105 STAT. 214 PUBLIC LAW 102-40—MAY 7, 1991 before being designated Director, Chaplain Service, and all service as Director, Chaplain Service, shall be creditable as service in the former position. "SUBCHAPTER II—GENERAL AUTHORITY AND ADMINISTRATION "§ 7311. Quality assurance "(a) The Secretary shall— "(1) establish and conduct a comprehensive program to monitor and evaluate the quality of health care furnished by the Veterans Health Administration (hereinafter in this section referred to as the 'quality-assurance program'); and "(2) delineate the responsibilities of the Chief Medical Director with respect to the quality-assurance program, including the duties prescribed in this section. "(b)(1) As part of the quality-assurance program, the Chief Medical Director shall periodically evaluate— "(A) whether there are significant deviations in mortality and morbidity rates for surgical procedures performed by the Administration from prevailing national mortality and morbidity standards for similar procedures; and "(B) if there are such deviations, whether they indicate deficiencies in the quality of health care provided by the Administration. "(2) The evaluation under paragraph (I)(A) shall be made using the information compiled under subsection (c)(1). The evaluation under paragraph (1)(B) shall be made taking into account the factors described in subsection (c)(2)(B). "(3) If, based upon an evaluation under paragraph (1)(A), the Chief Medical Director determines that there is a deviation referred to in that paragraph, the Chief Medical Director shall explain the deviation in the report submitted under subsection (f). "(c)(1) The Chief Medical Director shall— "(A) determine the prevailing national mortality and morbidity standards for each type of surgical procedure performed by the Administration; and Records. "(B) collect data and other information on mortality and morbidity rates in the Administration for each type of surgical procedure performed by the Administration and (with respect to each such procedure) compile the data and other information so collected— "(i) for each medical facility of the Department, in the case of cardiac surgery, heart transplant, and renal transplant programs; and "(ii) in the aggregate, for each other type of surgical procedure. "(2) The Chief Medical Director shall— "(A) compare the mortality and morbidity rates compiled under paragraph (I)(B) with the national mortality and morbidity standards determined under paragraph (I)(A); and "(B) analyze any deviation between such rates and such standards in terms of the following: "(i) The characteristics of the respective patient populations.
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