Mich. Admin. Code R. 330.260 - Regional performance improvement
Rule 10.
(1) Each
regional stroke system shall develop and implement a regional stroke care
performance improvement program. This program must include the standards under
R 330.254(1)(d) and
R 330.257(5) and the
development of an annual process for reporting to the department a review of
all region-wide policies, procedures, and protocols.
(2) Each regional stroke system is
responsible for monitoring, assessing, and evaluating the system to improve
stroke care, reduce death and disability, surveillance of stroke incidence and
implementation of stroke risk reduction initiatives.
(3) Each regional stroke system shall appoint
an RPSRO.
(4) Deviations from
protocols established and adopted by local MCAs and approved by the department
for stroke patients must be addressed through a documented stroke care
performance improvement process established by a PSRO.
(5) Each regional stroke care advisory
council shall observe the confidentiality provisions of 45 CFR Part 164 , the
health insurance portability and accountability act of 1996,
Public Law
104-191 , the data confidentiality provisions under
the code, and any confidentiality provisions established by the
RPSRO.
(6) The performance
improvement process must include the standards under
R 330.254(1)(d), and
include all of the following system components to be evaluated:
(a) Components of the regional stroke care
plan.
(b) Triage criteria and
effectiveness.
(c) Stroke center
diversion.
(d) Data driven
provision of care defined by available data metrics supported by the region,
the statewide stroke care advisory subcommittee, and the department.
(7) Each regional stroke system is
responsible for the ongoing evaluation of the stroke system of care.
Accordingly, each region shall develop a procedure for receiving information
from the regional stroke care system constituents on the implementation of
various components of that region's stroke care system, and include the
standards under R
330.254(1)(e), and include all the
following:
(a) Components of the regional
stroke care plan.
(b) Triage
criteria, and effectiveness.
(c)
Stroke center diversion.
(d) Data
analytics as defined by the department with the advice of the statewide stroke
care advisory subcommittee.
(8) Based on 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, if
needed. The report must be made available to all regional stroke system
constituents.
(9) The region shall
ensure that all stroke centers participate in this annual evaluation process
and encourage all other hospitals that treat stroke patients to participate.
The region shall not release specific information related to an individual
patient or practitioner. Aggregate system performance information and
evaluation must be available for review.
Notes
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