§ 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.