Rule 3701-22-46. Quality assessment and performance improvement - open-heart surgery service

119.03 (A) In addition to the general quality assessment and performance improvement requirements set forth in rule 3701-22-07 of the Administrative Code, each open-heart surgery service will: (1) As part of the service's overall quality assessment and performance improvement process: (a) Utilize the quality performance measures outcomes data obtained from the service's participation in a data registry to monitor operator and institutional volumes and outcomes; and (b) Include a periodic review and evaluation of the multidisciplinary meetings required by paragraph (I) of rule 3701-22-43 of the Administrative Code. (2) Have a regular formal morbidity and mortality conference chaired by the medical director of the open-heart surgery service or the medical director's designee. The morbidity and mortality conferences will: (a) Be held at least once every sixty days or more frequently depending on the need; and (b) Review all deaths and complications such as reoperation for bleeding, deep sternal wound infection, stroke, and perioperative myocardial infarction and any patterns that might indicate a problem will be investigated and remedied if necessary. (B) Each open-heart surgery service will maintain a clinical pathway for coronary bypass graft surgery and valve replacements. Last updated September 2, 2025 at 9:07 AM Supplemental Information Authorized By: 3722.06 Amplifies: 3722.06 8/31/2030