Evaluation of Quality

(A) In addition to the requirements set forth in 105 CMR 140.370, the quality assurance program established by each clinic licensed to perform surgery shall include reviews of at least the following: (1) medical necessity of procedures performed, including the review of tissue removed at surgery to determine agreement or disagreement among the preoperative, postoperative and pathological diagnoses; (2) whether adequate pre and postoperative services and procedures met patient needs; and (3) all complications. (B) Each clinic shall use the findings of the assessments required by 105 CMR 140.613(A) in the revision of clinic policies and consideration of clinical privileges. (C) Each clinic shall document all such reviews conducted and their findings and shall make such documentation available to the Department upon request.