15 Miss. Code. R. 12-32-3.4.9 - Performance Improvement/Evaluation
1. A key element in
trauma system planning is evaluation. All licensed hospitals which have
organized emergency services or departments will be required to participate in
the statewide trauma registry for the purpose of supporting peer review and
performance improvement activities at the local, regional and state levels.
Since these data relate to specific trauma patients and are used to evaluate
and improve the quality of health care services, this data is confidential as
provided in Miss. Code Ann.§
41-59-77.
Level II trauma facilities may be responsible for direct assistance to all
other levels of referring facilities in providing data for inclusion in the
registry.
2. Each trauma center
must develop an internal Performance Improvement plan that minimally addresses
the following key components and is fully integrated into the hospital wide
program:
a. An organizational structure that
facilitates performance improvement (Multidisciplinary Trauma
Committee).
b. Clearly defined
authority and accountability for the program.
c. Clearly stated goals and objectives one of
which should be reduction of inappropriate variations in care.
d. Development of expectations (criteria)
from evidenced based guidelines, pathways and protocols. These should be
appropriate, objectively defined standards to determine quality of
care.
e. Explicit definitions of
outcomes derived from institutional standards
f. Documentation system to monitor
performance, corrective action and the result of the actions taken.
g. A process to delineate privileges
credentialing all trauma service physicians.
h. An informed peer review process utilizing
a multidisciplinary method.
i. A
method for comparing patient outcomes with computed survival
probability.
j. Autopsy information
on all deaths when available.
k.
Review of prehospital care.
l.
Review of times and reasons for trauma bypass.
m. Review of times and reasons for trauma
transfers.
n. Audit all trauma
deaths.
o. Morbidity and Mortality
review.
3.
Representatives from the Level II trauma center shall participate in the Trauma
Care Region and statewide performance improvement process.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.