2023 New York Laws › PBH - Public Health › Article 28 - Hospitals › 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.