35-2-910. Quality management functions for health care facilities; confidentiality; immunity; whistle blowing; peer review.

(a) Each licensee shall implement a quality management function to evaluate and improve patient and resident care and services in accordance with rules and regulations promulgated by the division. Quality management information relating to the evaluation or improvement of the quality of health care services is confidential. Any person who in good faith and within the scope of the functions of a quality management program participates in the reporting, collection, evaluation, or use of quality management information or performs other functions as part of a quality management program with regard to a specific circumstance shall be immune from suit in any civil action based on such functions brought by a health care provider or person to whom the quality information pertains. In no event shall this immunity apply to any negligent or intentional act or omission in the provision of care.

(b) Health care facilities subject to or licensed pursuant to this act shall not harass, threaten discipline or in any manner discriminate against any resident, patient or employee of any health care facility for reporting to the division a violation of any state or federal law or rule and regulation. Any employee found to have knowingly made a false report to the division shall be subject to disciplinary action by the employing health care facility, including but not limited to, dismissal.

(c) No hospital shall be issued a license or have its license renewed unless it provides for the review of professional practices in the hospital for the purpose of reducing morbidity and mortality and for the improvement of the care of patients in the hospital. This review shall include, but not be limited to:

(i) The quality and necessity of the care provided to patients as rendered in the hospital;

(ii) The prevention of complications and deaths occurring in the hospital;

(iii) The review of medical treatments and diagnostic and surgical procedures in order to ensure safe and adequate treatment of patients in the hospital; and

(iv) The evaluation of medical and health care services and the qualifications and professional competence of persons performing or seeking to perform those services.

(d) The review required in subsection (c) of this section shall be performed according to the decision of a hospital's governing board by:

(i) A peer review committee appointed by the organized medical staff of the hospital;

(ii) A state, local or specialty medical society; or

(iii) Any other organization of physicians established pursuant to state or federal law and engaged by the hospital for the purposes of subsection (c) of this section.