Md. Code Regs. 30.08.08.14

Current through Register Vol. 51, No. 24, December 2, 2024

Section 30.08.08.14 - Quality Management

A. The hospital shall have ongoing QM of the pediatric trauma program that is integrated into the hospital's overall QM program and reported to the hospital's governing body.

B. The following shall be included in the pediatric QM program:

(1) A structure to ensure that defined program outcomes and performance measures are developed and monitored regularly;

(2) A special audit of all pediatric trauma deaths;

(3) Review of morbidity and mortality;

(4) Evaluation of medical care, nursing care, utilization review, tissue review, and prehospital care;

(5) Monthly review, at an appropriate interdisciplinary forum, of the performance of the pediatric trauma program, including:

(a) Trends;

(b) All deaths;

(c) All transfers;

(d) Morbidities;

(e) Problem identification and solution;

(f) Issues identified from the QM process; and

(g) System or administrative issues;

(6) Maintenance of minutes for all meetings in accordance with the hospital QM program;

(7) Requirements for designated liaisons (medical and nursing) to attend at least 50 percent of the trauma peer review meetings, and with supporting documentation;

(8) Requirements for all pediatric general surgeons who take pediatric trauma call to attend at least 50 percent of the trauma peer review meetings;

(9) Documentation of QM to demonstrate the interdisciplinary approach to the QM program, including:

(a) Problem identification;

(b) Analysis;

(c) Action planning;

(d) Implementation;

(e) Reevaluation; and

(f) Corrective action; and

(10) Monitoring of Level I Pediatric Trauma Center bypass status including "fly-by" and re-route events.

Md. Code Regs. 30.08.08.14

Regulation .14 adopted effective 50:14 Md. R. 594, eff. 7/24/2023