Mich. Admin. Code R. 325.135 - Regional performance improvement
Rule 11.
(1) Each
trauma care region shall be required to develop and implement a regional trauma
performance improvement program. This program shall include the standards that
are incorporated by reference pursuant to
R
325.129(1)(e),
R
325.129(1)(k), and
R 325.130(6)(d), and
shall include the development of an annual process for reporting to the
department a review of all region-wide policies, procedures, and
protocols.
(2) Each regional trauma
network is responsible for monitoring, assessing, and evaluating its regional
trauma system to improve trauma care, reduce death and disability, surveillance
of injury, and implementation of injury prevention activities.
(3) Each regional trauma network shall
appoint a RPSRO.
(4) Deviations
from protocols, which are established and adopted by local medical control and
approved by the department for trauma patients, shall be addressed through a
documented trauma performance improvement process established by a professional
standards review organization.
(5)
Each regional trauma advisory council shall observe the confidentiality
provisions of the health insurance portability and accountability act under 45
CFR Part 164, data confidentiality provisions under the code, or as established
by the regional professional standards review organization.
(6) The performance improvement process shall
include the following standards that are incorporated by reference in these
rules, pursuant to
R
325.129(1)(e),
R
325.129(1)(k), and
R 325.130(6)(d) and
include all of the following system components to be evaluated for both
pediatrics and adults:
(a) Components of the
regional trauma plan.
(b) Triage
criteria and effectiveness.
(c)
Trauma center diversion.
(d) Data
driven provision of care defined by available data metrics supported by the
region, the statewide trauma advisory subcommittee, and the
department.
(7) Each
trauma care region shall be responsible for the ongoing evaluation of its
trauma care system. Accordingly, each region shall be responsible for the
ongoing receipt of information from the regional trauma system constituents on
the implementation of various components of that regions trauma system, and
shall include the standards that are incorporated by reference pursuant to
R
325.129(1)(e), R 325. 129(A)(12), and
R 325.130(6)(d), and
include all of the following system components to be evaluated:
(a) Components of the regional trauma
plan.
(b) Triage criteria and
effectiveness.
(c) Trauma center
diversion.
(d) Data analytics as
defined by the department with the advice of the statewide trauma advisory
subcommittee.
(8) Based
upon information received by the region in the evaluation process, the region
shall annually prepare a report containing results of the evaluation and a
performance improvement plan. The report shall be made available to all
regional trauma system constituents. The region shall ensure that all trauma
facilities participate in this annual evaluation process, and encourage all
other hospitals that treat trauma patients to participate in the annual
evaluation process. The region shall not release specific information related
to an individual patient or practitioner. Aggregate system performance
information and evaluation will be available for review.
Notes
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