Evaluation of Quality

(A) Each clinic shall establish an organized, comprehensive program adequate to regularly review and evaluate the quality of care provided. The program shall: (1) be defined in writing and approved by its governing body; (2) identify an individual to be responsible for the implementation and continuity of the program; (3) be reevaluated at least annually; and (4) describe the mechanisms in effect to identify and resolve problems. (B) The findings of the program shall, as appropriate, be utilized in the revision of clinic policies and procedures. (C) Clinics licensed for surgical services shall meet the additional requirements set forth in 105 CMR 140.613.