§ 2805-j. Medical, dental and podiatric malpractice prevention\nprogram. 1. Every hospital shall maintain a coordinated program for the\nidentification and prevention of medical, dental and podiatric\nmalpractice. Such program shall include at least the following:\n (a) The establishment of a quality assurance committee with the\nresponsibility to review the services rendered in the hospital in order\nto improve the quality of medical, dental and podiatric care of patients\nand to prevent medical, dental and podiatric malpractice. Such\ncommittee shall oversee and coordinate the medical, dental and podiatric\nmalpractice prevention program and shall insure that information\ngathered pursuant to the program is utilized to review and to revise\nhospital policies and procedures. At least one member of the committee\nshall be a member of the governing board of the hospital who is not\notherwise affiliated with the hospital in an employment or contractual\ncapacity;\n (b) A medical, dental and podiatric staff privileges sanction\nprocedure through which credentials, physical and mental capacity and\ncompetence in delivering health care services are periodically reviewed,\nand reviewed as otherwise warranted in specific instances and\ncircumstances, as part of an evaluation of staff privileges;\n (c) The periodic review and the review as otherwise warranted in\nspecific instances and circumstances of the credentials, physical and\nmental capacity and competence in delivering health care services of all\npersons who are employed or associated with the hospital;\n (d) A procedure for the prompt resolution of grievances by patients or\ntheir representatives related to accidents, injuries, treatment and\nother events that may result in claims of medical, dental or podiatric\nmalpractice;\n (e) The maintenance and continuous collection of information\nconcerning the hospital's experience with negative health care outcomes\nand incidents injurious to patients, patient grievances, professional\nliability premiums, settlements, awards, costs incurred by the hospital\nfor patient injury prevention and safety improvement activities;\n (f) The maintenance of relevant and appropriate information gathered\npursuant to paragraphs (a) through (e) of this subdivision concerning\nindividual physicians, dentists and podiatrists within the physician's,\ndentist's or podiatrist's personnel or credential file maintained by the\nhospital;\n (g) Education programs dealing with patient safety, injury prevention,\nstaff responsibility to report professional misconduct, the legal\naspects of patient care, improved communication with patients and causes\nof malpractice claims for staff personnel engaged in patient care\nactivities;\n (h) Continuing education programs for medical, dental and podiatric\nstaff in their areas of specialty; and\n (i) Policies to ensure compliance with the reporting requirements of\nsection twenty-eight hundred three-e of this article and subdivision\neleven of section two hundred thirty of this chapter.\n (j) For the purposes of this section, the term "hospital" shall have\nthe same meaning as is set forth in subdivision ten of section\ntwenty-eight hundred one of this article.\n 2. Any person who, in good faith and without malice, provides\ninformation to further the purposes of the medical, dental and podiatric\nmalpractice prevention program or who, in good faith and without malice,\nparticipates on the quality assurance committee shall not be subject to\nan action for civil damages or other relief as a result of such\nactivity. Any hospital, or any person acting on behalf of such hospital,\nwho, in good faith and without malice, takes or fails to take any action\nas a result of a review conducted pursuant to paragraph (b) or (c) of\nsubdivision one of this section, shall not be subject to an action for\ncivil damages or other monetary relief as a result of such action or\nfailure to act, provided, however, that no
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