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Authority: AS 47.32.010 AS 47.32.030 7 AAC 12.418. Evaluation and improvement of quality of care. (a) The birth center shall develop and implement a program for evaluating and improving the quality of

(1) direct care services to childbearing families; and

(2) the environment in which services are provided. (b) The birth center shall

(1) include in its evaluation and improvement program an organizational plan to identify and resolve problems; and

(2) hold regular meetings of the clinical staff to review the management of care of individual clients and newborns and to make recommendations for improving the plan of care. (c) In the evaluation and improvement program for direct care services for clients and newborns, the birth center shall review and document at least annually

(1) protocols, policies, and procedures relating to client and newborn care, and revise any protocol, policy, or procedure as necessary;

(2) the appropriateness of the risk assessment standards developed under 7 AAC 12.403(f) for determining eligibility for admission to and continuation in the birth center program of care;

(3) the appropriateness of diagnostic and screening procedures, including laboratory studies, sonography, and non-stress tests, as those procedures affect quality of care and cost to the client;

(4) the appropriateness of medications prescribed, dispensed, or administered by the birth center;

(5) performance evaluation, including peer review, for each employee, including contract staff, with results maintained in the personnel record;

(6) transfers of clients and newborns to hospital care; to determine the appropriateness and quality of each transfer, the birth center shall establish procedures for the evaluation of emergency and non-emergency transfers, including

(A) the amount of time to complete transfers;