N.Y. Public Health Law § 2805-j: Medical, dental and podiatric malpractice prevention program

§ 2805-j. Medical, dental and podiatric malpractice prevention

program. 1. Every hospital shall maintain a coordinated program for the

identification and prevention of medical, dental and podiatric

malpractice. Such program shall include at least the following:

(a) The establishment of a quality assurance committee with the

responsibility to review the services rendered in the hospital in order

to improve the quality of medical, dental and podiatric care of patients

and to prevent medical, dental and podiatric malpractice. Such

committee shall oversee and coordinate the medical, dental and podiatric

malpractice prevention program and shall insure that information

gathered pursuant to the program is utilized to review and to revise

hospital policies and procedures. At least one member of the committee

shall be a member of the governing board of the hospital who is not

otherwise affiliated with the hospital in an employment or contractual

capacity;

(b) A medical, dental and podiatric staff privileges sanction

procedure through which credentials, physical and mental capacity and

competence in delivering health care services are periodically reviewed,

and reviewed as otherwise warranted in specific instances and

circumstances, as part of an evaluation of staff privileges;

(c) The periodic review and the review as otherwise warranted in

specific instances and circumstances of the credentials, physical and

mental capacity and competence in delivering health care services of all

persons who are employed or associated with the hospital;

(d) A procedure for the prompt resolution of grievances by patients or

their representatives related to accidents, injuries, treatment and

other events that may result in claims of medical, dental or podiatric

malpractice;

(e) The maintenance and continuous collection of information

concerning the hospital's experience with negative health care outcomes

and incidents injurious to patients, patient grievances, professional

liability premiums, settlements, awards, costs incurred by the hospital

for patient injury prevention and safety improvement activities;

(f) The maintenance of relevant and appropriate information gathered

pursuant to paragraphs (a) through (e) of this subdivision concerning

individual physicians, dentists and podiatrists within the physician's,

dentist's or podiatrist's personnel or credential file maintained by the

hospital;

(g) Education programs dealing with patient safety, injury prevention,

staff responsibility to report professional misconduct, the legal

aspects of patient care, improved communication with patients and causes

of malpractice claims for staff personnel engaged in patient care

activities;

(h) Continuing education programs for medical, dental and podiatric

staff in their areas of specialty; and

(i) Policies to ensure compliance with the reporting requirements of

section twenty-eight hundred three-e of this article and subdivision

eleven of section two hundred thirty of this chapter.

(j) For the purposes of this section, the term "hospital" shall have

the same meaning as is set forth in subdivision ten of section

twenty-eight hundred one of this article.

2. Any person who, in good faith and without malice, provides

information to further the purposes of the medical, dental and podiatric

malpractice prevention program or who, in good faith and without malice,

participates on the quality assurance committee shall not be subject to

an action for civil damages or other relief as a result of such

activity. Any hospital, or any person acting on behalf of such hospital,

who, in good faith and without malice, takes or fails to take any action

as a result of a review conducted pursuant to paragraph (b) or (c) of

subdivision one of this section, shall not be subject to an action for

civil damages or other monetary relief as a result of such action or

failure to act, provided, however, that nothing in this subdivision

shall relieve any hospital of any liability in an action for medical,

dental or podiatric malpractice based on an act or failure to act as a

result of a review conducted pursuant to paragraph (b) or (c) of

subdivision one of this section, and provided further that nothing

herein shall affect the authority of the commissioner pursuant to this

chapter.

3. The commissioner shall make, adopt, promulgate and enforce such

rules and regulations as he may deem appropriate to effectuate the

purposes of this section.