Florida Regulations 59A-12.007: Quality Assurance
Current as of: 2024 | Check for updates
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(1) Each HMO or PHC shall have an ongoing quality assurance program designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care and resolve identified problems at the prevailing professional standard of care.
(2) The quality assurance plan shall be in writing and shall describe the program’s objectives, organization and problem solving activities.
(3) The scope of the program shall include, at a minimum, the following:
(a) Evaluation of clinical performance (peer review);
(b) Review of medication usage;
(c) Evaluation as to appropriate use of tests and studies, for example: lab, x-ray and EKG;
(d) Evaluation of subscriber grievances;
(e) A utilization review process;
(f) Evaluation of outcomes of care using criteria developed by physicians and other health professionals to evaluate patient care patterns and clinical performance for health services provided; and,
(g) Written procedures for taking appropriate remedial action whenever, as determined under the quality assurance program, inappropriate or substandard services have been provided or services which should have been provided were not.
(4) All findings, conclusions, recommendations, actions taken and results of actions taken shall be documented and reported through organizational channels that have been established.
Rulemaking Authority 641.56 FS. Law Implemented 641.49(3)(o), 641.495, 641.51 FS. History-New 1-28-88, Amended 3-11-92, Formerly 10D-100.007, Amended 4-10-03.
(3) The scope of the program shall include, at a minimum, the following:
(a) Evaluation of clinical performance (peer review);
(b) Review of medication usage;
(c) Evaluation as to appropriate use of tests and studies, for example: lab, x-ray and EKG;
(d) Evaluation of subscriber grievances;
(e) A utilization review process;
(f) Evaluation of outcomes of care using criteria developed by physicians and other health professionals to evaluate patient care patterns and clinical performance for health services provided; and,
(g) Written procedures for taking appropriate remedial action whenever, as determined under the quality assurance program, inappropriate or substandard services have been provided or services which should have been provided were not.
(4) All findings, conclusions, recommendations, actions taken and results of actions taken shall be documented and reported through organizational channels that have been established.
Rulemaking Authority 641.56 FS. Law Implemented 641.49(3)(o), 641.495, 641.51 FS. History-New 1-28-88, Amended 3-11-92, Formerly 10D-100.007, Amended 4-10-03.