal studies, rate of surgical referral);

2. Laboratory and physician performance including physician performance guidelines (for example, patient volume, mortality and complication rates per physician); and

3. Quality of studies (for example, number of incomplete studies, diagnostic adequacy of films, number of restudies performed elsewhere).

(b) In all cases, there shall be documentation that criteria selection is based on sound medical practice and consistent with the literature. Internal quality assurance procedures shall be adopted to address patient safety issues and the clinical appropriateness of the services being provided.

(c) Each peer review team shall include at least one cardiovascular surgeon from the surgical center to which surgical candidates are commonly referred.

(d) All facilities applying to provide or providing a low risk cardiac catheterization facility or a full service adult diagnostic cardiac catheterization facility shall also provide written documentation that the proposed services shall adhere to the following quality of care outcome measures:

1. A low-risk patient mortality and morbidity rate as reviewed by the hospital's peer review mechanism and submitted to the Department of Health and Senior Services for review and approval;

2. A physician-specific and overall low risk laboratory percentage of normal studies that does not exceed 25 percent of total annual cardiac catheterization cases calculated with the application of a confidence interval;

3. Review by the hospital's peer review mechanism of any low risk laboratory reporting more than 50 percent increase in the number of normal studies during any quarterly reporting period and the submission to the Department within 60 days of such review of a plan for corrective action to restore normal studies to the level permitted herein;

4. The percentage of all patients undergoing diagnostic cardiac catheterization in the low risk catheterization facility who have subsequently undergone a therapeutic interventional cardiac procedure (for example, coronary angioplasty, directional atherectomy, coronary bypass surgery) as a direct result of the findings of the diagnostic cardiac catheterization procedure performed at this low risk catheterization facility will be monitored by the Department; and

5. Careful monitoring of the clinical appropriateness of the performance of right heart catheterization procedures.

(e) All facilities applying to provide or providing full service adult diagnostic cardiac catheterization services shall also provide written documentation that the proposed services shall adhere to the following quality of care outcome measures:

1. A full service patient mortality and morbidity rate as reviewed by the hospital's peer review mechanism and submitted to the Department of Health and Senior Services on a quarterly basis for review and approval; and

2. The percentage of all patients undergoing diagnostic cardiac catheterization in the full service catheterization program who have subsequently undergone a therapeutic interventional cardiac procedure (for example, coronary angioplasty, directional atherectomy, coronary bypass surgery) as a direct result of the findings of the diagnostic cardiac catheterization procedure performed at this full service catheterization program shall be monitored by the Department.

N.J. Admin. Code § 8:33E-1.6

Amended by R.2001 d.210, effective 6/18/2001.
See: 33 New Jersey Register 616(b), 33 New Jersey Register 2105(a).
Rewrote (b) and (d); added (e).
Amended by R.2004 d.37, effective 1/20/2004.
See: 35 New Jersey Register 3773(a), 36 New Jersey Register 416(a).
In (d)2, added "calculated without application of a confidence interval".
Amended by R.2006 d.263, effective 7/17/2006.
See: 38 N.J.R. 53(a), 38 N.J.R. 3025(a).
In (d)2, substituted "with the" for "without".